per capita cost
per_cap_cst_amtDefinition
ISO-11179 Definition
The average healthcare expenditure per attributed member calculated by dividing total cost of care by the total member months in the measurement population, used as the primary financial performance metric in value based care contracts and population health management programs. Per capita cost enables fair comparison of cost performance across provider groups serving different population sizes and is the foundation for shared savings and shared losses calculations in ACO arrangements. Risk-adjusted per capita cost accounts for differences in patient complexity by applying HCC risk scores or similar models before comparing provider performance.
CMS publishes Medicare per capita expenditure benchmarks by county and ACO participant that serve as the targets against which ACO performance is measured. Healthcare data teams calculate per_cap_cst_amt by aggregating all attributed member claim payments, converting to a per-member-per-month basis, applying risk adjustment, and comparing against contract benchmarks to determine shared savings eligibility and payment amounts.
Standard Abbreviation
per_cap_cst_amt
Category
Production DDL — FACT_QUALITY_MEASURE
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
qlty_key INTEGER NOT NULL -- surrogate key,
mbr_key INTEGER NOT NULL -- FK to DIM_MEMBER,
plan_key INTEGER NOT NULL -- FK to DIM_PLAN,
meas_yr SMALLINT -- measurement year,
hedis_meas_cd VARCHAR(20) -- HEDIS measure code,
denom_ind CHAR(1) -- denominator eligible,
numer_ind CHAR(1) -- numerator met,
excl_ind CHAR(1) -- exclusion indicator,
gap_open_ind CHAR(1) -- care gap open,
star_rtg_nbr DECIMAL(3,1) -- star rating,
qlty_scr DECIMAL(5,2) -- quality score,
perf_thrsh_pct DECIMAL(5,2) -- performance threshold,
raf_scr DECIMAL(10,3) -- risk adjustment factor,
outreach_cnt SMALLINT -- outreach attempts,
load_dt TIMESTAMP_NTZ NOT NULL -- load timestamp
);
Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →
Why This Term Matters
Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.
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