risk adjusted cost
rsk_adj_cst_amtDefinition
ISO-11179 Definition
The healthcare expenditure for a patient population normalized to account for differences in member health status and clinical complexity using risk adjustment models, enabling fair comparison of cost efficiency across providers serving populations with different acuity levels. Risk adjusted cost prevents the misleading conclusion that providers serving healthier populations are more efficient than those serving complex patients — by controlling for risk, cost comparisons reflect true efficiency differences rather than patient selection effects. CMS uses HCC risk scores to calculate risk-adjusted per capita expenditure for ACO performance measurement, ensuring that ACOs serving higher-complexity populations receive appropriately higher benchmarks.
Commercial value based contracts apply prospective risk adjustment using diagnostic cost grouper models or HCC-based risk scores. Healthcare data teams calculate rsk_adj_cst_amt by dividing actual expenditure by the average risk score of the population, effectively converting all populations to a common risk-equivalent basis for meaningful cost comparison across provider groups and performance periods.
Standard Abbreviation
rsk_adj_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.
Related Content
Related Definitions
Looking for more healthcare terms?
Browse our complete library of 100,000+ standardized healthcare data terms
Browse All Terms