total cost of care
tot_cst_care_amtDefinition
ISO-11179 Definition
The aggregate expenditure for all healthcare services received by a defined patient population over a specified measurement period, including medical, pharmacy, behavioral health, and ancillary services regardless of care setting. Total cost of care is the primary financial metric in value based care contracts — ACOs, shared savings programs, and full risk arrangements all benchmark actual spending against an expected total cost of care calculated from historical utilization patterns adjusted for risk, demographics, and market factors. Reducing total cost of care while maintaining or improving quality is the fundamental objective of value based payment reform.
Healthcare data teams build total cost of care measurement pipelines that aggregate claims payments across all service categories, apply risk adjustment models to normalize for patient complexity differences, compare actual spending against benchmark expenditure targets, identify high-cost utilization drivers including avoidable hospitalizations and high-cost imaging, and produce cost trend analytics that guide care management program prioritization.
Standard Abbreviation
tot_cst_care_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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