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upside risk

upsde_rsk_ind
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

A boolean indicator identifying that a value based care contract entitles the provider organization to receive a share of savings when total cost of care for the attributed population falls below the established benchmark expenditure. Upside risk represents the financial opportunity side of value based payment — the potential to earn additional revenue above standard fee-for-service reimbursement by delivering efficient, high-quality care that reduces unnecessary utilization. One-sided risk contracts that offer only upside savings without downside loss exposure are common entry points for provider organizations new to value based payment.

CMS MSSP Basic track participants receive upside-only savings sharing in their first three years. Commercial payers offer upside-only arrangements as introductory value based contracts before requiring organizations to accept two-sided risk. Healthcare data teams model upside savings potential by calculating projected cost performance relative to benchmark, estimating shared savings amounts at various performance scenarios, and analyzing the care management investments that generate the greatest return in terms of quality improvement and cost reduction.

Standard Abbreviation

upsde_rsk_ind

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
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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