Is There a Benchmark for HCC Prevalence in Medicare Advantage?

I received an inquiry from a Medicare Advantage plan asking if I knew of any resource that would show the prevalence rates of HCC codes among Medicare Advantage populations.  The notion was to obtain something as a benchmark against which a plan could gauge their own prevalence from risk adjustment work for reasonableness. 

Where do you turn to find out such information?  Among others, I automatically think of Richard Lieberman, "the mad scientist".  He has a great background in research and development in the risk adjustment arena.  Here is what the "mad scientist" had to say:

Dear Kevin:


Other than the EDPS database that CMS has, there is no comprehensive source of benchmarks for HCC prevalence.  That said, I also don’t think it is possible to get a single set of HCC-specific prevalence benchmarks that would be remotely usable.  CMS could, at some point, calculate benchmark prevalence for a 1.0 risk score plan (ideally they would produce 1.0-HMO rates, 1.0-PPO rates, etc.).  But such “benchmark” prevalence rates would only be reasonable for a plan with an average 1.0 risk score.  A 1.1 risk score plan would, of course, have different prevalence rates, as would a 0.9 risk score.  Since risk adjustment is a (loose) measure of morbidity and morbidity varies across plans, I don’t see how one gets to an “expected” number of HCCs that can serve as a viable benchmark.


I would recommend to anyone seeking something resembling a benchmark to look at the historical risk score statistics

This is a veritable treasure trove of data- risk scores by county, by plan type, by plan, by PBP, everything!  This is the closest thing to a benchmark, because it tells you the actual morbidity levels for a particular kind of member.  One can even tie risk scores to particular benefit designs using the PBP and the landscape files.  HCC prevalence rates would have to be presented in a similar way and that is not possible given the limitations of available data.




Richard Lieberman

Chief Data Scientist

Office: 720-446-7785 x 102



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