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



Log on to Your Rise Account

Forgot your password?
Create an Account


Latest Posts

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ...
Read More

Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago....
Read More

Upcoming Conference


Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.


Upcoming Webinar

The Impact of Quality Incentive Models in Medicaid Markets


Thirty-one of our fifty states now have Medicaid managed care, and several markets are expected to implement managed care in the next few years. More than $160B in Medicaid spending occurs through the Managed Care Organizations. As more and more states seek to do more with less, increasing accountability for health quality outcomes is placed on health plans. Join this webinar to learn the typical quality payment approaches states use, issues often faced by health plans under each model and what states are expected to do with payment models tied to quality performance in light of near term Medicaid reform efforts.


Connect With Us

Copyright © 2014 Resource Initiative & Society for Education. All rights reserved.