Association Between Physician Risk Assessment, Hierarchical Condition Categories, and Utilization of Medical Services

Area of Science:

• Health Services Research
• Clinical Informatics
• Risk Adjustment Methodologies

Background:

• Hierarchical Condition Categories (HCCs) are utilized for risk adjustment to align care management with population health needs.
• Physician-determined clinical risk (CR) scores offer a subjective assessment of patient risk for adverse events.

Purpose of the Study:

• To examine the association between HCC scores and physician-determined CR scores.
• To evaluate the relationship between HCC scores, CR scores, healthcare charges, and utilization of medical services.

Main Methods:

• A study involving 128 primary care physicians (PCPs) assessed 6167 patients across 31 practices.
• PCPs assigned CR scores for the top 50 high-risk patients based on HCC scores.
• Statistical analysis correlated HCC scores with CR scores, annual charges, and healthcare utilization.

Main Results:

• A moderate-to-weak correlation (44.0%) was found between HCC scores and physician CR scores.
• Only 18.5% of PCPs demonstrated a correlation greater than 60% between HCC and CR scores.
• Both HCC and CR scores positively correlated with healthcare charges, hospital admissions, emergency department visits, and advanced imaging utilization.

Conclusions:

• HCC scores demonstrate a moderate-to-weak correlation with physician assessments of patient risk for ED visits or hospital admissions.
• While HCCs and CR scores are associated with increased healthcare charges and utilization, the limited concordance with physician judgment suggests cautious application.
• HCCs may aid in health resource allocation, but their predictive accuracy for individual patient risk requires careful consideration.