Which of the following Medicare patients demonstrates the highest level of risk based on the above chart?

The highest risk is demonstrated by the patient with the greatest number of risk-adjusting factors. In the CMS-HCC model, risk is determined by demographics (age, sex, disability, institutional status) and health status (diagnoses/HCCs). Both patients C and D have institutional status (living in a skilled nursing facility) and the same high-risk diagnoses (diabetes with neuropathy, morbid obesity, depression). However, patient D is 94 years old, while patient C is 72. The CMS-HCC model assigns a significantly higher demographic risk score based on advanced age, especially for institutionalized individuals. Therefore, with all other factors being equal, the 94-year-old patient has the highest overall risk score.

A. This patient is younger, lives in the community (lower demographic score), and has fewer specified complications compared to the others.

B. While disability increases the risk score, institutional status (in C and D) typically carries a higher risk coefficient in the CMS-HCC model.

C. This patient has a high-risk profile, but the 94-year-old patient (D) has a higher demographic risk score due to advanced age, making their total score higher.

1. Centers for Medicare & Medicaid Services (CMS). (2023). CMS-HCC Risk Adjustment Model for 2024. The model coefficients published by CMS show that risk scores for the age component increase with age, and the institutional status factor is a significant multiplier. For example, in the V28 model, the age-sex coefficient for a 94-year-old institutionalized female is higher than for a 72-year-old.

2. Pope, G. C., Kautter, J., Ellis, R. P., et al. (2004). Risk adjustment of Medicare capitation payments: A sociotechnical history. RTI Press. https://doi.org/10.3768/rtipress.2009.bk.0001.1. This publication provides the foundational principles of the CMS-HCC model, explaining the key components, including demographic factors like age and institutional status, as primary drivers of the risk score.