Hierarchical Condition Category (HCC Segmentation by Risk, Disease, Costs)

This report provides a retrospective view of the population considering risk, disease, and cost utilizing the most recent 12 months of data.  This report is very similar to the Segmentation by Risk, Disease, Cost report with the exception of using the HCC Risk Score instead of the ACG Risk Score. The total population can be filtered in multiple ways:  Chronic Condition, Cost, # of Chronic Conditions, Age, Risk, Hierarchy Levels, Provider, and Provider Group, are the most commonly used filters.  The report also allows multiple filters to be applied simultaneously.

Target Audience for this Report

Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, Quality Management, Utilization Management.


Business Processes Impacted by this Report

Population health management functions will rely on this report for identification, stratification, and assessment of the members.  Not only will the high-risk members be an area of focus but those in the pipeline to become high-risk.  The leadership/administration of the health plan will be informed by this report and will find by increasing the understanding of the membership, cost drivers, provider performance, and disease prevalence, the strategies developed can be focused and effective.

Provider relations and the CMO/Medical Director have actionable data derived from this report.   The ability to understand provider behavior is critical to developing ways to support providers in their care delivery at a population health level.  Education of providers can be specific and outcome based rather than anecdotal and infrequent.  Sales and client relations will benefit from the employer filtered results and can provide reports of the membership of a specific employer.  This is a differentiator for a health plan to become a partner with the employer to drive improved health outcomes by identifying high risk, opportunities for preventive care, and outcome data.

Medical Management will focus their member interactions as well as their interface with the providers/facilities.  Targeted care management and member outreach for all populations – low, rising, and high risk – is informed by this report.

Detail and Definitions


Report Filters 

  • Age – Allows for defining the patient age in a from and to filter.
  • Total Costs – Sets a minimum amount of medical claim dollars for the most recent 12 months.
  • Chronic Condition – Values are CMS defined chronic diseases that are deemed to be population high-impact and/or cost.  Members are associated with these diseases via diagnoses coded with their claims in the most recent 12 months.  Filter allows for selecting one or more Chronic Conditions to include in report results.  The chronic condition list with associated disease type is available for review in Appendix A.



  • Members – Members included in results.
  • Population Avg. Risk – Average Risk of members in results.


Cost by Group

  • PCP Group
  • Members
  • Total Costs
  • Avg HCC Risk
  • Avg Cost



  • PCP
  • PCP Name
  • Members
  • Total Cost
  • Avg HCC Risk


Patient Cost vs Risk (Graph)

  • Total Patient Cost
  • Avg HCC Risk


High Cost Patients

  • Member Number
  • Member Name
  • Total Paid
  • Age
  • Avg HCC Risk