HAC HAC Risk Stratification & Care Management Analytics 2 — Questions and Answers
Question 1: Social determinants of health (SDOH) data are increasingly incorporated into risk stratification models because:
- CMS requires SDOH fields in all claims submissions as of 2022
- Non-clinical factors like housing instability and food insecurity independently predict poor health outcomes and utilization (Correct answer)
- SDOH data replace the need for diagnosis-based risk scoring
- Including SDOH automatically qualifies organizations for value-based incentive payments
Correct answer: Non-clinical factors like housing instability and food insecurity independently predict poor health outcomes and utilization
Research consistently shows that social factors such as food insecurity, housing, and transportation barriers are strong independent predictors of health outcomes.
Question 2: What is the purpose of a 'propensity score' in healthcare program evaluation analytics?
- To rank patients by willingness to pay for services
- To statistically balance comparison groups in observational studies to reduce selection bias when measuring program impact (Correct answer)
- To calculate physician compensation under pay-for-performance contracts
- To weight hospital quality scores by patient volume
Correct answer: To statistically balance comparison groups in observational studies to reduce selection bias when measuring program impact
Propensity scoring estimates the probability that a subject receives a treatment given observed covariates, enabling fairer comparison between intervention and control groups.
Question 3: Which utilization management metric measures the proportion of inpatient admissions that were potentially avoidable through better outpatient or preventive care?
- Ambulatory care sensitive condition (ACSC) admission rate (Correct answer)
- Length of stay per DRG
- Emergency department left-without-being-seen rate
- Elective surgical case cancellation rate
Correct answer: Ambulatory care sensitive condition (ACSC) admission rate
ACSC admission rates track hospitalizations for conditions like uncontrolled diabetes or asthma that good outpatient care should prevent, serving as a proxy for care management effectiveness.
Question 4: In transitional care analytics, what does a high '30-day post-discharge ED visit rate' typically signal?
- That patients prefer the ED for routine follow-up
- Gaps in discharge planning, medication reconciliation, or outpatient follow-up that leave patients vulnerable after leaving the hospital (Correct answer)
- Successful early discharge protocols reducing length of stay
- High patient satisfaction with emergency department services
Correct answer: Gaps in discharge planning, medication reconciliation, or outpatient follow-up that leave patients vulnerable after leaving the hospital
Frequent ED visits shortly after discharge indicate that patients' needs are not being adequately managed in the community, often due to poor care transition processes.
Question 5: A risk stratification model has high sensitivity but low specificity. What does this mean for care management resource allocation?
- It catches most truly high-risk patients but also flags many low-risk patients, leading to inefficient use of care management resources (Correct answer)
- It misses most high-risk patients and wastes resources on low-risk patients
- It perfectly identifies only those who need intensive management
- It cannot be used for care management without recalibration
Correct answer: It catches most truly high-risk patients but also flags many low-risk patients, leading to inefficient use of care management resources
High sensitivity ensures few high-risk patients are missed, but low specificity means many low-risk patients are also flagged, diluting care management resources across unnecessary enrollments.
Question 6: Which analytical method is MOST appropriate for identifying clusters of patients with similar chronic disease patterns and utilization behaviors?
- Linear regression
- K-means clustering (Correct answer)
- Survival analysis
- Chi-square testing
Correct answer: K-means clustering
K-means clustering partitions patients into groups with similar characteristics without predefined labels, making it ideal for discovering natural subpopulations.
HAC HAC Risk Stratification & Care Management Analytics 2
Social determinants of health (SDOH) data are increasingly incorporated into risk stratification models because: