From Scores to Shortages: Hierarchical Condition Categories Disparities and the Rural Healthcare Crisis

Background: Healthcare inequities in rural networks are well documented. Over 100 rural hospitals closed between 2013 and 2020 alone (1), with another 432 at risk of closure (2), forcing patients to travel further. Rural residents experience higher mortality rates and more chronic conditions than urban residents (3), compounded by lower socioeconomic status (4). Medicare’s value-based care models incentivize providers to treat at-risk patients using Hierarchical Condition Categories (HCC) scores to adjust for patient complexity (5). In theory, HCC scores should be higher for rural patients with increased comorbidity. However, urban beneficiaries have been reported to have higher HCC scores due to increased coding capture and greater healthcare access (6). We examine the relationship between rurality, socioeconomic factors, and HCC scores to highlight rural health disparities. Methods: In this retrospective cross-sectional study, data from the Area Health Resources Files (2024-2025 release) was used to examine mean HCC scores, percentages of household income distribution and hospital utilization, stratified by Rural-Urban Continuum Codes (RUCC). One-way analysis of variance (ANOVA) tested for differences in HCC scores across RUCC categories. Results: Our results showed a statistically significant relationship between RUCC and HCC risk scores (p < .01), substantiating urban counties having higher HCC scores. HCC scores declined with the increasing prevalence of low-income households. Furthermore, hospital utilization declined with increasing rurality, signaling financial vulnerability. Conclusion: Decreased HCC risk scores do not reflect lower health burden, but rather underutilization of healthcare services. Ongoing hospital closures may push rural America toward healthcare shortages seen in low- and middle-income countries.