Glossary
GLOSSARY
INDEX
INDEX
ABMS: American Board of Medical Specialties
A nonprofit organization composed of 24 certifying boards (Member Boards) that develop and implement professional standards certifying physicians in their declared medical/surgical specialty. Over 840,000 doctors are certified by one or more ABMS Member Boards in over 150 specialties and subspecialties; over 500,000 physicians participate in an ABMS program for maintenance of certification, recognized by the Joint Commission, the National Committee for Quality Assurance, URAC, hospitals, health insurers, government agencies, and other entities as the highest healthcare industry standard attesting to a physician's knowledge, experience, and skills within a given medical specialty.
Fact sheet. American Board of Medical Specialties. 2016
http://www.abms.org/media/100051/abms_factsheet_2016.pdfAccessed February 23, 2016.
ACA: Affordable Care Act
The Patient Protection and Affordable Care Act—also known as the "Affordable Care Act" or "ACA," and generally referred to as "Obamacare"—is the landmark health reform legislation passed by the 111th Congress and signed into law by President Barack Obama in March 2010. The legislation offered Americans new benefits, rights, and protections in healthcare that began taking effect in 2010.
These include setting up health insurance marketplaces, where people can purchase federally regulated and subsidized health insurance during annual open enrollment periods; expanded Medicaid coverage in some states to all adults below a certain income level; improving Medicare for seniors and those with long-term disabilities; expanding employer coverage to millions of employees; mandating that most people have coverage each month from 2014 onward, or pay a fee; introducing new taxes (primarily affecting high earners and large businesses) and tax credits (primarily affecting low- to middle-income Americans and small businesses); implementing measures to lower healthcare costs and improve system efficiency; and eliminating such health insurance industry practices as cancellation of coverage (rescission) and denial of coverage owing to preexisting conditions.
One controversial provision of the ACA—the mandate that most Americans purchase health insurance regardless of whether or they want it or pay a fine, which opponents charged was an illegal tax—survived a Supreme Court challenge in June 2015, establishing the ACA as settled law.
These include setting up health insurance marketplaces, where people can purchase federally regulated and subsidized health insurance during annual open enrollment periods; expanded Medicaid coverage in some states to all adults below a certain income level; improving Medicare for seniors and those with long-term disabilities; expanding employer coverage to millions of employees; mandating that most people have coverage each month from 2014 onward, or pay a fee; introducing new taxes (primarily affecting high earners and large businesses) and tax credits (primarily affecting low- to middle-income Americans and small businesses); implementing measures to lower healthcare costs and improve system efficiency; and eliminating such health insurance industry practices as cancellation of coverage (rescission) and denial of coverage owing to preexisting conditions.
One controversial provision of the ACA—the mandate that most Americans purchase health insurance regardless of whether or they want it or pay a fine, which opponents charged was an illegal tax—survived a Supreme Court challenge in June 2015, establishing the ACA as settled law.
ObamaCare Facts: an independent site for ACA advice. Obamacare Facts.
http://obamacarefacts.com/whatis-obamacare/Accessed February 23, 2016.
Health insurance glossary. Affordable Care Act (ACA)? HealthInsurance.org. 2015.
https://www.healthinsurance.org/glossary/affordable-care-act/Accessed February 23, 2016.
ACO: Accountable Care Organization
A network of primary care doctors, specialists, other healthcare providers, and often hospitals, which coordinate care for insured patients. The goal: to improve care quality and reduce costs, as called for in the ACA. An estimated 23.5 million Americans (about 6 million of them Medicare beneficiaries) are now in one of at least 744 existing ACOs. ACO providers are jointly accountable for the health of their patients.
In the traditional fee-for-service model, providers are paid for performing more services. ACOs don't do away with fee-for-service, but an incentive is created to be more efficient by avoiding "unnecessary" tests and procedures, with Medicare offering bonuses when ACO providers keep costs down (and often levying penalties when they don't). To qualify for bonuses, doctors and hospitals must meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. However, the ultimate goal, still years off, is that ACOs will take full financial responsibility for the care of a population of patients for a fixed payment.
In the traditional fee-for-service model, providers are paid for performing more services. ACOs don't do away with fee-for-service, but an incentive is created to be more efficient by avoiding "unnecessary" tests and procedures, with Medicare offering bonuses when ACO providers keep costs down (and often levying penalties when they don't). To qualify for bonuses, doctors and hospitals must meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. However, the ultimate goal, still years off, is that ACOs will take full financial responsibility for the care of a population of patients for a fixed payment.
Accountable care organizations. Centers for Medicare & Medicaid Services (CMS). January 6, 2015.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html?redirect=/ACO/Accessed February 22, 2016.
Gold J. Accountable care organizations, explained. Kaiser Health News. September 15, 2015.
http://khn.org/news/aco-accountable-care-organization-faq/Accessed February 22, 2016.
AHRQ: Agency for Healthcare Research and Quality
The leading federal agency charged with improving the safety and quality of US healthcare, AHRQ develops the knowledge, tools, and data needed to improve the healthcare system and help patients, healthcare professionals, and policymakers make informed health decisions. AHRQ's website offers patients information on care planning, diagnosis and treatment, and disease prevention, among other topics.
Doctors and other providers will find clinical guidelines and recommendations, continuing education and training materials, hospital and long-term-care resources, evidence-based decision-making tools, and healthcare quality and patient safety programs and tools. AHRQ works with Department of Health and Human Services agencies and other partners to ensure this information is understood and used to achieve better care, smarter spending of healthcare dollars, and healthier people.
Doctors and other providers will find clinical guidelines and recommendations, continuing education and training materials, hospital and long-term-care resources, evidence-based decision-making tools, and healthcare quality and patient safety programs and tools. AHRQ works with Department of Health and Human Services agencies and other partners to ensure this information is understood and used to achieve better care, smarter spending of healthcare dollars, and healthier people.
Agency for Healthcare Research and Quality (AHRQ). How we make a difference. 2016.
http://www.ahrq.gov/Accessed February 23, 2016.
CCMC: Chronic Care Management Code
Starting in 2015, Medicare began to reimburse providers separately under the Medicare Physician Fee Schedule, using Current Procedural Terminology code 99490, for non–face-to-face care coordination services delivered to Medicare beneficiaries with multiple chronic conditions. Services must take at least 20 minutes of clinical staff time per month, directed by a physician or other qualified provider (certified nurse-midwife, clinical nurse specialist, nurse practitioner, or physician assistant).
In addition, a patient must have two or more chronic conditions (for example, Alzheimer disease, arthritis, asthma, atrial fibrillation, cancer, depression, diabetes, hypertension, or osteoporosis) that are expected to last at least 12 months or until the patient's death. Chronic conditions must place the patient at significant risk for death, acute exacerbation or decompensation, or functional decline. In addition, a comprehensive care plan must be established, implemented, revised, or monitored.
In addition, a patient must have two or more chronic conditions (for example, Alzheimer disease, arthritis, asthma, atrial fibrillation, cancer, depression, diabetes, hypertension, or osteoporosis) that are expected to last at least 12 months or until the patient's death. Chronic conditions must place the patient at significant risk for death, acute exacerbation or decompensation, or functional decline. In addition, a comprehensive care plan must be established, implemented, revised, or monitored.
Chronic care management services. Centers for Medicare & Medicaid Services. May 2015.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdfAccessed February 25, 2016.
Evidence-Based Medicine or Practice
The use of current best evidence in making decisions about the care of individual patients. Evidence-based medicine integrates a physician's clinical expertise with the best available external clinical evidence from systematic research; neither alone is enough. Clinical expertise enables physicians to judge when excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, however, a doctor's empirical experience of what works best risks becoming rapidly out of date.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ.1996;312:71-73.
Evidence-based medicine definitions. NYU School of Medicine Frederick L. Ehrman Medical Library. January 2006.
https://library.med.nyu.edu/library/instruction/handouts/pdf/ebmdefinitions.pdfAccessed February 25, 2016.
FFS: Fee-for-Service
The traditional payment system for professional services—such as office visits, procedures, tests, and imaging studies—provided by physicians. Because the FFS system may reward productivity (the more tests a doctor orders, for example, the more he or she earns), FFS has been cited as a major factor in the rise in the cost of healthcare. As advocated by the ACA, the Centers for Medicare & Medicaid Services (CMS) is working toward transitioning doctors who care for Medicare and Medicaid patients, the nation's two largest groups of insured patients, from FFS payments to fixed fees for caring for a population of patients, and commercial insurers are following suit.
However, changing how hundreds of thousands of doctors will be reimbursed is an incremental, evolutionary process that is expected to take many years. In the meantime, physicians who are members of ACOs (as many increasingly are), while still receiving fee-for-service payments, are being offered economic incentives by CMS and commercial insurers to avoid what some have called unnecessary tests and procedures and to control healthcare costs.
However, changing how hundreds of thousands of doctors will be reimbursed is an incremental, evolutionary process that is expected to take many years. In the meantime, physicians who are members of ACOs (as many increasingly are), while still receiving fee-for-service payments, are being offered economic incentives by CMS and commercial insurers to avoid what some have called unnecessary tests and procedures and to control healthcare costs.
Fee-for-service. Medicaid.gov.
https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/fee-for-service.htmlAccessed February 25, 2016.
Fee-for-service. HealthInsurance.org. 2015.
https://www.healthinsurance.org/glossary/fee-for-service/Accessed February 25, 2016.
Schleifer D. Patients' views on reforming the physician fee-for-service payment system. Health Affairs Blog. February 28, 2014.
http://healthaffairs.org/blog/2014/02/28/patients-views-on-reforming-the-physician-fee-for-service-payment-system/Accessed February 25, 2016.
HIMSS: Healthcare Information and Management Systems Society
A not-for-profit organization dedicated to improving healthcare quality, safety, cost-effectiveness, and access, through the best use of health information technology (HIT) and management systems. Its membership includes healthcare IT and software vendors. HIMSS members work on developing many of today's key innovations in healthcare delivery and administration, including telemedicine.
Most of its individual members work in healthcare provider, governmental, and other organizations. Over 600 corporations and 250 not-for-profit partner organizations are also members. The HIMSS website offers information on numerous HIT topics, including ACOs, clinical decision support, clinical informatics, EHRs, and health information exchange. At HIMSS's Annual Conference, new research in HIT is presented and general education sessions are held.
Most of its individual members work in healthcare provider, governmental, and other organizations. Over 600 corporations and 250 not-for-profit partner organizations are also members. The HIMSS website offers information on numerous HIT topics, including ACOs, clinical decision support, clinical informatics, EHRs, and health information exchange. At HIMSS's Annual Conference, new research in HIT is presented and general education sessions are held.
Healthcare Information and Management Systems Society. Wikipedia. February 8, 2016.
https://en.wikipedia.org/wiki/Healthcare_Information_and_Management_Systems_SocietyAccessed March 2, 2016.
HIPAA: Health Information Portability and Accountability Act
HIPAA, passed by Congress in 1996, provides the ability to transfer and continue health insurance coverage for millions of Americans and their families when they change or lose their jobs; reduces healthcare fraud and abuse; mandates industry-wide standards for healthcare information on electronic billing and other processes; and requires the protection and confidential handling of protected health information, whether in paper charts or in electronic health records (EHRs).
Health Insurance Portability and Accountability Act. Wikipedia. February 1, 2016.
https://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_ActAccessed March 2, 2016.
Health information privacy. US Department of Health Human Services.
http://www.hhs.gov/hipaa/Accessed March 2, 2016.
Health Insurance Portability and Accountability Act. California Department of Health Care Services. 2016.
http://www.dhcs.ca.gov/formsandpubs/laws/hipaa/Pages/1.00WhatisHIPAA.aspxAccessed March 2, 2016.
HIT: Health Information Technology
The exchange of health information electronically, via computers and computer networks, which is intended to improve the quality of patient care, prevent medical errors, and reduce healthcare costs. The most important example of HIT is EHRs—the complex software applications used by physicians and other healthcare providers in hospitals and outpatient practices to record patient information, including office visit notes, physical examination findings, and the results of tests, imaging studies, and procedures; send electronic prescriptions to pharmacies; apply the correct International Classification of Diseases codes for work performed so that it can be appropriately billed to and reimbursed by health insurers; and permit patients to remotely access information in their personal health records.
Many of the anticipated benefits of HIT remain works in progress. Often, patient information cannot be seamlessly exchanged electronically with all of a patient's healthcare providers, because the EHRs of different vendors are unable to communicate with each other. As a result, patient records and EHRs are not yet living up to their potential. EHR vendors say that many of these shortcomings will eventually be resolved.
Many of the anticipated benefits of HIT remain works in progress. Often, patient information cannot be seamlessly exchanged electronically with all of a patient's healthcare providers, because the EHRs of different vendors are unable to communicate with each other. As a result, patient records and EHRs are not yet living up to their potential. EHR vendors say that many of these shortcomings will eventually be resolved.
Health information technology. US Department of Health & Human Services.
http://www.hhs.gov/hipaa/for-professionals/special-topics/health-information-technology/index.htmlAccessed March 2, 2016.
Health information technology. Wikipedia. February 1, 2016.
https://en.wikipedia.org/wiki/Health_information_technologyAccessed March 2, 2016.
What is health IT? Health Resources and Services Administration.
http://www.hrsa.gov/healthit/toolbox/oralhealthittoolbox/introduction/whatishealthit.htmlAccessed March 2, 2016.
HITECH: Health Information Technology for Economic and Clinical Health Act
Part of the ACA, HITECH contains incentives related to HIT (such as the creation of a national healthcare infrastructure), as well as specific incentives to accelerate the adoption of EHRs among providers. The legislation also widens the scope of privacy and security protections available under HIPAA.
The HITECH Act. HIPAA Survival Guide.
http://www.hipaasurvivalguide.com/hitech-act-summary.phpAccessed March 2, 2016.
Health Information Technology for Economic and Clinical Health Act. Wikipedia. February 26, 2016.
https://en.wikipedia.org/wiki/Health_Information_Technology_for_Economic_and_Clinical_Health_ActAccessed March 2, 2016.
IDN: Integrated Delivery Network
Also known as an "integrated delivery system" (IDS), an IDN is a system of providers and sites of care under a parent holding company that provides both healthcare services and a health insurance plan to patients in a given geographic area. Although IDN functions can vary, they generally include acute care, long-term health, specialty clinics, primary care, and home care services, all supporting an owned health plan.
Among the nation's largest IDNs are Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Geisinger Health System, and Partners Healthcare. Massachusetts-based Partners Healthcare, for example, includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care, and other health-related entities.
Among the nation's largest IDNs are Kaiser Permanente, Mayo Clinic, Cleveland Clinic, Geisinger Health System, and Partners Healthcare. Massachusetts-based Partners Healthcare, for example, includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care, and other health-related entities.
Landis J. Post-acute care cheat sheet: integrated delivery networks. The Advisory Board Company. April 28, 2014.
https://www.advisory.com/research/post-acute-care-collaborative/members/resources/cheat-sheets/integrated-delivery-networksAccessed March 3, 2016.
Integrated delivery system. Wikipedia. November 29, 2013.
https://en.wikipedia.org/wiki/Integrated_delivery_systemAccessed March 3, 2016.
About Partners Healthcare. Partners Healthcare.
http://www.partners.org/About/Default.aspxAccessed March 3, 2016.
Interoperability
In healthcare, interoperability is the ability of different information technology (IT) systems and software applications, particularly EHRs, to communicate, exchange data, and use the information that has been exchanged. A complex healthcare system requires diverse EHRs. One size does not fit all. To realize their full potential, EHRs must be able to share information seamlessly. An interoperable HIT environment would make this possible.
This is the key to meeting the goals of the HITECH Act. The standards and specifications supporting those goals are being developed by the federal Office of the National Coordinator for Health Information Technology (ONC). In creating an interoperable HIT environment, standards are critical for how EHRs interact with users (such as e-prescribing); how EHRs communicate with each other (such as messaging standards); how information is processed and managed (such as health information exchange); and how consumer devices (such as smartphones and tablets) exchange data with EHRs. A 2015 ONC report, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, calls for most providers to be able to use their EHRs to send, receive, and use "a common set of electronic clinical informationâ¦at the nationwide level by the end of 2017."
This is the key to meeting the goals of the HITECH Act. The standards and specifications supporting those goals are being developed by the federal Office of the National Coordinator for Health Information Technology (ONC). In creating an interoperable HIT environment, standards are critical for how EHRs interact with users (such as e-prescribing); how EHRs communicate with each other (such as messaging standards); how information is processed and managed (such as health information exchange); and how consumer devices (such as smartphones and tablets) exchange data with EHRs. A 2015 ONC report, Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, calls for most providers to be able to use their EHRs to send, receive, and use "a common set of electronic clinical informationâ¦at the nationwide level by the end of 2017."
What is interoperability? HIMSS. 2016.
http://www.himss.org/library/interoperability-standards/what-is-interoperabilityAccessed March 5, 2016.
Health information exchange. Standards & interoperability. HealthIT.gov. February 27, 2014.
https://www.healthit.gov/providers-professionals/standards-interoperabilityAccessed March 5, 2016.
What is EHR interoperability and why is it important? HealthIT.gov. January 15, 2013.
https://www.healthit.gov/providers-professionals/faqs/what-ehr-interoperability-and-why-it-importantAccessed March 5, 2016.
Conn J. Federal health IT coordinator sets 2017 goal for interoperability. Modern Healthcare. January 30, 2015.
http://www.modernhealthcare.com/article/20150130/NEWS/301309955Accessed March 5, 2016.
Connecting health and care for the nation: a shared nationwide interoperability roadmap. Office of the National Coordinator for Health Information Technology. 2015.
https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdfAccessed March 5, 2016.
IOM: Institute of Medicine
The IOM is a division of the National Academies of Sciences, Engineering, and Medicine. The Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions related to science, technology, and medicine. The IOM's aim is to help those in government and the private sector make informed health decisions by providing evidence on which they can rely.
The New York Times called the IOM the United States' "most esteemed and authoritative adviser on issues of health and medicine, and its reports can transform medical thinking around the world." To Err Is Human: Building a Safer Healthcare System, the IOM's landmark 2000 report on medical errors, drew national attention to medical errors that could have been prevented. More recently, Improving Diagnosis in Health Care (2015) also focused on diagnostic errors.
The New York Times called the IOM the United States' "most esteemed and authoritative adviser on issues of health and medicine, and its reports can transform medical thinking around the world." To Err Is Human: Building a Safer Healthcare System, the IOM's landmark 2000 report on medical errors, drew national attention to medical errors that could have been prevented. More recently, Improving Diagnosis in Health Care (2015) also focused on diagnostic errors.
About IOM. Institute of Medicine. October 28, 2015.
http://www.nationalacademies.org/about/index.htmlAccessed March 5, 2016.
National Academy of Medicine. Wikipedia. February 10, 2016.
https://en.wikipedia.org/wiki/National_Academy_of_MedicineAccessed March 5, 2016.
Harris G. Vaccine cleared as culprit in autism. New York Times. August 25, 2011.
http://www.nytimes.com/2011/08/26/health/26vaccine.html?_r=0Accessed March 5, 2016.
IPA: Independent Practice Association
A network that is a legal entity, organized and directed by physicians in private practice, to negotiate contracts with insurers on their behalf. Participating physicians are usually paid on a capitated or modified fee-for-service basis. Doctors in an IPA may also continue to care for patients not covered by the insurers with whom the IPA contracts.
Using its own administrative staff, the IPA organizes the delivery of care. It negotiates contracts with insurers; credentials member physicians; establishes primary care and specialist physician responsibilities; disburses payment to physicians; and conducts utilization review and quality assurance. Perhaps the most significant function of an IPA is to exert influence on behalf of its members to counterbalance the leverage of insurers.
Using its own administrative staff, the IPA organizes the delivery of care. It negotiates contracts with insurers; credentials member physicians; establishes primary care and specialist physician responsibilities; disburses payment to physicians; and conducts utilization review and quality assurance. Perhaps the most significant function of an IPA is to exert influence on behalf of its members to counterbalance the leverage of insurers.
Independent physician associations (IPAs) definition. American Academy of Family Physicians. 2015.
http://www.aafp.org/about/policies/all/independent-physicianassoc.htmlAccessed March 2, 2016.
Independent practice association. Wikipedia. January 5, 2016.
https://en.wikipedia.org/wiki/Independent_practice_associationAccessed March 2, 2016.
The Joint Commission
Formerly the Joint Commission on Accreditation of Healthcare Organizations, the Joint Commission is an independent, not-for-profit group that administers voluntary accreditation programs for nearly 21,000 hospitals, home care organizations, nursing homes, laboratories, and other healthcare organizations.
The Joint Commission develops standards for patient care, medication safety, infection control, and consumer rights that enable these facilities to measure and improve their performance; accreditation and certification for meeting these standards are recognized nationwide as a symbol of quality. Most state governments require that healthcare organizations receive Joint Commission accreditation as a condition for licensing and Medicaid reimbursement.
Healthcare facilities that receive Joint Commission accreditation can participate in the federal Medicare program. To keep its accredited status, a facility receives an onsite evaluation at least every 3 years (every 2 years for laboratories).
The Joint Commission develops standards for patient care, medication safety, infection control, and consumer rights that enable these facilities to measure and improve their performance; accreditation and certification for meeting these standards are recognized nationwide as a symbol of quality. Most state governments require that healthcare organizations receive Joint Commission accreditation as a condition for licensing and Medicaid reimbursement.
Healthcare facilities that receive Joint Commission accreditation can participate in the federal Medicare program. To keep its accredited status, a facility receives an onsite evaluation at least every 3 years (every 2 years for laboratories).
About the Joint Commission. The Joint Commission. 2016.
http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspxAccessed March 5, 2016.
Joint Commission. Wikipedia. February 9, 2016.
https://en.wikipedia.org/wiki/Joint_CommissionAccessed March 5, 2016.
Meaningful Use
The use of certified (ie, government-approved) EHR technology to improve quality, safety, and efficiency in patient care; improve care coordination among providers and healthcare facilities, such as hospitals and nursing homes; and maintain the privacy and security of a patient's protected health information.
Ultimately, it is hoped that MU compliance will result in better clinical outcomes. MU sets specific objectives that "eligible professionals" (doctors and other healthcare providers) and hospitals must achieve to qualify for CMS incentive programs. Stage 1 (2011-2012) focused on data capture and sharing; stage 2 (2014) focused on advanced clinical processes; and stage 3 (2016) focused on improved outcomes.
However, many physicians and hospitals have found the MU program to be burdensome, and in January 2016, CMS Acting Administrator Andy Slavitt said that 2016 would probably see the end of the program altogether. It would be replaced by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which emphasizes a new merit-based incentive payment system and alternative payment models (such as ACOs and patient-centered medical homes). Details on MACRA's new, streamlined regulatory approach are expected in the coming months.
Ultimately, it is hoped that MU compliance will result in better clinical outcomes. MU sets specific objectives that "eligible professionals" (doctors and other healthcare providers) and hospitals must achieve to qualify for CMS incentive programs. Stage 1 (2011-2012) focused on data capture and sharing; stage 2 (2014) focused on advanced clinical processes; and stage 3 (2016) focused on improved outcomes.
However, many physicians and hospitals have found the MU program to be burdensome, and in January 2016, CMS Acting Administrator Andy Slavitt said that 2016 would probably see the end of the program altogether. It would be replaced by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which emphasizes a new merit-based incentive payment system and alternative payment models (such as ACOs and patient-centered medical homes). Details on MACRA's new, streamlined regulatory approach are expected in the coming months.
EHR incentives & certification. HealthIT.gov. February 6, 2015.
https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectivesAccessed March 7, 2016.
Meaningful use. Centers for Disease Control and Prevention. October 11, 2012.
http://www.cdc.gov/ehrmeaningfuluse/introduction.htmlAccessed March 7, 2016.
Hayden C. Expert: end of meaningful use heralds the era of 'precision reimbursement.' Healthcare IT News. January 20, 2016.
http://www.healthcareitnews.com/news/expert-end-meaningful-use-heralds-era-precision-reimbursementAccessed March 7, 2016.
Miliard M. Meaningful use will likely end in 2016, CMS chief Andy Slavitt says. Healthcare IT News. January 12, 2016.
http://www.healthcareitnews.com/node/476236Accessed March 7, 2016.
Medicare Star Rating
Medicare uses a star rating system to measure how well Medicare Advantage and prescription drug (Part D) plans perform. Medicare scores how well plans did in several categories, including quality of care and customer service. Ratings range from 1 to 5 stars, with 5 being the highest and 1 being the lowest score. Medicare assigns plans one overall star rating to summarize the plan's performance as a whole.
Plans also get separate star ratings in each individual category reviewed: staying healthy (screenings, tests, and vaccines); managing chronic conditions; plan responsiveness and care; member complaints, problems getting services, and choosing to leave the plan; and customer service. Medicare drug plans are rated on how well they perform in customer service; member complaints, problems getting services, and choosing to leave the plan; member experience with the plan; and drug pricing and patient safety.
Plans also get separate star ratings in each individual category reviewed: staying healthy (screenings, tests, and vaccines); managing chronic conditions; plan responsiveness and care; member complaints, problems getting services, and choosing to leave the plan; and customer service. Medicare drug plans are rated on how well they perform in customer service; member complaints, problems getting services, and choosing to leave the plan; member experience with the plan; and drug pricing and patient safety.
The five-star rating system and Medicare plan enrollment. MedicareInteractive.org. 2016.
http://www.medicareinteractive.org/get-answers/overview-of-medicare-health-coverage-options/changing-medicare-health-coverage/the-five-star-rating-system-and-medicare-plan-enrollmentAccessed March 7, 2016.
Star ratings. Medicare.gov.
https://www.medicare.gov/find-a-plan/staticpages/rating/planrating-help.aspx?AspxAutoDetectCookieSupport=1Accessed March 7, 2016.
MOC: Maintenance of Certification
MOC is a process of physician certification maintenance by one of 24 approved medical specialty boards of the ABMS and 18 approved boards of the American Osteopathic Association (AOA).
The MOC process is controversial within the medical community. Proponents claim that it is a voluntary program that improves physician knowledge and demonstrates a commitment to lifelong learning, which are needed to keep abreast of rapidly changing advances in medicine. Critics claim that MOC is expensive, burdensome, not really voluntary (certification, for example, is often a mandatory requirement for hospital credentialing), and clinically irrelevant (because physicians are already required to undergo regular continuing medical education to maintain their licenses). MOC, its detractors claim, is really a money-making vehicle for the ABMS and the AOA.
The MOC process is controversial within the medical community. Proponents claim that it is a voluntary program that improves physician knowledge and demonstrates a commitment to lifelong learning, which are needed to keep abreast of rapidly changing advances in medicine. Critics claim that MOC is expensive, burdensome, not really voluntary (certification, for example, is often a mandatory requirement for hospital credentialing), and clinically irrelevant (because physicians are already required to undergo regular continuing medical education to maintain their licenses). MOC, its detractors claim, is really a money-making vehicle for the ABMS and the AOA.
Maintenance of certification (MOC). American Board of Internal Medicine. 2016.
https://www.abim.org/maintenance-of-certification/default.aspxAccessed March 5, 2016.
Maintenance of certification. Wikipedia. October 13, 2015.
https://en.wikipedia.org/wiki/Maintenance_of_CertificationAccessed March 5, 2016.
Frellick M. 2015 MOC standards reflect feedback, fail to stem critics. Medscape Medical News. January 7, 2015.
http://www.medscape.com/viewarticle/837701Accessed March 5, 2016.
Narrow-Network Plan
An insurance plan that offers consumers lower premiums but limits choice of physician. The use of narrow provider networks in health insurance plans is a cost-containment strategy that has proliferated in the new marketplaces established by the ACA. It has also become more common in Medicare Advantage commercial plans.
Insurers may offer narrow-network plans to attract price-sensitive consumers who are willing to trade network breadth for less costly premiums and other out-of-pocket payments. However, the resulting provider networks may be narrower than consumers and physicians foresaw. Physicians have also found that they have been excluded from some narrow-network plans, thus limiting their potential patient pool.
Insurers may offer narrow-network plans to attract price-sensitive consumers who are willing to trade network breadth for less costly premiums and other out-of-pocket payments. However, the resulting provider networks may be narrower than consumers and physicians foresaw. Physicians have also found that they have been excluded from some narrow-network plans, thus limiting their potential patient pool.
Polsky D, Weiner J. The skinny on narrow networks in health insurance marketplace plans. Robert Wood Johnson Foundation. June 2015.
http://www.rwjf.org/en/library/research/2015/06/the-skinny-on-narrow-networks-in-health-insurance-marketplace-pl.htmlAccessed March 7, 2016.
Research insights. Health plan features: implications of narrow networks and the trade-off between price and choice. Academy Health. December 10, 2014.
http://www.academyhealth.org/files/publications/files/FileDownloads/RIBrief0315.pdfAccessed March 7, 2016.
NCQA: National Committee for Quality Assurance
A private not-for-profit organization, the NCQA drives improvement in the healthcare system by administering evidence-based standards, measures, and voluntary accreditation programs for individual physicians, health plans, and medical groups. The NCQA builds consensus on key healthcare quality issues by working with large employers, policy-makers, doctors, patients, and health plans to decide what's important, how to measure it, and how to promote improvement.
The NCQA seal indicates that an organization has met its standards for management and quality care and service. Healthcare entities seeking to use the seal in advertising and marketing materials must pass a comprehensive review and annually report on their performance.
The NCQA seal indicates that an organization has met its standards for management and quality care and service. Healthcare entities seeking to use the seal in advertising and marketing materials must pass a comprehensive review and annually report on their performance.
National Committee for Quality Assurance. Wikipedia. January 8, 2016.
https://en.wikipedia.org/wiki/National_Committee_for_Quality_AssuranceAccessed March 7, 2016.
NQMC: National Quality Measures Clearinghouse
An initiative of the AHRQ, the NQMC is a database and website for information on specific evidence-based healthcare quality measures and measure sets. For example, there are over 20 measures on diseases, ranging from bacterial infections and mycoses to wounds and injuries.
There are 220 specific measures for cardiovascular diseases alone. In addition, the NQMC website includes expert commentaries on such topics as developing and implementing quality measures for multiple chronic conditions; tutorials on quality measures, such as selecting health outcome measures for clinical quality measurement; and a measure matrix that makes it easy to locate the desired measures in the large inventory available online.
There are 220 specific measures for cardiovascular diseases alone. In addition, the NQMC website includes expert commentaries on such topics as developing and implementing quality measures for multiple chronic conditions; tutorials on quality measures, such as selecting health outcome measures for clinical quality measurement; and a measure matrix that makes it easy to locate the desired measures in the large inventory available online.
National Quality Measures Clearinghouse (NQMC). Agency for Healthcare Research and Quality (AHRQ).
https://www.qualitymeasures.ahrq.gov/index.aspxAccessed March 7, 2016.
Patient-Centered Care
The IOM defines patient-centered care as "providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions." Patient-centered care is generally defined by or in consultation with patients rather than by physician-dependent tools and standards. The goal is to engage patients as active participants.
Rickert J. Patient-centered care: what it means and how to get there. Health Affairs Blog. January 24, 2012.
http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/Accessed March 7, 2016.
Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9:100-103.
Patient-centered care. Wikipedia. March 1, 2016.
https://en.wikipedia.org/wiki/Patient-centered_careAccessed March 7, 2016.
Institute of Medicine. Crossing the Quality Chasm: A New Healthcare System for the 21st Century. Washington, DC: National Academies Press; 2001.
PCMH: Patient-Centered Medical Home
A model for transforming how primary care is organized and delivered. A PCMH is accountable for meeting most of each patient's physical and mental healthcare needs, including prevention and wellness and acute and chronic care. This requires a team of providers, which might include physicians advanced practice nurses, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
There are specific guidelines and rules for becoming an official PCMH. Care is coordinated across the broader healthcare system, including specialty care, hospital care, home healthcare, and community services.
There are specific guidelines and rules for becoming an official PCMH. Care is coordinated across the broader healthcare system, including specialty care, hospital care, home healthcare, and community services.
Patient-centered medical home. American Academy of Family Physicians. 2016.
http://www.aafp.org/about/policies/all/pcmh.htmlAccessed March 7, 2016.
What is a medical home? Why is it important? HRSA.
http://www.hrsa.gov/healthit/toolbox/Childrenstoolbox/BuildingMedicalHome/whyimportant.htmlAccessed March 7, 2016.
What is the patient-centered medical home? American College of Physicians. 2016.
https://www.acponline.org/practice-resources/business-resources/payment/delivery-and-payment-models/patient-centered-medical-home/understanding-the-patient-centered-medical-home/what-is-the-patient-centered-medical-homeAccessed March 7, 2016.
The three-part payment model. American College of Physicians. 2016.
https://www.acponline.org/practice-resources/business-resources/payment/delivery-and-payment-models/patient-centered-medical-home/costs-benefits-incentivesAccessed March 7, 2016.