Glossary of Accountable Care Organization Related Terms
The medical industry is notorious for having abbreviations. Here is a short list of medical industry terms related to accountable care organizations that will help bridge some gaps of communication.
Value Based: reimbursement model that promotes quality over quantity, aims for quality at lower cost, promotes cost control and quality gains, reimbursement that ties payments to quality, alternative to traditional fee-based or fee-for-service model. Takes into account access, price, efficiency and alignment of incentives.
Value Based Healthcare: aims to provide better patient care (outcome), improve population health management strategies, and reduce healthcare costs. Providers are incentivized to use evidence-based procedures, engage patients, optimize EMR software and use data analytics (performance informatics) to get rewarded with optimum reimbursement for their services.
Medicare Shared Savings Program (MSSP):
- Created by CMS (Centers for Medicare and Medicaid Services) at request by the Affordable Care Act to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service beneficiaries and reduce unnecessary costs.
Promotes accountability for care of Medicare FFS beneficiaries, requires coordinated care for all services provided under Medicare FFS. Encourages investments in infrastructure and redesigned care processes.
Rewards ACOs that lower health car costs while meeting quality care standards.
- Provider participation is optional.
Requires that ACOs promote evidence-based medicine, promote patient engagement, report internally on quality and cost metrics, provide coordinated care between primary care physicians, specialist and acute and post-acute providers.
MACRA (Medicare Access and CHIP Reauthorization Act):
Combines parts of the Physician Quality Reporting System (PQRS), Value- based Payment Modifier (VBM), and Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment (MIPS).
Focused on quality, value and accountability.
Rewards health care providers for giving better care instead of more service.
Alternative Payment Model (APM):
- Combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment (MIPS).
- Focused on quality, value and accountability.
- Rewards health care providers for giving better care instead of more service.
Alternative Payment Model (APM)
- Gives added incentive payments to provide high-quality and cost efficient care
- Can apply to a specific clinical condition, a care episode, or a population
- Advanced APMs are a subset of APMs and can earn a 5% incentive payment by improving patient care and taking on risk related to their patient outcomes.
Merit-Based Incentive Program (MIPS)
- Performance-based payment system that is one of participation tracks under the Quality Payment Program, which moves Medicare Part B providers to a performance-based payment system.
- Determines Medicare payment adjustments using a composite performance score based on 4 performance categories:
- Quality (weighted 50%)
- Resource use (weighted 10%)
- Clinical practice improvement activities (CPIA) (weighted 15%)
- Meaningful Use of certified electronic health records (EHR) technology (weighted 25%)
- Providers will have a “MIPS score” (0 to 100)
- Performance for MIPS started Jan 1, 2017
Accountable Care Organization (ACO)
- Organizations that aims for the goal of value-based care, promotes more effective care coordination to treat patients proactively and reduce expensive hospitalizations, holds organizations accountable for cost control and quality gains, ties payments to quality metrics of quality healthcare, promoted by the Affordable Care Act.
Quality Payment Program (QPP)
- Part of MACRA
- Helps providers focus on care quality
- Has 2 tracks you can choose from: MIPS and APMs (Advanced Alternative Payment Models)
- Ends the Sustainable Growth Rate formula – provides tools, models and resources to provide best patient care possible
- Started Jan 1, 2017
- Program will have ramp-up period in the beginning with less financial risk for providers
- The science of processing performance data for storage, retrieval and optimal use of information for better communication, problem-solving and decision-making for better outcomes.
- The use of information to enhance performance.
- Used as a part of the information management optimization process
- In value-based healthcare is used to deliver better healthcare at lower cost
- Performed by information technology and individuals working together
- In value-based healthcare, Performance Informatics utilizes healthcare information technology to improve patient outcomes
- A statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs.
- An actuarial tool used to calibrate payments to health plans or other stakeholders based on the relative health of the at-risk populations
Collaborative Accountable Care (CAC)
- Healthcare philosophy that promotes quality care with lower costs through collaboration between payers, physicians, and patients.
- Requires accountability for achieving improved health, affordability and patient experience.
- ACOs collaborate with physician partners, listening to what physicians needs are and what their definitions of success are to collectively decide how work together to deliver a better quality service and product for patients
- Aim to achieve Triple Aim: 1) Quality Improvement (clinical quality) 2) Best possible patient experience 3) Lower Costs (economic results)
- Aligns financial incentives to deliver best possible quality and value
- Use specific actionable information for physicians on their patients
- Has care coordinators – resources that help facilitate patient care
Independent Physician Association (IPA)
- A business entity organized and owned by a network of independent physician practices formed to reduce overhead and/or gain business ventures such contracts with employers, ACOs and MCOs (managed care organizations).
- Provides opportunities to provide unique, innovative and collaborative health care delivery
- Promotes collaboration between multiple entities such as specialty practices, imaging centers, home health agencies and hospital systems.
- Has benefits such as:
- Appropriate alignment of physicians’ financial incentives
- Practice administration and management run efficiency
- Influences medical and provider community
- Peer Support
- Optimized facilities
- Enhanced ability to negotiate favorable contracts with other entities such as MCOs, ACOs, radiology, laboratory, and hospital systems
- Autonomy and local financial and care management control in managed care
- Improved services, including, expanded hours, urgent care, outreach services for prevention, telephone triage, and follow-up expertise
- Promotes collaboration between multiple entities such as specialty practices, imaging centers, home health agencies and hospital systems.
- Where an organization acts as a neutral messenger between managed care payers and physician providers. The messenger conveys information on fees and terms that a physician is willing to accept. Each physician is an independent agent, and chooses terms on an individual basis. The messenger process is not a joint negotiation of fees.
- Primary advantage of messenger model is a single-point communications conduit for providers and payers
Management Service Organization (MSO)
- An organization owned by groups of physicians, a physician hospital joint venture, and investors in conjunction with physicians or health plans. MSOs provided practice management and administrative support services to individual physicians and group practices.
- Entities designed to help physicians with administrative or non-medical work involved in running a practice. Ensures lowest pricing on supplies and services.
- An MSO can assist a practice with: operational issues, financial management, human resources, staff education and training, coding, billing, collections, discounts and provision of EHRs and medical equipment, regulatory compliance, credentialing and contract management, savings with group purchasing.
- Relieves physicians of non-medical business functions so that they can focus on the clinical aspects of their practice
- Purchases their services as a group so they have economies of scale and those savings (such as from preferred pricing on everything from medical supplies to healthcare insurance) can be passed down to physicians.
Business Associate Agreement (BAA)
- A contract between a HIPAA-covered entity and a HIPAA business associate (BA). The contract protects personal health information (PHI) in accordance with HIPAA guidelines.
- HIPAA business associates include: when a health plan uses a third-party administrator to help with claims processing, if a CPA firm provides accounting services to a healthcare provider and they have access to protected health info, when a hospital has a consultant perform utilization reviews, when a physician uses an independent medical transcriptionist’s services, when a pharmacy benefits manager manages a health plan’s pharmacist network
Physician Participation Agreement (PPA)
- An agreement a physician completes to participate in a Medicare program which spells out meaning of assignment, effective date, term and termination of agreement.
- MSSP accountable care payment model that has less risk for providers than Tracks 2 or 3, designed to encourage more practices, especially small practices, to transition to performance-based risk. This model also allows all hospitals, including small rural hospitals, to participate.
- Model opportunity begins 2018.
- Allows providers to join Advanced Alternative Payment Model (APM) to improve patient care and potentially earn an incentive payment under the Quality Payment Program (QPP)
- CMS used stakeholder feedback (including from physician groups) to design this model.
- ACOs can join as part of 2018, 2019, 2020 Shared Savings Program application cycles
- Based on Track 1 but incorporates elements of Track 3 including “prospective beneficiary assignment to allow ACOs to know in advance the patient population for which they are responsible; the introduction of downside risk (which is lower than Track 3), and option to request a Skilled Nursing Facility 3-Day Rule Waiver” to better coordinate and deliver high quality care”.
- Good article about Track 1+ here
- Tracks 2 and 3 options under CMS MSSP (Medicare Share Savings Program) (in addition to one-sided (Track 1)) that ACOs can participate in
- Alternative payment healthcare models are moving the risk from government (one-sided) to shared risk (two-sided) to transform healthcare
- In a two-sided risk model an ACO would share in some portion of savings (and be at risk for the same portion of spending over the target)
- Good article about Two-sided risk here
- Means for allocating risks and providing incentives in the PPP (public-private partnership) contract. A useful way to approach the design of the payment mechanism is to start with basic/ideal structure for the Authority.
Group Practice Reporting Option (GPRO)
- Allows clinicians to report to CMS as a group (of two or more clinicians) under a TIN (tax identification number) that’s registered as a group. Clinicians who do this must register their TIN with CMS to report MIPS data through the group practice reporting option (GPRO) by June 30, 2017.
Consumer Assessment of Healthcare Providers and Systems (CAHPS ®)
- CMS surveys that ask patients to report on and evaluate their experience with health care.
- Cover topics that patients say are important to them in healthcare and focus on aspects of healthcare quality such as provider communication skills, ease of access to health care services, understanding medical instruction, and the coordination of the healthcare needs.
- Ask patients about their experiences with and their ratings of provider, hospital, home health care agency, hospital, doctor, health and drug plan, and other aspects.
- Individuals and organizations use the survey results to evaluate and compare health care providers and to improve health care quality.
- Results are publicly reported and some surveys affect payments to CMS providers.
Advancing Care Information (ACI)
- Replaces the Meaningful Use program for Medicare physicians
- Applies to all physicians and other clinicians participating in MIPS
- Streamlines measures and emphasizes interoperability, information exchange, and security measures. Clinical Decision Support and Computerized Provider Order Entry are no longer required.
- Customizable – physicians or clinicians can choose which best measures fit their practice
- Flexible EHR (electronic health record) measurement and quality reporting
- Aligned with other Medicare reporting programs. No need to report quality measures as part of this category.
- ACI Fact Sheet here
Meaningful Use (MU)
- Using certified electronic health record (EHR) technology to improve quality, safety, efficiency, and reduce health disparities, improve patient engagement, care coordination and population and public health, maintain privacy and security of patient health information.
Centers for Medicare & Medicaid Services (CMS)
- Federal agency of the U.S. Department of Health and Human Services (HHS) that administers the Medicare and Medicaid programs, partnering with state governments to administer Medicaid, CHIP, and “health insurance portability standards.”
- has developed accountable care organization, bundled payments, and patient-centered medical homes models for providers to participate in value-based care model.
Office of Inspector General (OIG)
- Office under the Department of Health and Human Services to fight waste, fraud and abuse in Medicare, Medicaid and other Health and Human Services (HHS) programs. Performs audits, investigations and evaluations in order to establish policy recommendations for decision-makers and the public.
- Established by act of Congress in 1976
Sustainable Growth Rate (SGR)
- Maximum rate of growth that a firm can sustain without having to increase financial leverage or look for outside financing
- how large and how quickly a firm can grow without borrowing more money
- SGR = ROE (Return on Equity) x (1-dividend-payout ratio)
Clinical Practice Improvement Activity (CPIA)
- One of the 4 performance categories used to determine Medicare payment adjustments using a composite performance score.
- Clinical practice improvement activities (CPIA) are weighted 15% for the score.
- Each activity in the CPIA activity list is worth a certain number of points
- Must achieve 60 points to get maximum credit
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