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References

ACO(Accountable Care Organization) - CMS Definition Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

Medicare Shared Savings Program - CMS Definition

FFS - Fee-For-Service (FFS) - http://en.wikipedia.org/wiki/Fee-for-service

Bundled Payment - http://en.wikipedia.org/wiki/Bundled_payment AKA episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, package pricing, or packaged pricing

Capitation - http://www.acponline.org/residents_fellows/career_counseling/understandcapit.htm

PQRS - Physician Quality Reporting System http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/

PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs).

The program provides an incentive payment to practices with EPs (identified on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]). EPs satisfactorily report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries (including Railroad Retirement Board and Medicare Secondary Payer).

PMPM - Per Member Per Month

This measure is used to assess the total cost of care population-based per member per month (PMPM) index. Total Cost Index (TCI) is a measure of a primary care provider's risk adjusted cost effectiveness at managing the population they care for. The Total Cost of Care (TCOC) includes all costs associated with treating members including professional, facility inpatient and outpatient, pharmacy, lab, radiology, ancillary and behavioral health services. For example, if a 10,000 member HMO in one month's time spends $20,000 on cardiovascular surgery, the cost on a PMPM basis would be $20,000 divided by 10,000 equaling $2 per member per month.

CMS - Centers for Medicare & Medicaid Services

HEDIS - http://www.ncqa.org/HEDISQualityMeasurement.aspx

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis.

NCQA - http://www.ncqa.org/HomePage.aspx

PCMH(Patient Centered Medical Home) - PCMH Website

Managed Care - Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts as intermediate between the person seeking care and the physician.

Claims and Claims Line Feed (CCLF)

GPRO - Group Practice Reporting Option http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html

CMS created a new group practice reporting option (GPRO) for the Physician Quality Reporting System (PQRS) in 2010. Group practices participating in GPRO that satisfactorily report data on PQRS measures for a particular reporting period are eligible to earn a PQRS incentive payment equal to a specified percentage of the group practice's total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during the reporting period.

To earn an incentive for the 2014 PQRS program year, group practices participating in GPRO may register to participate in GPRO via:

(1) Qualified PQRS registry (2) Web interface (for groups of 25+ only) (3) Direct electronic health record (EHR) using certified EHR technology (CEHRT) (4) CERHT via Data Submission Vendor (5) CAHPS via CMS-certified survey vendor (for groups of 25+ only)

External links

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