Learn The Lingo
APhA Staff
There’s a continuing trend away from fee-for-service care in favor of care models that emphasize outcomes over volume of services provided. These value-based models could provide better, more cost-efficient patient outcomes, but this also means there are a lot of new terms to learn. APhA–APPM’s Medical Home/ACO Special Interest Group is here to help by adding more definitions for key terms related to value-based care models, which are available on their Learn the Lingo page on pharmacist.com. Here are some brief summaries.
Alternative payment model (APM): a type of reimbursement model designed to incentivize low-cost,
high-value patient care, applicable to a specific condition, care episode, or population. Though APM designs and measures can vary between entities, all entities structure reimbursement plans to hold providers and organizations accountable for meeting patient-centered goals, encouraging quality over quantity of care.
Care coordination: the organizing and planning of patient care activities and sharing of information between two or more participants involved with the patient’s care to achieve better health outcomes and provide safer care. Care coordination also consists of providing patients with community resources and taking into account the patient’s individual goals. It is strongly linked with case management, as both combat the disjointed nature of current health care systems and standardize the care that a patient may be receiving from multiple settings, especially when it comes to chronic conditions.
Case management: the assessment, planning, and coordination of services to meet a patient’s individual health care needs. Case managers often advocate for patients’ safety and positive health outcomes through appropriate care coordination and communication. Both case management and care coordination emphasize that improving the quality of a patient’s care is a team effort and that the proper coordination of care across a continuum of services is crucial to such quality of care.
Empanelment: the process of assigning patients to primary care providers (PCPs) and care teams within a value-based payment model such as Patient Centered Medical Home (PCMH) or an Accountable Care Organization (ACO). Patient and family preference may be considered during the assignment as patients continue to visit their PCP or care team for wellness visits. The PCP leads the team and works collaboratively with all members. Empanelment is the basis of population health management because it removes the focus from those who attend office visits. The PCMH accepts responsibility for the entire panel of patients and works to improve outcomes for all.
Federally Qualified Health Center (FQHC): a community-based outpatient clinic that provides comprehensive primary care services to a designated Medically Underserved Area (MUA) or Medically Underserved Population (MUP). These MUAs and MUPs can have characteristics like a large older adult population, high poverty or infant mortality rates, or a lack of PCPs. The comprehensive services of an FQHC can include preventive care, dental care, chronic disease management, mental health and substance abuse, or hospital and specialty care. The criteria for certification as an FQHC includes
- offering a sliding fee payment scale determined by a patient’s ability to pay for services based on annual income and family size
- having an ongoing quality assurance program
- having a governing board of directors
A variety of health care providers such as physicians, physician assistants, dentists, certified nurse-midwives, clinical psychologists, clinical social workers, and pharmacists can provide services at an FQHC.
Fee-for-service: a traditional health care model where health care providers and hospitals are reimbursed based on the number of services and procedures they provide. This model focuses on volume of services provided.
While this is a common reimbursement model for health care services, this model may result in high out-of-pocket costs for individuals or high costs for their health plan and can result in uneven care between patients, excessive services, and health care inflation.
Hospital Outpatient Prospective Payment System (HOPPS): a payment system established in August 2000 by government legislation to create prospectively set payment rates for designated hospital outpatient services. The following services are covered under HOPPS:
- Designated hospital outpatient items and services
- Certain Medicare Part B services for hospital inpatients when Medicare can’t pay under Part A
- Community Mental Health Centers partial hospitalization services and certain inpatient hospital services Medicare Part B pays
- Home Health Agency hepatitis B shots and their administration, splints, casts, and antigens for patients not under a home health plan of care or for hospice patients for treatment of non-terminal illness or related conditions
- Comprehensive Outpatient Rehabil-itation Facility provided hepatitis B shots and their administration
- Initial Preventive Physical Exami-nations within the first 12 months of Medicare Part B coverage
Telehealth: the exchange of medical information through electronic communication to improve a patient’s health. Although often used interchangeably with “telemedicine,”
telehealth encompasses a broader array of services and activities. Telemedicine solely describes the use of telecommunication to provide health care directly to a patient, while telehealth includes talking to a doctor live via phone or video chat, sending/receiving secure messages between providers, and remote monitoring of medical devices.
Telehealth is one element of digital health, which is a broader term that includes disruptive technologies that provide digital and objective data accessible to both caregivers and patients, like wearable devices and mobile health technologies. ■
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Want to learn more?
See www.pharmacist.com/Practice/Practice-Resources/Learn-the-Lingo for a deeper discussion of value-based care terms.