From the Desk of the CEO

“Pay-for-performance (P4P) is an umbrella term for initiatives aimed at improving the quality, efficiency, and overall value of health care.”¹ It is a term involving payment models that tie reimbursement to metric-driven outcomes, practice guidelines, and patient satisfaction in order to improve the overall quality and value of health care. There are numerous quality metrics that can be utilized, with the majority spanning across 4 domains: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk populations. The metrics used are publically reported, creating transparency and further incentivizing organizations to protect and strengthen their reputations. Both the Centers for Medicare and Medicaid Services (CMS) and commercial payers have created P4P models in order to play a role in the national strategy to transition health care to value-based medicine.

Case management is defined as the assessment, planning, and care 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.¹ Meanwhile, care coordination refers to the organization and planning of patient care activities and sharing of information between two or more participants who are involved with the patient’s care in order to achieve better health outcomes and provide safer care.² Both of these terms go hand in hand to ensure patients’ unique health care needs are met and to achieve better health outcomes. If a patient's care is well-coordinated, this can avoid ER visits and hospital readmissions, decrease medical errors, and decrease health care costs.³

A Federally Qualified Health Center (FQHC) is a community-based outpatient clinic that provides comprehensive primary care services to a designated Medically Underserved Area (MUA) or Medically Underserved Population (MUP).¹ Defining characteristics of MUAs and MUPs can include a large elderly population, high poverty, infant mortality rates, or a lack of primary care providers.² 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.³ FQHCs are eligible to receive funding from the Health Resources & Services Administration (HRSA) in addition to reimbursement from Medicare and Medicaid if they meet certain criteria.¹ The criteria for certification as a 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, and having a governing board of directors.⁴ 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.⁵

An alternative payment model (APM) is a type of reimbursement model designed to incentivize coordinated, low-cost, high-value patient care and is applicable to a specific condition, care episode, type of provider, or population.¹ An APM is a deviation from the traditional fee-for-service approach, in which health care providers are paid for each individual service provided, which often maximizes quantity but can compromise the quality of patient care.²

Fee-for-service (FFS) is a traditional health care model in which 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, as opposed to focusing on quality outcomes.