Care Models
As the shift toward value-based payment models continues, there are new ways for pharmacists to improve patient care in medical homes, accountable care organizations, and other innovative care models. To help you take advantage of these opportunities, APhA’s Medical Home/ACO Special Interest Group has collected definitions for key terms commonly used regarding value-based models that are accessible on a new Learn the Lingo page on pharmacist.com.
Accountable Care Organization (ACO): a group of health care providers and hospitals partnered to provide high-quality, coordinated care and decrease overall health care costs for a defined population (e.g., Medicare recipients) with the goal of sharing these savings.
Bundled payment: an alternative reimbursement model designed to move from traditional fee-for-service (FFS) payment models to value-based care. In this system, all providers and/or health care facilities associated with a patient in a specific clinical episode (e.g., hospital stay, surgery, or treated condition) are paid in a single fixed amount called a “target price.” Providers and facilities share in the financial risks and associated with the clinical episode.
Capitation: a fixed amount paid in advance to the health care provider for delivery of health care services. This amount is fixed per patient per unit of time and depends on the services provided, number of patients involved, and duration of time; it is often set at per member, per month (PMPM) or per member, per year (PMPY).
Healthcare Effectiveness Data and Information Set (HEDIS): a comprehensive set of standardized performance measures that allows purchasers and consumers to compare the performance of health plans.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): legislation that transitioned health care clinician payment from the volume-based model to a value-based one. It created the Quality Payment Program (QPP) and Merit-based Incentive Payment System (MIPS).
Medicare Shared Savings Program (Shared Savings Program or MSSP): a program that enables health care providers and suppliers (e.g., physicians and hospitals) to set up ACOs. It also holds ACOs accountable to certain standards while providing patient care, including quality, cost, and patient experience.
Merit-based Incentive Payment System (MIPS): a system in which clinicians receive payment adjusted payment for services provided to Medicare patients. The adjustments are based on 4 categories: quality, cost, improvement activities, and promotion of interoperability.
Patient-Centered Medical Home (PCMH): an organizational model that in which primary care practices deliver the core functions of primary health care:
- Comprehensive care
- Patient-centered care
- Coordinated care
- Accessible services
- Quality and safety
These are also called medical homes, primary care medical homes, medical neighborhoods, advanced primary care practices, and patient-centered health care homes.
Population health: the outcomes (including their distribution) of a group of individuals with similar characteristics and the role of health determinants. These health determinants include medical care, public health, social environment, genetics, and individual behavior.
Primary Care First/Seriously Ill Population: a set of payment model options that financially incentivize value and quality of care for Medicare beneficiaries in primary care settings, especially those with complex medical conditions. Its principals are similar to those of the current Comprehensive Primary Care Plus (CPC+) model, especially financially rewarding improvement in health outcomes, and decreasing administrative burden.
Public health: the organization and education of individuals as well as public and private communities to prevent disease and promote health. Its primary aims are prevention of disease and promotion of health.
Social determinants of health (SDOH): conditions in the living and working environments that affect a wide range of health and quality-of-life outcomes.
These factors impact a patient’s access to and understanding of health care as well as the extent to which a patient or population can engage with health care and live healthily.
Triple Aim: a framework of approaching health care that prioritizes enhancing patient experience, improving population health, and reducing costs.
Quadruple Aim: an expansion of the Triple Aim to include an additional goal of improving the work life of health care providers.
This additional aim focuses on the work life of clinicians and staff to create a more symbiotic relationship between patients and health care providers.
Quality Payment Program (QPP): a program that rewards high-value, high-quality Medicare clinicians with payment increases while reducing payments to clinicians who do not meet performance standards. It repeals previous payment formulas that used the FFS model.
Value-based programs: programs that reward health care providers with incentive payments for the quality of care provided to Medicare recipients. These programs align with the Triple Aim.
Resources
Want to learn more?
See www.pharmacist.com/Practice/Practice-Resources/Learn-the-Lingo for deeper discussion of value-based care terms.