From the Desk of the CEO

Risk-based contracting is the act of establishing a contract between providers and payers that makes the provider (namely, the provider group) responsible for all the costs incurred in the care of empaneled health plan members. This includes not only primary care costs, but costs related to hospital visits (e.g., inpatient and emergency department), medications, and specialists. The provider is given a fixed amount of payment per member per month (PMPM) paid in advance for the delivery of all health care services to the health plan’s members, whether the patient utilizes the services or not.¹

The Plan-Do-Study-Act (PDSA) cycle is a continual, four-step model that is used in quality improvement efforts in order to test change.¹

Consumer Assessment of Healthcare Providers and Systems (CAHPS) is an Agency for Healthcare Research and Quality (AHRQ) program that has conducted research and developed standardized surveys to gather information about patients’ experiences with health plans, providers, and facilities.^1,2 CAHPS surveys contain standardized questions to ensure valid comparison of data across health care settings.³ These surveys collect patients’ perceptions of various aspects of health care including, but not limited to, communication with doctors, ability to schedule appointments in a timely manner, level of coordinated care, and ease of access to information, etc.¹

“Incident to” services are defined as services that are furnished as an integral, although incidental, part of a physician’s professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.^1,2 In the Medicare program administered by the Centers for Medicare and Medicaid Services (CMS), auxiliary personnel such as pharmacists; nurses; and nonphysician practitioners (NPPs) like physician assistants, nurse practitioners, or clinical nurse specialists can provide some services traditionally performed by physicians in certain practice settings under incident to services arrangements.^1,2 These services must be part of a patient’s normal course of treatment and are billed by the CMS-recognized provider under that provider’s National Provider Identifier (NPI).^1,2

The Hospital Outpatient Prospective Payment System (HOPPS) is a payment system that was established in August 2000 by government legislation to create prospectively set payment rates for designated hospital outpatient services. It is administered by the Centers for Medicare and Medicaid (CMS).