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Learn The Lingo

Learn the Lingo: Key Terms for Navigating the Value Based Care World

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG.

Empanelment

Empanelment

Empanelment is the process of assigning patients to primary care providers (PCPs) and care teams within a value-based payment model such as a Patient Centered Medical Homes (PCMH) or Accountable Care Organization (ACO).1 Patient and family preference may be considered during the assignment as patients continue to visit their PCP or care team for wellness visits.1 The PCP leads the team and works collaboratively with all members.1

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)

Federally Qualified Health Center (FQHC)

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

Fee-for-service

Fee-for-service

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.1

Healthcare Effectiveness Data and Information Set (HEDIS)

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information needed for reliable comparison of health plan performance.1-3 Performance is evaluated using over 90 measurements across 6 domains of care: effectiveness of care, access/availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems.2 Claims and survey data are aggregated and analyzed retrospectively to depict the quality of care and customer service delivered to patients.

Hospital Outpatient Prospective Payment System (HOPPS)

Hospital Outpatient Prospective Payment System (HOPPS)

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). The following services are covered under HOPPS1:

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