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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.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS)
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS)

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS)

MACRA is legislation signed in April 2015 that is designed to transform the basis of health care clinician payment from volume to value.1 MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.2,3 It also created bonus payments for entities participating in APMs.

Medicare Shared Savings Program

Medicare Shared Savings Program

The Medicare Shared Savings Program (Shared Savings Program or MSSP) is a program developed by CMS in 2012 that enables providers and suppliers of health care such as physicians and hospitals to set up an accountable care organization (ACO). The Shared Savings Program is a novel Medicare payment model which shifts away from the focus on volume-based reimbursement metrics and toward improved patient outcomes and increased value (value-based care). Under the MSSP, the ACO is charged with serving an assigned FFS Medicare beneficiary population, with a focus on improving patient outcomes while reducing cost of care. The Shared Savings Program holds ACOs accountable to certain standards while providing patient care, including quality, cost, and patient experience. These metrics are tied to the ACO’s reimbursement for services provided.

Patient-Centered Medical Home (PCMH)

Patient-Centered Medical Home (PCMH)

According to the Agency for Healthcare Research and Quality (AHRQ), a PCMH is a model of the organization of primary care that delivers the core functions of primary health care.1 They are also often called medical homes, primary care medical homes, medical neighborhoods, advanced primary care practices, and patient-centered health care homes. In adopting the PCMH model, primary care practices transform their practice to integrate the following functions.

Pay-for-performance

Pay-for-performance

“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.

Population Health

Population Health

Population Health refers to the outcomes of a group of individuals with similar characteristics—including the distribution of such outcomes within the group—and the role of health determinants. These health determinants can include medical care, public health, social environment, genetics, and individual behavior.1 According to the Centers for Disease Control and Prevention (CDC), population health allows for health care organizations to collaborate and improve outcomes in the community.

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