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.

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basis of health care clinician payment from volume to value.¹ MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.^2,3 It also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.

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.

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.

According to CMS, "value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare."¹ Value-based programs support CMS' three-part aim, a strategy that targets improved health care at an individual level, improved health of the population, and lower costs.