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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.

Alternative Payment Model (APM)

Alternative Payment Model (APM)

An alternative payment model (APM) is a type of reimbursement model designed to incentivize low-cost, high-value patient care and is applicable to a specific condition, care episode, or population.1 An APM is a deviation from the traditional fee-for-service approach, in which health care providers are paid for each individual service provided, which often maximizes quantity but can compromise the quality of patient care.2 In contrast, the overarching goal of an APM is to provide quality and cost-efficient patient care. Each APM has entity-specific quality measures which must be met to be reimbursed. Though APM designs and measures can vary between entities, all entities structure reimbursement plans to hold providers and organizations accountable for meeting patient-centered goals, thereby encouraging quality over quantity of care.

Case Management/Care Coordination

Case Management/Care Coordination

Case management is defined as the assessment, planning, and care coordination of services to meet a patient’s individual health care needs. Case managers often advocate for patients’ safety and positive health outcomes through appropriate care coordination and communication.1 Meanwhile, care coordination refers to the organization and planning of patient care activities and sharing of information between two or more participants who are involved with the patient’s care in order to achieve better health outcomes and provide safer care.2 Both of these terms go hand in hand to ensure patients’ unique health care needs are met and to achieve better health outcomes. If a patient's care is well-coordinated, this can avoid ER visits and hospital readmissions, decrease medical errors, and decrease health care costs.3

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

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