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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.

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.

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basis of health care clinician payment from volume to value.1 MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.2,3 It also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

Quadruple Aim
Quadruple Aim

Quadruple Aim

Definition: Quadruple Aim is the expansion of the Triple Aim (enhancing patient experience, improving population health, and reducing costs) to include an additional goal of improving the work life of health care providers.1 Organizations view this expansion in different ways, but the Institute for Healthcare Improvement calls this new aim “Joy in Work.”1 Many health care organizations have adopted the framework of the Triple Aim, but the stressful work life of clinicians and staff has proven to play a large role in the ability to achieve and maintain the 3 aims. In primary care, the adoption of the Triple Aim has enhanced the patient experience, but resources are lacking to help providers and staff maintain these overarching goals. Professional burnout and reduced job satisfaction have hindered the ability of providers and staff to provide quality care.2 Therefore, a fourth aim focusing on the improvement in work life of clinicians and staff has been proposed to create a more symbiotic relationship between patients and health care providers.

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