Accountable Care Organizations (ACOs)
Medicare contracted groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.
In the primary care practice, involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care. There are two ways of achieving coordinated care: using broad approaches that are commonly used to improve health care delivery to segmented groups of patients based on common diagnoses or chronic conditions, and using specific care coordination activities that are targeted at individual patients and their specific needs.
A term that describes the integration of clinical information and healthcare delivery services from distinct entities. Clinical integration refers to the coordination of care across a continuum of service disciplines, including preventive, outpatient, inpatient acute hospital care, post-acute and sub-acute care, including skilled nursing, rehabilitation, home based services, and hospice and palliative care to improve the value and the efficacy of the care provided. Through risk stratification, the most chronically ill, frail, and high-risk patients are targeted and referred to case management or disease management programs where their condition(s) is heavily monitored. Health information is made available to the providers within a clinically integrated network through the development of a clinical data repository to ensure the collection and dissemination of all relevant patient data. The collection of these integrated providers is often referred to as a Clinically Integrated Network (CIN). Additional types of clinically integrated systems include Community Care Organizations (CCOs), and Accountable Care Organizations (ACOs) that serve Medicare populations.
Health Information Exchange (HIE)
The mobilization of healthcare information electronically across organizations within a region, community or hospital system. In practice the term HIE may also refer to the organization that facilitates the exchange. HIE provides the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care.
Per-Member, Per-Month (PMPM)
It can refer to capitation payments, like in an HMO (Health Maintenance Organization) where an insurance company pays a PMPM amount to a primary care physician based on the number of members on the physician’s panel. It can also refer to a measure of cost. Total yearly healthcare costs for a group divided by the number of members divided by 12 months in a year calculate healthcare costs PMPM.
Patient-Centered Medical Home (PCMH)
Away of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care. Elements of PCMH include:
- Physician-led practice: Patients have access to a personal physician who leads the care team within a medical practice.
- Whole-person orientation: The care team provides comprehensive care, including acute care, chronic care, preventive services, and end-of-life care, at all stages of life.
- Integrated and coordinated care: Practices take steps to ensure that patients receive the care and services they need from the medical neighborhood, in a culturally and linguistically appropriate manner.
- Focus on quality and safety: Practices use the quality improvement process and evidence-based medicine to continually improve patient outcomes.
- Access: Practices commit to enhancing patients’ access to care.
- Providing continuous, comprehensive and coordinated care.
- The NCQA (National Committee for Quality Assurance) recognizes practices that meet established standards for participation in the NCQA PCMH program.
The health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. It is an approach to health that aims to improve the health of an entire human population.
Incentives place a degree of financial responsibility on the providers in hopes of improving care management and limiting unnecessary expenditures, by comparing the actual total costs of care to a historical baseline, and agreeing to split the difference between the payer and the providers.
Also known as Administrative Services Only (ASO) is a self-insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds. This is different from fully insured plans where the employer contracts an insurance company to cover the employees and dependents. In self-funded health care, the employer assumes the direct risk for payment of the claims for benefits. The terms of eligibility and covered benefits are set forth in a plan document which includes provisions similar to those found in a typical group health insurance policy. Unless exempted, such plans create rights and obligations under the Employee Retirement Income Security Act of 1974 (“ERISA”).
Framework that serves as the foundation for organizations and communities to navigate the transition from a focus on health care to optimizing health for individuals and populations. Improving the US health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population. (Berwick DM, Nolan TW, Whittington J. Health Affairs. 2008 May/June)