ACA – Affordable Care Act
ACO – Accountable Care Organization. In some contexts, this term refers specifically to groups taking part in one of three Medicare’s ACO programs (Shared Savings Program, Advance Payment ACO Model, or Pioneer ACO Model), but it is also used generically for a collection of providers (clinicians, hospitals) that contract as a group to provide coordinated care, usually with some kind of financial incentives for reducing costs and improving quality.
ACT – Assertive Community Treatment. “A team treatment approach designed to provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness such as schizophrenia.” (actassociation.org)
AMH – Addictions and Mental Health Services. Oregon state agency under the Oregon Health Authority.
APM – Alternative Payment Model (method, mechanism). Refers to a way of paying health care providers that is different from fee-for-service system. See Payment Methods table. Examples include global payments and bundled or episodic payments. Other models that retain fee-for-service payment but withhold or add a small percentage (such as shared savings or pay-for-performance) are also often called APMs.
AQC – Alternative Quality Contract. An alternative contracting model between Blue Cross Blue Shield of Massachusetts and providers where providers share risk with BCBS within a modified global budget. Started in 2009.
BH – Behavioral Health. Usually includes mental health treatment, treatment related to health behaviors, and substance-abuse or addiction treatment
Capitation – Payment based on a per-member, per-month basis rather than on individual procedural charges.
Carve-Out – Removal of a sub-category of care from a more general coverage plan or budget. For example, mental health care is often “carved out” of general health coverage and paid through separate funds.
CCO – Coordinated Care Organization
CHC – Community Health Center
CIN – Clinically Integrated Network. A health network working together, using evidence-based protocols and measures, it improve patient care, decrease cost, and demonstrate value to the market. The network focuses on a specific target population, much like an ACO.
CMI – Case-Mix Index. Informally, a measure for “how sick” a hospital’s patients are relative to patients with the same diagnosis at other hospitals. CMI calculations are based on the Center for Medicare & Medicaid Services’
DRG – Weighting system and take into account principal and secondary diagnoses, age, procedures performed, comorbidities and complications, discharge status and gender.
CMS – Centers for Medicare & Medicaid Services (United States)
DME – Durable Medical Equipment
DRG – Diagnosis-Related Group. A system for grouping inpatient services into one of about 500 categories for payment purposes, based on the primary diagnosis. Designed for Medicare, the system is also used in contracting by many private and state-levels payers. Beginning in 2007, the Centers for Medicare & Medicaid Services added a severity-of-illness component to the system, creating the Medicare-severity DRG (MS-DRG).
EHR – Electronic Health Record
EMR – Electronic Medical Record
ERISA – Employee Retirement Income Security Act. Federal law passed in 1974 to regulate employer self-funded pension and health-insurance plans. Health policies that fall under ERISA are exempted from state legislation.
FFS – Fee-for-Service. Form of health care payment.
FQHC – Federally Qualified Health Center. Organizations receiving enhanced Medicare and Medicaid support that serve underserved areas or populations, offer sliding-scale fees, and meet other requirements spelled out in the US Public Health Service Act.
Fully-Insured Employer – Employer that contracts for coverage with an insurer that then bears all risk if employee claims exceed projected amounts.
Global Payment – Payment method where a “global” dollar amount is contracted for care of a population.
GPRO – Group Practice Reporting Option. An internet-based reporting mechanism for quality data. GPRO is pre-populated with a sample of data and serves as the data collection tool for groups to use in collecting and submitting data to CMS.
HEDIS – Healthcare Effectiveness Data and Information Set. A set of clinical quality performance measures established by the non-profit National Committee for Quality Assurance and often used as metrics in health care contracting.
HIE – Health Information Exchange
HIT, Health IT – Health Information Technology. Includes electronic health or medical records and other systems providers use to record and share data on patients and services.
IPA – Independent Physicians Association (usually; for Portland, Interhospital Physicians Association). Regional professional organization of doctors which may facilitate contracting arrangements but is limited by federal anti-trust laws.
MHO – Mental Health Organization
MLR – Medical Loss Ratio. The proportion of dollars paid by a health care payer that goes to actual medical services (excluding profit and administrative costs).
NPI – National Providers Identifiers
NTHW – Non-Traditional Health Worker (sometimes also “Traditional Health Worker”). A health care worker who does not hold a standard clinical license such as MD, nurse practitioner, or physician’s assistant. In Oregon, this category is explicitly community health workers, peer wellness and peer support specialists, personal health navigators, and doulas.
P4P – “Pay for Performance.” A payment arrangement in which providers are rewarded for meeting pre-established targets for delivery of health care services.
PBM – Pharmacy Benefits Manager
PCP – Primary Care Provider
PCPCH – Patient-Centered Primary Care Home (also PCMH for “primary care medical home”)
PEBB – Public Employees Benefit Board. The group within Oregon state government responsible for contracting for state employee benefits.
PMPM – Per-Member, Per-Month. In capitated or global-budget health care purchasing, the dollar amount paid for each patient covered for a given month.
Reinsurance – (Also called “stop-loss”) For self-insured employers, a back-up insurance plan providing coverage for exceedingly higher-than-projected employee health claims.
Risk-Adjustment – Statistical or actuarial means of compensating for differences in risk between two dissimilar groups. For example, the federal health exchange uses risk adjustment to compute additional compensation for health plans that enroll less-healthy, higher-risk members.
Self-Insured Employer – Employer that pays employee health claims using its own funds and is at risk if employee expenses exceed projected amounts. A third-party administrator (TPA) is often used to negotiate contracts and process claims.
SDH – Social Determinants of Health
Service Line – Department or group of services within a hospital or health care system (for example, orthopedics or maternity)
SIM – State Innovation Model. Centers for Medicare & Medicaid Innovation grant initiative supporting Oregon’s coordinated care model and its spread beyond Medicaid.
SOL – Severity of Illness. Formally, “the extent of physiologic decompensation or organ system loss of function,” rated from minor to extreme, within a given diagnosis-related group.
SPMI – Severe and Persistent Mental Illness
THW – Traditional Health Worker. See “Nontraditional Health Worker.”
TPA – Third-Party Administrator. Type of company often hired by employers with self-funded health insurance to handle claims processing and administration.
Withhold – Portion of payments in a contract that are “held back” unless certain goals (such as quality measures or spending targets) are reached. Withheld funds serve as an incentive for reaching goals. May exist at multiple levels in a system (for example, the state withholds 2% from CCOs for a quality pool, while individual CCOs may withhold a percentage of payments from physician groups unless they reach spending targets).