30-Day Post-Operative Infection Rate
Any infection that occurs within 30 days of operation and may be related to the operation itself or the postoperative course. To calculate:
- # of post-operative infections [in patients tied to value-based contracts] within 30 days of operation
- Total # of patients [tied to value-based contracts]
Advanced Alternative Payment Model (APM)
A payment approach to paying for medical care that holds providers accountable for achieving specific quality performance goals in an efficient manner. In turn, group practices participating in an APM receive added incentive payments to achieve those goals. APMs can apply to a specific clinical condition, a care episode, or a patient population.
CMS Merit-based Incentive Payment System (MIPS)
Eligible clinicians are subject to upward, neutral, or downward payment adjustments based on performance in four performance categories: quality, cost, promoting interoperability (formerly advancing care information), and improvement activities.
Covered Lives
The number of people (and their dependents) enrolled in a particular health insurance program.
Emergency Department (ED) Utilization
Patients who utilized the emergency department and is discharged from there.To calculate:
- # of inpatient and/or outpatient ED admissions [for patients tied to value-based contracts]
- Total # of patients [tied to value-based contracts]
Generic Dispensing Rate (GDR)
The number of generic prescriptions filled divided by the total number of prescriptions filled.
Hierarchal Condition Category (HCC) Coding
A risk-adjustment model developed by the Centers for Medicare & Medicaid (CMS) to pay differentially based on disease burden and demographics. HCC relies on ICD-10 coding, which are grouped into categories and assigned a risk factor. There is weighting, or hierarchy, which assigns higher values to more serious conditions, in addition to demographic factors (such as age and gender). Two conditions in the same category are counted only once. Using the HCC model, the condition must be reported annually to be credited to that patient.
Hospital 30-Day Readmission Rate
Patients readmitted to the hospital within 30 days or less of being discharged from a previous hospital stay. To calculate:
- # of patients [tied to value-based contracts] with hospital readmissions within 30 days
- Total # of patient hospital discharges [tied to value-based contracts]
Hospital 30-Day Readmission Rate
Patients admitted to the hospital for an extended stay. To calculate:
- # of patient hospital admissions [tied to value-based contract]
- Total # of patients [tied to value-based contracts]
Reimbursement Methodologies
Bundled Payment (may also be known as “episode-based payment”): A method of reimbursement where a single comprehensive payment covers all services related to an episode of care. If actual costs exceed the payment amount, the provider is accountable for the difference.
Full capitation (may also be known as “global capitation”): A method of reimbursement where providers may receive a fixed amount of money per patient over a defined period (such as per member per month) covering all health care services, such as primary care, hospitalizations, and specialist care. Providers are responsible for costs exceeding the fixed amount. However, they are also able to receive financial gains when costs are below the fixed amount.
Partial capitation: A method of reimbursement where providers may receive a fixed amount of money per patient over a defined period (such as per member per month) where a set of services, such as laboratory or primary care, may be covered. However, services provided outside of scope are reimbursed using fee-for-service.
Shared risk (may also be known as “upside and downside” or “two-sided”): A method of reimbursement where providers share in savings and in potential losses. When the actual cost of care exceeds the projected cost, the provider is accountable for the excess costs. However, when the actual cost of care is below the projected costs, the provider receives a percentage of the difference.
Shared savings (may also be known as “upside only” or “one-sided”): A method of reimbursement where providers share in savings but not risk. When the actual cost of care is below the projected costs, the provider receives a percentage of the difference. If costs exceed the projected cost, the provider is not responsible.
Risk Stratification of Patient Population
Segmenting patients into distinct groups of similar complexity (e.g., chronic care management patients and non-chronic care management patients) using objective and subjective data. By identifying and segmenting the patients that are most at-risk, practices may be able to provide them greater access and resources, which in turn could reduce costs and improve care.
Social Determinants of Health (SDOH)
Conditions in the environments where people are born, live, learn, work, and play that affect a wide range of health, functioning, and quality of life outcomes and risks. SDOH can be five key areas: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.
Value-Based Contracts
Contractual arrangements in which payment for providing healthcare goods and services is tied to terms that are based on clinical quality, patient outcomes, cost effectiveness and other specified measures of the appropriateness and effectiveness of the services rendered.
- Commercial: Private insurance excluding Medicare Advantage Programs.
- Government: May include CMS’s Quality Payment Program (QPP), which includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).
- Medicare Advantage: Part of the Medicare Program, and may include Part A, B and D benefits, however, the benefits are instead offered through contracts with private insurers.