Key terms and definitions in value-based care
A federal program requiring drug manufacturers to provide outpatient drugs at significantly reduced prices (25-50% off) to eligible healthcare organizations serving low-income patients. Hospitals buy at discounted prices but are reimbursed at full rates, creating a significant margin.
A Special Enrollment Period available year-round that allows Medicare beneficiaries to enroll in a Medicare Advantage or Part D plan that has earned a 5-star overall quality rating from CMS. Beneficiaries may use this SEP once per calendar year to switch to a 5-star rated plan. Designed to incentivize plan quality and reward high-performing plans with easier beneficiary access.
The Adjusted Average Per Capita Cost (AAPCC) is a historical measure used by Medicare to estimate the average cost of providing care to a beneficiary in a specific geographic area. It served as a basis for payments to Medicare Advantage plans before being replaced by more refined risk adjustment models. AAPCC calculations considered factors like age, gender, and Medicaid status.
CMS Form R-131. A notice that fee-for-service Medicare providers and suppliers must give beneficiaries before furnishing items or services they believe Medicare will not cover as "not reasonable and necessary." Shifts financial liability to the beneficiary if they choose to receive the service. While ABNs are specific to Original Medicare, MA plans have analogous financial liability protections through the IDN process.
The Accelerated Approval pathway is a regulatory mechanism by the FDA that expedites the approval of drugs for serious conditions that fill an unmet medical need. This pathway allows for earlier approval based on a surrogate endpoint, with the requirement of post-marketing studies to confirm clinical benefit. It is designed to bring promising therapies to patients more quickly.
In healthcare, ACCESS refers to the ability of individuals to obtain necessary medical services. It encompasses factors such as availability of services, affordability, and cultural competence of healthcare providers. Ensuring access is a fundamental goal of health policy to improve population health outcomes.
ACO REACH is a model under the CMS Innovation Center aimed at improving health equity, access, and community health through accountable care organizations. It focuses on providing high-quality, coordinated care to Medicare beneficiaries while addressing social determinants of health. The model emphasizes provider accountability and patient-centered care.
Angiotensin-Converting Enzyme (ACE) inhibitors are a class of medications used to treat high blood pressure and heart failure by relaxing blood vessels. They work by inhibiting the enzyme responsible for converting angiotensin I to angiotensin II, a potent vasoconstrictor. Common ACE inhibitors include lisinopril and enalapril.
The Administration for Children and Families (ACF) is a division of the U.S. Department of Health and Human Services responsible for promoting the economic and social well-being of families, children, individuals, and communities. ACF administers programs that provide services and support for vulnerable populations, including Head Start and Temporary Assistance for Needy Families (TANF).
A group of doctors, hospitals, and other healthcare providers who voluntarily come together to provide coordinated, high-quality care to their Medicare patients. The goal is to ensure patients receive the right care at the right time while avoiding unnecessary duplication of services.
A CMMI model variant providing ACOs flexibility to offer enhanced primary care benefits to attributed beneficiaries, including expanded telehealth and home-based care, as part of broader ACO total-cost-of-care accountability.
CMS's redesigned direct contracting model that replaced the Global and Professional Direct Contracting (GPDC) Model. It focuses on health equity, beneficiary protections, and accountable care while offering participating organizations different risk-sharing arrangements.
The application of statistical and mathematical methods to assess risk in healthcare insurance. Actuaries predict healthcare costs and utilization to set premiums and reserves.
The Administration for Children and Families (ACF) is a division of the U.S. Department of Health and Human Services that focuses on promoting the economic and social well-being of families, children, individuals, and communities. ACF administers a range of programs designed to provide support and services to vulnerable populations, including child welfare and family assistance programs.
Unnecessary spending on billing, claims processing, and bureaucratic activities that do not contribute to patient care. Estimated at $266+ billion annually in the U.S., fueling revenue for RCM vendors and coding consultants.
A category of Alternative Payment Models under MACRA that meets specific criteria -- bearing more than nominal financial risk or qualifying as a Medical Home Model -- exempting participating clinicians from MIPS reporting and providing a 5% Medicare incentive payment.
In healthcare policy, an Advanced Notice refers to the preliminary communication issued by CMS regarding proposed changes to Medicare Advantage payment methodologies and policies. These notices allow stakeholders to review and provide feedback before final rules are established. They are crucial for ensuring transparency and stakeholder engagement in policy development.
AHEAD is a healthcare initiative aimed at promoting health equity across all payer systems by developing and implementing strategies that address social determinants of health and reduce disparities in healthcare access and outcomes.
ACCESS is a program designed to improve the management of chronic diseases through scalable and effective solutions, focusing on enhancing patient outcomes and reducing healthcare costs by leveraging innovative care models and technologies.
The period from October 15 through December 7 each year when Medicare beneficiaries can join, switch, or drop a Medicare Advantage or Part D plan. Changes made during AEP take effect January 1 of the following year. Also called the Fall Open Enrollment Period.
The American Geriatrics Society (AGS) is a professional organization dedicated to improving the health, independence, and quality of life of older people. AGS provides leadership to healthcare professionals, policymakers, and the public in the field of geriatrics. It also offers educational resources, clinical guidelines, and advocacy for geriatric care.
The national organization representing hospitals and health systems, advocating for policy positions on payment reform, regulatory relief, and healthcare delivery transformation before Congress and federal agencies.
A CMMI model testing state-level hospital global budgets combined with primary care transformation, where hospitals receive fixed annual payments independent of volume, promoting alignment between hospital and primary care spending goals.
The national trade association representing health insurance companies, including commercial insurers, Medicaid managed care organizations, and Medicare Advantage plans, advocating on regulatory and policy issues.
A state-level database aggregating medical, pharmacy, and dental claims data from all payers (commercial, Medicare, Medicaid), enabling population-level analysis of healthcare utilization, spending, and quality for benchmarking and policy evaluation.
The largest national professional association of physicians, advocating on issues including scope of practice, prior authorization reform, physician payment, and the impact of VBC models on clinical practice.
AI-powered tools that passively listen to patient-clinician conversations and automatically generate clinical documentation, reducing EHR documentation burden. Rapidly adopted by health systems to address physician burnout and improve coding accuracy.
A healthcare facility where surgical procedures that do not require overnight hospitalization are performed. Often lower cost than hospital outpatient departments, making them attractive for value-based care.
A standardized notice that Medicare Advantage and Part D plans must send to all enrollees for receipt no later than September 30 each year. Details all changes to the plan for the upcoming contract year, including changes to premiums, cost-sharing, benefits, formulary, provider network, and service area. Enables enrollees to make informed decisions during the Annual Enrollment Period (October 15 – December 7).
A federal criminal law prohibiting the exchange of anything of value to induce or reward referrals of federal healthcare program business, with specific safe harbors for VBC arrangements that protect bona fide shared savings and care coordination activities.
The payment classification system used in Medicare's OPPS to group outpatient services and procedures with similar clinical characteristics and costs, determining the per-service payment rate for hospital outpatient departments.
A trade association representing physician organizations engaged in coordinated, accountable care, advocating for policies that support capitation, risk-based contracting, and physician-led VBC delivery.
A payment approach that gives added incentives to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
Angiotensin II Receptor Blockers (ARBs) are a group of drugs used to manage hypertension and heart failure by blocking the effects of angiotensin II, a chemical that narrows blood vessels. This action helps to lower blood pressure and improve heart function. Examples of ARBs include losartan and valsartan.
A federal research agency within HHS modeled after DARPA, created to drive breakthrough health research by funding high-risk, high-reward biomedical and health projects that traditional research institutions may not pursue.
A CMMI specialty care model testing episode-based payments for ambulatory specialty procedures, designed to bring value-based payment to outpatient specialty settings that have largely remained in fee-for-service.
The patients assigned to a particular provider or healthcare organization for purposes of measuring quality and cost performance in value-based contracts.
The methodology CMS uses to assign Medicare beneficiaries to a specific ACO or provider organization for cost and quality accountability, typically based on where beneficiaries receive the plurality of their primary care services.
A yearly preventive visit covered by Medicare to develop or update a personalized prevention plan, including health risk assessment and screening schedule.
BALANCE refers to a healthcare initiative or program focused on promoting comprehensive health through balanced lifestyle and nutrition interventions, aiming to improve overall health outcomes and prevent chronic diseases.
The Balanced Budget Act (BBA) of 1997 is a significant legislative act that introduced major changes to Medicare and Medicaid, including the establishment of the Medicare+Choice program and various cost-saving measures.
A reference point or standard against which performance or outcomes can be measured. In value-based care, benchmarks are often based on historical spending or quality metrics.
The BALANCE program is an initiative focused on improving health outcomes through lifestyle and nutritional interventions, aiming to provide comprehensive health benefits and prevent chronic diseases.
An independent organization contracted by CMS to handle fast-track appeals of service termination decisions in Medicare Advantage plans and Original Medicare. When a beneficiary receives a NOMNC and disagrees with the planned service termination, they can contact the BFCC-QIO for an expedited review. The QIO must make a decision within one full day after receiving the necessary information. Services continue during the review period if the appeal is timely filed.
BIMZELX is a pharmaceutical drug used for the treatment of certain autoimmune conditions, such as psoriasis, by targeting specific pathways in the immune system to reduce inflammation and other symptoms.
A biomarker is a biological molecule found in blood, other body fluids, or tissues that is a sign of a normal or abnormal process, or of a condition or disease, and is used in clinical assessments to guide diagnosis and treatment decisions.
The industry segment that researches, develops, and manufactures pharmaceutical drugs and biologics. Characterized by high R&D costs, patent protection, and net income margins of 15-25%.
A biological product highly similar to an already-approved reference biologic with no clinically meaningful differences in safety or efficacy, offering lower-cost alternatives to expensive biologics and creating significant savings opportunities for VBC organizations.
A pharmaceutical product generating over $1 billion in annual sales. These drugs significantly impact manufacturer profit pools and often drive overall industry growth trends.
Body Mass Index (BMI) is a numerical value derived from an individual's weight and height, used as a screening tool to categorize individuals into weight categories such as underweight, normal weight, overweight, and obesity.
Bundled Payments for Care Improvement Advanced (BPCI Advanced) is a voluntary Medicare program that encourages healthcare providers to coordinate care and improve quality while reducing costs through bundled payment models.
A voluntary episodic payment model where participants can earn additional payment or owe CMS based on quality and cost performance during 90-day clinical episodes.
The minimum hospital bed utilization rate needed to cover operating costs. Labor inflation has raised this threshold from ~70% in 2019 to 75-80% in 2023 for many facilities.
A single payment for all services related to a treatment or condition, covering multiple providers and settings of care over a defined period.
Standardized surveys used to measure patients' experiences with healthcare, including communication with providers, access to care, and health plan services.
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Clinician & Group Survey with Item Set for Addressing Health Literacy (CAI) is a tool used to measure patients' experiences with healthcare providers and systems, focusing on health literacy. It helps organizations assess how well they communicate with patients and identify areas for improvement. This survey is part of broader efforts to enhance patient-centered care.
California's multi-year initiative to transform Medi-Cal by integrating behavioral health, addressing social determinants of health through Community Supports, and implementing Enhanced Care Management for high-need populations.
A payment arrangement where providers receive a set amount per patient per period, regardless of how many services the patient uses.
The deliberate organization of patient care activities between multiple participants involved in a patient's care to facilitate appropriate delivery of healthcare services.
The systems, processes, and models through which healthcare services are provided to patients. Includes how care is organized, coordinated, and delivered across different settings and providers.
A set of activities designed to assist patients and their support systems in managing medical conditions more effectively, often targeting high-risk or high-cost patients.
The Center for Consumer Information and Insurance Oversight (CCIIO) is a division of the Centers for Medicare & Medicaid Services (CMS) responsible for implementing provisions of the Affordable Care Act related to private health insurance. CCIIO oversees the Health Insurance Marketplace and ensures compliance with market reforms. It plays a crucial role in regulating and monitoring health insurance policies to protect consumers.
A Medicare billing code and care management approach for patients with multiple chronic conditions, involving care planning, medication management, and care coordination.
The Centers for Disease Control and Prevention (CDC) is a national public health institute in the United States, under the Department of Health and Human Services (HHS). It is responsible for protecting public health and safety through the control and prevention of disease, injury, and disability. The CDC conducts critical scientific research and provides health information to enhance health decisions.
Clinical Documentation Improvement (CDI) refers to a process used in healthcare to improve the accuracy and completeness of patient medical records. CDI programs help ensure that healthcare providers' documentation accurately reflects the care provided and supports appropriate coding and billing. This process is essential for quality reporting, reimbursement, and compliance with regulatory requirements.
The Centers for Disease Control and Prevention (CDC) is a national public health institute in the United States, under the Department of Health and Human Services. It is responsible for protecting public health and safety through the control and prevention of disease, injury, and disability. The CDC conducts critical science and provides health information that protects the nation against expensive and dangerous health threats.
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services that administers the nation's major healthcare programs including Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CMS also oversees the Health Insurance Marketplace and ensures compliance with healthcare regulations and standards.
The Code of Federal Regulations (CFR) is a codification of the general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government. It serves as the official record of all regulations and is divided into 50 titles that represent broad areas subject to federal regulation. The CFR is essential for understanding the legal framework within which healthcare and other sectors operate.
The Child Care and Development Fund (CCDF) is a federal and state partnership program that provides financial assistance to low-income families to access child care so they can work or attend training/education. The program also aims to improve the quality of child care and promote coordination among early childhood development programs. CCDF is administered by the Office of Child Care within the U.S. Department of Health and Human Services.
Child Care Facilities are establishments that provide care and supervision for children, typically from infancy through school age, during the day when parents or guardians are unavailable. These facilities are crucial for supporting working families and ensuring child development and safety. They must comply with state and federal regulations to ensure a safe and nurturing environment.
A joint federal-state program providing health coverage to uninsured children in families with incomes too high for Medicaid but too low to afford private insurance, covering over 7 million children nationwide.
The Church Amendments are a set of federal laws enacted in the 1970s to protect healthcare providers and entities from discrimination based on their refusal to perform or assist in sterilization or abortion procedures due to religious or moral objections. These amendments ensure that individuals and institutions are not compelled to act against their beliefs in federally funded programs.
A Corporate Integrity Agreement (CIA) is a document outlining the obligations a healthcare organization agrees to as part of a civil settlement with the Office of Inspector General (OIG) to avoid exclusion from federal healthcare programs. CIAs typically include requirements for compliance programs, training, reporting, and monitoring activities. They are designed to promote adherence to healthcare regulations and prevent fraud and abuse.
A network of healthcare providers who collaborate on clinical protocols, quality improvement, and data sharing to deliver coordinated care, often forming the organizational backbone for ACO participation and value-based payer contracts.
Civil Monetary Penalties (CMPs) are fines imposed by government agencies as a punitive measure for violations of laws and regulations, particularly in healthcare settings. These penalties are designed to enforce compliance and deter fraudulent or abusive practices in programs like Medicare and Medicaid. CMPs can be levied for a range of infractions, including false claims and violations of patient safety standards.
A mandatory bundled payment model for hip and knee replacements in selected geographic areas, holding hospitals accountable for quality and cost of care from surgery through 90-day recovery.
An option within the Kidney Care Choices model providing full capitated payments for kidney care, allowing Kidney Care Entities to take on global risk for managing beneficiaries with ESRD or late-stage CKD.
Chronic Kidney Disease (CKD) is a long-term condition characterized by a gradual loss of kidney function over time. It is often caused by diabetes, hypertension, and other chronic conditions, and can lead to kidney failure if not managed properly. CKD requires ongoing management to slow progression and reduce the risk of complications.
The process by which health insurers review, validate, and determine payment for healthcare claims submitted by providers. A major source of administrative friction and cost.
When a health insurer refuses to pay for a medical service or procedure. Medicare Advantage denial rates increased 55.7% between 2022 and 2023, forcing providers to spend more on administrative appeals.
A defined period of care in bundled payment models — typically triggered by a hospitalization or procedure and extending 90 days post-discharge — during which all related Medicare expenditures are aggregated for comparison against a target price.
A clinical trial is a research study that tests how well new medical approaches work in people, including treatments, drugs, or devices. These trials are essential for determining the safety and efficacy of new interventions before they can be approved for general use. Clinical trials are conducted in phases and are subject to rigorous ethical and regulatory standards.
The CMS center responsible for testing innovative payment and service delivery models to reduce Medicare/Medicaid expenditures while improving quality of care.
The Center for Medicare and Medicaid Innovation (CMMI) Hierarchical Condition Categories (HCC) model is used to adjust payments based on the health status and risk of beneficiaries. This model helps ensure that payments reflect the expected costs of providing care to patients with varying health conditions. It is a critical component in risk adjustment and value-based payment models.
A Civil Monetary Penalty (CMP) is a financial penalty imposed on healthcare providers for violations of healthcare laws and regulations, such as fraud or abuse. CMPs are used as a deterrent against non-compliance and to encourage adherence to legal standards. They can be levied by agencies like the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS).
A Comprehensive Medication Review (CMR) is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, and developing a plan to resolve them. CMRs are typically conducted by pharmacists and are an essential component of medication therapy management (MTM) services. They aim to optimize therapeutic outcomes and enhance patient safety.
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) responsible for administering the nation’s major healthcare programs including Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CMS also oversees the Health Insurance Marketplace and enforces regulations to ensure quality and efficiency in healthcare delivery.
The federal agency that administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance Marketplace. Its Office of the Actuary defines National Health Expenditures.
The official notice that Part D plan sponsors must issue when denying coverage for a prescription drug, including denials based on formulary restrictions, prior authorization requirements, step therapy protocols, or quantity limits. Must include the specific reason for denial, the enrollee's right to request a coverage determination or exception, and instructions for filing an appeal. Renewed by OMB effective January 1, 2025.
The "Medicare Prescription Drug Coverage and Your Rights" standardized pharmacy notice. Pharmacies must provide this form to Medicare Part D enrollees whenever a prescription claim is rejected at the point of sale. Informs the enrollee of their right to contact their plan to request a coverage determination, including exceptions to formulary restrictions, prior authorization, step therapy, and quantity limits. Available in Spanish, Chinese, Korean, and Vietnamese.
The CMS-Hierarchical Condition Categories (HCC) model is a risk adjustment tool used by CMS to estimate future healthcare costs for Medicare beneficiaries by categorizing patients based on their health conditions and demographic information. This model helps in adjusting payments to Medicare Advantage plans to reflect the expected costs of enrollees.
The CMS-Hierarchical Condition Categories (HCC) system is a risk adjustment methodology used by CMS to predict healthcare costs for Medicare beneficiaries. It assigns a risk score to individuals based on their health conditions and demographic factors, which is used to adjust payments to Medicare Advantage plans.
The percentage of healthcare costs that a patient pays after meeting their deductible. Often calculated based on list prices rather than net prices, increasing patient financial burden.
Community Health Centers are local, non-profit clinics that provide comprehensive primary care services to underserved populations, regardless of their ability to pay. These centers play a critical role in improving access to healthcare, particularly in rural and urban areas with limited healthcare resources. They are funded by the Health Resources and Services Administration (HRSA) and must meet specific federal requirements.
In the context of clinical trials and oncology, a 'Complete Response' refers to the disappearance of all signs of cancer in response to treatment. It does not necessarily mean the cancer has been cured, but it is a positive indicator of the treatment's effectiveness. Monitoring for complete response is a critical component of evaluating the success of cancer therapies.
An earlier CMMI model (predecessor to KCC) that tested whether ESRD Seamless Care Organizations -- partnerships between dialysis providers and nephrologists -- could improve outcomes and reduce costs for Medicare ESRD patients through coordinated, capitated care.
In the context of healthcare, construction refers to the planning, design, and building of healthcare facilities such as hospitals, clinics, and long-term care facilities. It involves ensuring that these structures meet specific regulatory and safety standards to provide a safe and effective environment for patient care.
A wearable device that continuously tracks blood glucose levels, providing real-time data to patients and providers for diabetes management. Medicare coverage expansion and integration with remote monitoring programs are driving adoption in VBC settings.
Temporary healthcare workers, particularly travel nurses, hired to fill staffing gaps. During the pandemic, these workers commanded $150+/hour, significantly impacting hospital margins.
A pharmacy that has an arrangement with a 340B-covered entity to dispense drugs on its behalf, often capturing significant margins from the difference between discounted acquisition costs and full reimbursement.
A health plan design where manufacturer copay assistance payments do not count toward a patient's deductible or out-of-pocket maximum, potentially leaving patients with unexpected costs when the assistance runs out. A growing concern in specialty drug access.
A fixed amount a patient pays for a covered healthcare service at the time of service, such as $20 for a doctor visit.
Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease characterized by increasing breathlessness. It includes conditions such as emphysema and chronic bronchitis, and is primarily caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke.
Actions taken to prevent unnecessary costs from occurring, such as preventing hospital readmissions or avoiding emergency department visits through proactive care.
The administrative expense incurred by providers to receive payment for services rendered, including billing, claims submission, and appeals. Rising denial rates increase this cost.
The initial decision made by a Part D plan sponsor regarding whether to approve or deny coverage for a prescription drug, including exception requests for non-formulary drugs or waiver of utilization management requirements. Standard decisions must be made within 72 hours; expedited decisions within 24 hours. A denial triggers the CMS-10146 Notice of Denial and the right to a redetermination appeal.
The phase of Medicare Part D coverage where the enrollee has exceeded initial coverage limits but not yet reached the catastrophic coverage threshold. Under the Inflation Reduction Act (effective 2025), the coverage gap was effectively eliminated — enrollees now pay $0 in the coverage gap phase. Previously, beneficiaries paid 25% of drug costs in this phase. Part D EOBs track enrollee progress through coverage phases.
COVID refers to the coronavirus disease caused by the SARS-CoV-2 virus, which emerged in late 2019 and led to a global pandemic. It primarily affects the respiratory system and can cause a wide range of symptoms, from mild to severe, and has significant implications for public health and healthcare systems worldwide.
COVID-19 is the infectious disease caused by the most recently discovered coronavirus, SARS-CoV-2, which was unknown before the outbreak began in Wuhan, China, in December 2019. The disease has led to a global pandemic, affecting millions worldwide, and has prompted extensive public health responses to control its spread.
A multi-payer advanced primary care model that provided enhanced, risk-adjusted per-beneficiary payments for practices to transform care delivery, focusing on access, continuity, care management, and planned care. Predecessor to PCF and MCP.
Current Procedural Terminology (CPT) codes are a set of medical codes used to report diagnostic, surgical, and medical services and procedures to entities such as physicians, health insurance companies, and accreditation organizations. Managed by the American Medical Association, CPT codes ensure uniformity and accuracy in the communication of medical services.
The standardized medical code set maintained by the AMA for reporting medical, surgical, and diagnostic procedures and services. CPT codes are foundational to Medicare and commercial claims billing and reimbursement.
In healthcare, CR commonly stands for Change Request, which is a formal proposal for an alteration to a system or product. Change Requests are used to manage and document changes in healthcare IT systems, ensuring that modifications are implemented systematically and with appropriate oversight.
A Change Request (CR) is a formal proposal to modify a system, process, or product, often used in project management and IT systems within healthcare settings. It ensures that changes are systematically reviewed, approved, and documented to maintain system integrity and compliance.
A notice that employers and other group health plan sponsors must provide annually to Medicare-eligible individuals before the Medicare Part D enrollment period. Discloses whether the entity's prescription drug coverage is "creditable" (expected to pay at least as much as Medicare Part D standard coverage). Critical because beneficiaries who go without creditable coverage for 63+ continuous days face a permanent Late Enrollment Penalty (LEP) when they later enroll in Part D.
A designation for small, rural hospitals that receive cost-based reimbursement from Medicare. These facilities often operate with negative margins and face significant financial challenges.
The practice where hospitals rely on higher reimbursement rates from commercial payers (often 200-300% of Medicare rates) to offset negative or break-even margins on government-insured patients.
The Complaint Tracking Module (CTM) is a system used by CMS to track and manage complaints related to Medicare Advantage and Part D plans. It helps ensure that complaints are addressed promptly and efficiently, contributing to improved service quality and beneficiary satisfaction.
CVD, or Cardiovascular Disease, refers to a class of diseases that involve the heart or blood vessels, including conditions such as coronary artery disease, heart attack, and stroke. It is a leading cause of morbidity and mortality worldwide, necessitating comprehensive prevention and management strategies in healthcare. Addressing CVD often involves lifestyle changes, medication, and sometimes surgical interventions.
A Medicare Advantage plan specifically designed for individuals who are eligible for both Medicare and Medicaid, offering coordinated benefits and additional services.
Data collection in healthcare involves systematically gathering information from various sources to analyze and improve patient care, outcomes, and operational efficiency. This process is essential for evidence-based decision-making and supports quality improvement initiatives.
Organizations that participated in the Global and Professional Direct Contracting Model, taking on financial risk for Medicare beneficiaries before transitioning to ACO REACH.
The amount a patient must pay out-of-pocket for healthcare services before insurance coverage begins. Rising deductibles have increased household financial burden.
An arrangement where a payer transfers financial risk and clinical management responsibilities for a defined population to a provider organization, MSO, or other entity, which then bears accountability for total cost and quality outcomes.
CMS Form 10124. A follow-up notice that must be provided after an enrollee receives a NOMNC and requests a fast-track appeal. The DENC explains in detail the specific clinical reasons why the MA plan or provider believes continued coverage is no longer medically necessary. Must be delivered by close of business on the day of the QIO notification.
The Department of Health and Human Services (HHS) is a federal agency responsible for protecting the health of all Americans and providing essential human services. It oversees programs related to public health, medical research, food and drug safety, and health insurance.
An approach to quality measurement using structured EHR data and FHIR-based standards to automate the extraction and submission of quality measure data, replacing manual chart review and reducing provider reporting burden.
A practice model where patients pay a flat monthly or annual fee directly to a primary care physician for a defined set of services, bypassing insurance billing and enabling longer visits, same-day access, and proactive care management.
A fee paid to pharmacies by PBMs for the service of dispensing prescription medications, separate from the ingredient cost of the drug itself.
Disease-Modifying Antirheumatic Drugs (DMARDs) are a class of medications used to treat inflammatory arthritis and other autoimmune conditions by slowing disease progression and reducing joint damage. They work by modulating the immune system to decrease inflammation and prevent tissue destruction.
Notices required under Medicare Part D Drug Management Programs for beneficiaries identified as at-risk for prescription drug misuse or abuse. Plan sponsors must provide an initial written notice of intent to limit access to frequently abused drugs, followed by a second notice when limitations are actually imposed. Required for all Part D sponsors since January 2022. Must include case management details and the beneficiary's right to appeal.
CMS Form 10066. A notice provided when a hospitalized Medicare beneficiary files a fast-track appeal of their discharge through the BFCC-QIO. Provides the specific clinical reasons why the hospital believes the beneficiary is ready for discharge. Only issued after the beneficiary has received the Important Message from Medicare (IM) and filed an appeal. Governed by 42 CFR 405.1206.
A value-based contract arrangement where providers may be required to repay a portion of healthcare costs if spending exceeds the target.
A patient classification system used by Medicare's IPPS to categorize inpatient hospital stays into clinically coherent groups with similar resource consumption, forming the basis for prospective hospital payment.
Drug pricing and negotiation refer to the processes and strategies used to determine the cost of pharmaceuticals and negotiate prices between manufacturers, insurers, and government entities. This is critical for ensuring medication affordability and access for patients.
Individuals who qualify for both Medicare and Medicaid, typically low-income seniors or people with disabilities who receive coverage from both programs.
A continuous Special Enrollment Period available to individuals who are dually eligible for both Medicare and Medicaid. Allows enrollment in, disenrollment from, or switching between Medicare Advantage plans (including D-SNPs) or Part D plans once per calendar quarter during the first three quarters of the year (January–September). Reflects the complex coverage needs of dual-eligible beneficiaries.
Executive Order 14182 is a directive issued by the President of the United States, focusing on specific policy areas within healthcare. Such orders typically aim to improve healthcare delivery, access, and affordability through federal actions and regulations.
The CPT code category covering office visits, hospital visits, and consultations — the most frequently billed physician services. E/M coding levels are based on medical decision-making complexity and directly impact physician reimbursement under the PFS.
Earnings Before Interest, Taxes, Depreciation, and Amortization. A common measure of operating profitability used to evaluate healthcare organizations. PE-backed physician platforms typically achieve 15-20% EBITDA margins.
Quality measures specified in a standard electronic format that can be extracted from electronic health records to assess healthcare quality.
The External Data Gathering Environment (EDGE) server is a system used by health insurers to submit claims data for risk adjustment and reinsurance programs under the Affordable Care Act. It ensures accurate data collection for calculating risk scores and financial transfers among insurers.
Encounter Data System (EDS) is a platform used by Medicare Advantage and Medicaid managed care plans to submit detailed information about the healthcare services provided to enrollees. This data is crucial for payment, quality measurement, and program integrity.
A digital version of a patient's medical history maintained by providers over time, including demographics, medications, vital signs, lab results, and clinical notes. Implementation costs have contributed to physician practice consolidation.
A medical procedure that is scheduled in advance and not considered an emergency. Includes surgeries like hip replacements and colonoscopies. Utilization of electives significantly impacts payer and provider finances.
A comprehensive document that Medicare Advantage and Part D plans must provide annually to all current enrollees by October 15. Details the plan's benefits, covered services, cost-sharing amounts, provider network rules, appeals and grievance procedures, and member rights and responsibilities. Serves as the binding contract between the plan and the enrollee for the upcoming plan year. Required under 42 CFR 422.2267(e).
A CMMI model testing whether enhanced care coordination, data sharing, and performance-based payment can improve cancer care quality and reduce costs for Medicare beneficiaries undergoing chemotherapy. Successor to the Oncology Care Model.
A payment model bundling all services related to a defined clinical episode -- such as a surgery plus 90 days of post-acute care -- into a single target price, creating incentives to coordinate care and reduce complications across providers.
Health insurance coverage provided through an employer, which benefits from tax exclusions that effectively subsidize the cost through foregone federal tax revenue. The dominant source of private coverage in the U.S.
End-Stage Renal Disease (ESRD) is the final stage of chronic kidney disease, where the kidneys can no longer function adequately to meet the body's needs. Patients with ESRD require dialysis or a kidney transplant to survive.
A mandatory CMMI model that adjusts Medicare payment amounts to incentivize greater use of home dialysis and kidney transplants for patients with end-stage renal disease, applying to dialysis facilities and transplant-managing physicians in selected geographic areas.
Emergency Use Authorization (EUA) is a mechanism by which the U.S. Food and Drug Administration (FDA) allows the use of unapproved medical products or unapproved uses of approved products during public health emergencies. This process facilitates access to necessary medical interventions when no adequate alternatives are available.
An additional charge that hospitals can bill for services provided in hospital outpatient departments, allowing them to charge more for the same services compared to independent physician offices. A key source of hospital margin.
A federal law imposing liability on persons and companies that defraud government programs. In healthcare, it is the primary tool for pursuing Medicare and Medicaid fraud, including upcoding, kickbacks, and billing for unnecessary services, with whistleblower (qui tam) provisions.
The Federal Food, Drug, and Cosmetic Act (FD&C Act) is a set of laws passed by Congress in 1938 that gives authority to the U.S. Food and Drug Administration (FDA) to oversee the safety of food, drugs, and cosmetics. It was enacted to ensure that products are safe, effective, and labeled correctly. The Act has been amended several times to include additional provisions for medical devices and other products.
The Food and Drug Administration (FDA) is a federal agency of the U.S. Department of Health and Human Services responsible for protecting public health by ensuring the safety, efficacy, and security of drugs, biological products, and medical devices. The FDA also oversees the safety of food, cosmetics, and radiation-emitting products. It plays a critical role in the regulation and approval of new medical treatments and technologies.
The federal agency within HHS responsible for approving drugs, biologics, and medical devices, whose decisions on biosimilar approvals, digital health tools, and drug pricing directly impact VBC cost management.
The official daily publication of the U.S. government containing proposed and final rules, notices, and executive orders. CMS publishes all major payment rules (IPPS, OPPS, PFS) and model changes through Federal Register rulemaking.
A traditional payment model where providers are paid for each service performed, regardless of the outcome or quality of care. Creates incentives for volume over value.
The Federal Emergency Management Agency (FEMA) is an agency of the U.S. Department of Homeland Security, responsible for coordinating the federal government's response to natural and man-made disasters. FEMA provides assistance to state and local governments, as well as individuals affected by disasters, to help them recover and rebuild. It plays a crucial role in disaster preparedness, response, and recovery efforts across the nation.
A modern health data standard developed by HL7 using web-based API technology to enable seamless exchange of electronic health information between systems, increasingly required by CMS interoperability rules for payers and providers.
The financial burden and distress experienced by patients due to healthcare costs, including out-of-pocket expenses, lost income, and medical debt.
The percentage of Medicaid costs that the federal government pays for each state, calculated based on state per capita income relative to the national average.
The Food and Drug Administration (FDA) is a federal agency under the U.S. Department of Health and Human Services responsible for ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices. It also oversees the safety of the nation's food supply, cosmetics, and products that emit radiation. The FDA plays a pivotal role in public health by regulating and supervising the development and marketing of various health-related products.
Programs that integrate nutrition interventions — including medically tailored meals, produce prescriptions, and nutrition counseling — into healthcare delivery to improve chronic disease outcomes and reduce costs, increasingly covered by Medicaid and MA plans.
A list of prescription drugs covered by a health insurance plan, typically organized into tiers with different cost-sharing levels. PBMs negotiate with manufacturers for favorable formulary placement.
A notice that Part D plans must send to affected enrollees when the plan makes a negative formulary change mid-year — such as removing a drug, adding new restrictions (prior authorization, step therapy, quantity limits), or moving a drug to a higher cost-sharing tier. Plans must provide 30-60 days advance notice or furnish a temporary transition supply. Governed by 42 CFR 423.120(b)(5).
Community-based healthcare providers that receive federal funding to provide primary care services in underserved areas, regardless of patients' ability to pay.
The independent, nonpartisan legislative agency that audits and investigates federal spending and programs, frequently publishing reports on Medicare, Medicaid, and VBC program performance.
The Generating Cost Reductions for U.S. Medicaid Model (GENEROUS) is a proposed initiative aimed at reducing healthcare costs within the Medicaid program while maintaining or improving quality of care. It focuses on implementing innovative care delivery and payment models to achieve cost savings. The model seeks to engage stakeholders in developing strategies that are both financially sustainable and beneficial to Medicaid beneficiaries.
The Global Benchmark for Efficient Drug Pricing Model (GLOBE) is a proposed framework aimed at aligning U.S. drug prices with international benchmarks to ensure cost-effectiveness and affordability. It seeks to leverage global pricing data to negotiate better prices for pharmaceuticals in the U.S. healthcare market.
A predetermined fixed amount of payment for all services delivered to a defined population over a specific time period, regardless of the actual volume of services provided.
A class of medications (such as Ozempic and Wegovy) originally developed for diabetes that have shown significant effectiveness for weight loss, driving explosive pharmaceutical spending growth in 2023.
A predecessor CMMI model to ACO REACH that tested total-cost-of-care accountability through Direct Contracting Entities, offering professional and global risk options. Transitioned to ACO REACH in 2023.
The Global and Professional Direct Contracting (GPDC) Model is a value-based care initiative by the Centers for Medicare & Medicaid Services (CMS) designed to reduce expenditures and enhance quality of care for Medicare beneficiaries. It allows healthcare providers to take on financial risk and reward through performance-based payments. The model aims to encourage innovative care delivery and coordination strategies.
An entity that aggregates purchasing volume to negotiate discounts on medical supplies and drugs for healthcare providers. GPO fees are a growing profit mechanism for PBMs.
A formal complaint filed by a Medicare Advantage or Part D enrollee about any aspect of plan operations, activities, or behavior other than a coverage denial. Includes complaints about quality of care, waiting times, provider behavior, customer service, and access issues. Plans must respond within 30 days (or 24 hours for expedited grievances related to plan refusal to expedite a coverage determination). Distinct from appeals, which challenge specific coverage denials.
The gap between a drug's list price (WAC) and its net price after rebates and discounts. This bubble reached $334 billion in 2023, representing total rebates paid by manufacturers to intermediaries.
The Guarding U.S. Medicare Against Rising Drug Costs Model (GUARD) is an initiative designed to protect Medicare from escalating drug costs by implementing cost-control measures and promoting price transparency. The model aims to ensure sustainable drug pricing while maintaining access to essential medications for Medicare beneficiaries.
A CMMI model providing a per-beneficiary-per-month payment for comprehensive dementia care services including care navigation, caregiver support, and respite services, aiming to reduce hospitalizations and institutional placement.
The Guiding an Improved Dementia Experience Model (GUIDE) is a care delivery approach focused on enhancing the quality of life for individuals with dementia and their caregivers. It emphasizes personalized care plans, caregiver support, and coordination of services to improve outcomes and reduce the burden of dementia care.
A condition developed during a hospital stay that was not present at admission, such as infections or falls. CMS reduces Medicare payments to hospitals in the worst-performing quartile on HAC rates through the HAC Reduction Program.
Medicaid-funded services that allow individuals — especially elderly and disabled populations — to receive long-term care in their homes and communities rather than institutional settings. A growing share of Medicaid long-term care spending.
Hierarchical Condition Categories (HCC) are a risk adjustment model used by Medicare to predict future healthcare costs for beneficiaries based on their health conditions. HCCs help determine payment rates for Medicare Advantage plans by accounting for the health status and demographic characteristics of enrollees.
A risk adjustment model used by CMS to calculate risk scores for Medicare Advantage members based on their diagnosed conditions. Accurate HCC coding directly impacts plan revenue.
HCC risk scoring is a methodology used to assign a risk score to Medicare beneficiaries based on their health conditions and demographics, influencing payment rates for Medicare Advantage plans. This scoring system ensures that plans receive appropriate compensation for enrollees with varying health needs.
A public-private partnership convened by HHS to align payers, providers, and purchasers around APM adoption, known for its APM Framework categorizing payment models and annual measurement of APM adoption progress.
The Healthcare Common Procedure Coding System (HCPCS) is a standardized coding system used in the U.S. to describe specific healthcare services, procedures, and equipment. It is essential for billing and claims processing in Medicare and other health insurance programs.
A coalition of patients, payers, providers, and purchasers working to accelerate the transition to value-based care through policy advocacy, best practice sharing, and collaborative action.
The U.S. Department of Health and Human Services (HHS) is a federal agency tasked with enhancing the health and well-being of all Americans. It oversees a wide array of programs related to health, social services, and public health, including Medicare, Medicaid, and the Affordable Care Act. HHS works to provide effective health and human services and foster advances in medicine, public health, and social services.
Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations.
The state in which everyone has a fair and just opportunity to attain their highest level of health, requiring removing obstacles like poverty, discrimination, and their consequences.
Health Information Technology (HIT) involves the use of various technologies to store, share, and analyze health information. It is essential for improving healthcare quality, reducing costs, and enhancing patient safety through systems like electronic health records (EHRs) and health information exchanges (HIEs). HIT facilitates better coordination of care and supports data-driven decision-making.
Healthcare affordability refers to the ability of individuals and families to access necessary medical services without financial hardship. It involves considerations of insurance coverage, out-of-pocket costs, and the overall cost of healthcare services. Ensuring healthcare affordability is a key goal of health policy, aiming to reduce financial barriers to care and improve health outcomes.
A healthy marriage refers to a stable and supportive marital relationship characterized by mutual respect, effective communication, and shared responsibilities. It is often promoted in public health programs as a means to improve family well-being and child outcomes.
The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the healthcare industry, developed by the National Committee for Quality Assurance (NCQA). HEDIS measures are used by health plans to evaluate the quality of care and service provided to their members.
A tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service. Maintained by NCQA.
The Health Equity Index (HEI) is a tool designed to measure and address disparities in healthcare access and outcomes across different population groups. It aims to promote equitable healthcare delivery by identifying and targeting areas where disparities exist.
A professional membership organization for healthcare finance executives, providing education, research, and certification on topics including revenue cycle, managed care contracting, and value-based payment.
An organization that provides skilled nursing, therapy, and other healthcare services to patients in their homes, typically following hospitalization or for chronic condition management.
CMS Form 10280. A notice issued by Home Health Agencies to Original Medicare beneficiaries when ongoing home health services are being reduced or changed (but not fully terminated). Distinct from the ABN (used when Medicare will likely deny coverage) and the NOMNC (used when services are ending entirely). Governed by 42 CFR 484.10(c).
The U.S. Department of Health and Human Services (HHS) is a federal agency responsible for protecting the health of all Americans and providing essential human services. HHS oversees a wide range of health-related programs, including Medicare, Medicaid, and public health initiatives.
The U.S. federal department responsible for protecting the health of all Americans, overseeing CMS, FDA, CDC, OIG, and other agencies that administer Medicare, Medicaid, and public health programs.
The HHS-Hierarchical Condition Categories (HHS-HCC) model is a risk adjustment methodology used in the Affordable Care Act (ACA) marketplaces to predict healthcare costs based on enrollee health conditions. It ensures that insurance plans receive appropriate compensation for covering individuals with varying health risks.
HHS-RADV stands for Health and Human Services Risk Adjustment Data Validation. It is a process used to ensure the accuracy of data submitted by health insurance issuers in the individual and small group markets, which is critical for the risk adjustment program under the Affordable Care Act. This validation helps maintain the integrity of risk adjustment transfers and ensures fair compensation for insurers covering higher-risk populations.
A CMS model that adjusts Medicare home health agency payments based on quality performance. Expanded nationwide in 2023, it ties up to 5% of payments to quality metrics including hospitalization rates, functional improvement, and patient experience.
The electronic sharing of health-related information among organizations according to nationally recognized standards, enabling better care coordination.
A health insurance plan with a higher annual deductible than typical plans, paired with lower premiums and eligibility for Health Savings Accounts (HSAs). Increasingly common in employer-sponsored coverage, shifting more first-dollar costs to patients.
Federal law establishing national standards for the protection of individually identifiable health information, including security and privacy rules governing electronic health data exchange, directly impacting VBC data sharing and care coordination.
Health Information Technology (HIT) refers to the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government, and quality entities. HIT is a critical component in improving healthcare quality, reducing costs, and enhancing patient safety. It encompasses a wide range of technologies, including electronic health records (EHRs) and telemedicine.
The Health Information Technology Advisory Committee (HITAC) is a federal advisory committee established under the 21st Century Cures Act to provide recommendations to the National Coordinator for Health Information Technology on policies, standards, implementation specifications, and certification criteria. HITAC aims to advance the use of health IT to improve healthcare quality and efficiency. The committee plays a crucial role in shaping the future of health IT policy in the United States.
An international standards-developing organization creating frameworks and standards for the exchange, integration, sharing, and retrieval of electronic health information, including the FHIR standard.
A Health Maintenance Organization (HMO) is a type of health insurance plan that provides healthcare services to members through a network of doctors, hospitals, and other providers. HMOs require members to choose a primary care physician and obtain referrals for specialist services, emphasizing preventive care and cost control. They typically offer lower premiums and out-of-pocket costs in exchange for less flexibility in choosing providers.
Home-based care involves providing healthcare services in a patient's home, allowing for personalized care and potentially reducing the need for hospital visits. It includes a range of services such as nursing care, physical therapy, and assistance with daily activities.
A clinical setting that is part of a hospital, allowing facilities to charge higher facility fees for services compared to independent physician offices, even for identical procedures. Subject to site-neutral payment reform proposals.
The Health Outcomes Survey (HOS) is a tool used by Medicare to assess the physical and mental health outcomes of Medicare Advantage beneficiaries over time. It helps evaluate the quality of care provided by health plans and informs improvements in healthcare delivery. The survey collects data on beneficiaries' health status, quality of life, and healthcare experiences.
A model of end-of-life care for patients with terminal illness and a life expectancy of six months or less, providing comfort-focused medical, emotional, and spiritual support while forgoing curative treatment, covered under Medicare Part A.
The Hospital Inpatient Prospective Payment System (IPPS) is a payment model used by Medicare to reimburse hospitals for inpatient stays. Under IPPS, hospitals receive a predetermined, fixed amount based on the diagnosis and severity of the patient's condition.
A care delivery model providing acute-level hospital services in a patient's home, including IV medications, monitoring, and daily physician visits, enabled by remote monitoring technology and shown to reduce costs and improve outcomes.
The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services responsible for improving access to healthcare services for people who are uninsured, isolated, or medically vulnerable. HRSA provides leadership and financial support to health care providers in every state and U.S. territory. It oversees programs that provide healthcare to underserved populations and support health workforce development.
The Hyde Amendment is a legislative provision that prohibits the use of federal funds for abortions, except in cases of rape, incest, or when the life of the mother is at risk. It has been included in annual appropriations bills since 1976.
A CMMI model integrating physical health, mental health, and substance use disorder treatment for Medicaid and Medicare beneficiaries, using a whole-person care approach to address root causes of health issues before they escalate.
The International Classification of Diseases (ICD) is a globally recognized system for coding diseases, symptoms, and procedures, facilitating international health data comparison and analysis. It is maintained by the World Health Organization and used extensively in healthcare settings for billing and epidemiology.
The diagnostic coding system used in the U.S. for classifying diseases, injuries, and health conditions on medical claims. ICD-10-CM codes drive DRG assignment, risk adjustment (HCC coding), and clinical documentation requirements.
ICD-9-CM, or the International Classification of Diseases, Ninth Revision, Clinical Modification, was used in the United States for coding and classifying morbidity data from inpatient and outpatient records. It has been largely replaced by ICD-10-CM as of October 1, 2015.
The period when a newly Medicare-eligible individual can first elect a Medicare Advantage plan. ICEP begins 3 months before the month of entitlement to both Part A and Part B and ends on the later of the last day of the month before entitlement or the last day of the Part B initial enrollment period. Distinct from IEP in that it specifically governs MA plan elections rather than Original Medicare enrollment.
An independent nonprofit organization that evaluates the clinical effectiveness and value of medical treatments, producing influential cost-effectiveness analyses and value-based price benchmarks that inform payer coverage and formulary decisions.
CMS Form 10003-NDMCP (Notice of Denial of Medical Coverage or Payment). The primary denial notice that MA plans must issue when denying, in whole or in part, an enrollee's request for medical coverage, or when discontinuing or reducing a previously authorized course of treatment. Integrates Medicare appeal rights and, for dual-eligible enrollees (D-SNPs), Medicaid appeal rights. Must include the specific clinical reason for denial and instructions for filing a reconsideration. OMB 0938-0829.
The 7-month window surrounding a beneficiary\'s 65th birthday (3 months before, the birth month, and 3 months after) during which they can first enroll in Medicare Part A, Part B, and a Part D or Medicare Advantage plan. Delaying enrollment beyond the IEP without creditable coverage may result in late enrollment penalties.
CMS Form 10065. A notice that hospitals must deliver to ALL Medicare inpatients — including MA enrollees, MSP, and dual-eligible patients — informing them of their hospital discharge appeal rights. Explains the right to appeal a discharge decision to the Beneficiary and Family Centered Care QIO (BFCC-QIO). Must be delivered no later than 2 calendar days after admission and again prior to discharge. Governed by 42 CFR 405.1205 and 42 CFR 422.620(b).
IMAAVY does not appear to be a recognized term in healthcare or value-based care. It may be a typographical error or an acronym not widely known in the industry.
The implementation date refers to the specific date on which a new policy, regulation, or system is put into effect. In healthcare, this date is critical for compliance and operational planning.
Providers and facilities that have contracted with a health insurance plan to provide services at negotiated rates, typically resulting in lower out-of-pocket costs for patients.
Inflation adjustment refers to the modification of financial figures to account for changes in the purchasing power of money over time, ensuring that payments or costs reflect real value. In healthcare, this often applies to adjusting reimbursement rates or budget allocations to maintain their value relative to inflation. This process helps maintain the economic stability of healthcare programs and services.
Federal legislation passed in 2022 that included provisions allowing Medicare to negotiate drug prices, caps on insulin costs, and extended ACA premium subsidies.
The cost of the actual drug product itself, separate from dispensing fees and other charges in pharmacy reimbursement.
Healthcare services provided to patients who are formally admitted to a hospital, typically requiring an overnight stay. Inpatient revenue growth has lagged outpatient in recent years.
A CMS-maintained list of procedures that Medicare will only reimburse when performed in an inpatient hospital setting. CMS has been progressively removing procedures from this list to allow ASC and outpatient reimbursement, a key driver of site-of-care shift.
A continuous Special Enrollment Period for Medicare beneficiaries who reside in or are moving into or out of an institution such as a skilled nursing facility, nursing facility, or intermediate care facility. Available at any time and allows enrollment in, disenrollment from, or switching MA or Part D plans without restriction. Recognizes the significant coverage implications of institutional care transitions.
The mechanisms and entities that provide financial coverage for healthcare services, including private insurers, government programs, and employer-sponsored plans that pool risk and manage claims.
The Interagency Pain Research Coordinating Committee (IPRCC) is a federal advisory committee created to enhance pain research efforts and promote collaboration across government agencies. It aims to improve understanding, treatment, and management of pain conditions. The committee also provides recommendations to the Department of Health and Human Services on pain research priorities.
The ability of different health information systems and software applications to communicate, exchange data, and use shared information.
A notice that Medicare Advantage plans must provide to enrollees being involuntarily disenrolled from the plan. Required reasons include moving out of the service area, loss of Medicare eligibility, failure to pay premiums, or disruptive behavior. Must advise the enrollee of the reason for disenrollment and, except in cases of plan termination or service area reduction, their right to a hearing. At least 30 days advance notice is required.
An association of independent physicians that contracts with health plans on behalf of its members, enabling small practices to collectively participate in managed care and value-based contracts they could not negotiate individually.
Medicare's payment system for inpatient hospital stays, using DRGs to determine payment amounts based on diagnosis and procedures.
The Interagency Pain Research Coordinating Committee (IPRCC) is a federal advisory committee that coordinates pain research activities across the Department of Health and Human Services and other federal agencies. It aims to enhance pain research efforts and improve pain management strategies.
The organization contracted by CMS to conduct Level 2 independent reviews of Medicare Advantage (Part C) and Part D plan decisions that were upheld at the plan level (reconsideration/redetermination). If the IRE also upholds the denial, the enrollee can appeal to an Administrative Law Judge (ALJ) if the amount in controversy meets the threshold ($190 in 2025). The IRE provides an additional layer of beneficiary protection outside the plan.
A hospital or hospital unit that provides intensive rehabilitation services to patients recovering from stroke, spinal cord injury, brain injury, and other conditions requiring coordinated therapy.
Interactive Voice Response (IVR) is a technology that allows computers to interact with humans through voice and keypad inputs. In healthcare, IVR systems are used for patient appointment reminders, medication adherence, and health surveys.
A CMMI voluntary model offering nephrologists, transplant providers, and dialysis facilities capitated or risk-based payment arrangements for managing patients with chronic kidney disease and ESRD, with options ranging from upside-only to full capitation.
A leading nonpartisan health policy research organization that publishes widely-cited analyses on Medicare, Medicaid, the ACA, and broader health system trends, frequently providing analytical context for government policy actions.
The sustained increase in healthcare workforce wages, particularly for nurses and clinical staff. A structural driver of healthcare cost growth, with hospitals raising base wages 5-10% in 2023.
A CMMI model making accountable care accessible to smaller, independent, and rural practices by providing enhanced support, simplified reporting, and graduated risk tracks for organizations that lack the infrastructure for existing ACO programs.
A permanent surcharge added to monthly Medicare Part D premiums for beneficiaries who did not maintain creditable prescription drug coverage for 63 or more consecutive days after their initial enrollment period. Calculated as 1% of the national base beneficiary premium ($38.99 in 2026) multiplied by the number of uncovered months. Waived for beneficiaries who qualify for Extra Help/Low-Income Subsidy (LIS).
Also called "Extra Help," a Medicare program that helps people with limited income and resources pay for Part D prescription drug costs.
A continuous Special Enrollment Period available to Medicare beneficiaries who qualify for the Low-Income Subsidy (Extra Help) program. Allows one plan change per calendar quarter during the first three quarters of the year (January–September). Ensures that low-income beneficiaries can adjust their Part D or MA-PD coverage to find the most affordable option for their medications.
The Long-term Enhanced ACO Design Model (LEAD) is an initiative aimed at improving the performance and sustainability of Accountable Care Organizations (ACOs) through innovative design and operational strategies. LEAD focuses on enhancing care coordination, patient outcomes, and cost efficiency over an extended period. This model supports ACOs in achieving long-term success in value-based care environments.
Acute care hospitals with an average length of stay greater than 25 days, specializing in treating patients with serious medical conditions requiring extended hospitalization.
Private health insurance plans that contract with Medicare to provide Part A and Part B benefits, often including additional coverage. Now covers more than half of all Medicare beneficiaries, with higher per-beneficiary costs than Traditional Medicare.
MA-PD stands for Medicare Advantage Prescription Drug plan, which is a type of Medicare Advantage plan that includes prescription drug coverage. These plans are offered by private insurance companies approved by Medicare and combine the benefits of Medicare Part A, Part B, and Part D. MA-PD plans provide an integrated approach to healthcare and medication coverage for Medicare beneficiaries.
An independent congressional agency that advises Congress on Medicaid and CHIP policy, publishing reports and recommendations on access, quality, payment, and program administration for these programs.
The 2015 law that ended the Sustainable Growth Rate (SGR) formula, created the Quality Payment Program, and established a new framework for physician payment based on value rather than volume.
MAHA ELEVATE is a program designed to enhance healthcare delivery and outcomes through innovative approaches and strategic partnerships. It focuses on leveraging technology and data analytics to improve patient care and operational efficiency. The program aims to elevate the standard of care by fostering collaboration among healthcare stakeholders.
MAHA ELEVATE is a legislative proposal aimed at improving public health through lifestyle changes and evaluating healthcare delivery using value-based approaches. The initiative focuses on evidence-based strategies to enhance health outcomes and reduce healthcare costs by promoting preventive care and healthy living. It seeks to integrate these strategies into existing healthcare frameworks to maximize their impact.
The process of negotiating reimbursement rates, quality requirements, and administrative terms between healthcare providers and managed care organizations or health plans, increasingly incorporating value-based payment arrangements alongside fee-for-service rates.
The reduction of profit margins, typically due to rising costs outpacing revenue growth. Hospitals experienced margin compression in 2022-2023 despite record volumes due to labor and supply costs.
The Maryland Primary Care Program (MDPCP) is a state-specific initiative designed to improve primary care delivery and patient outcomes through advanced care coordination and value-based payment models. It is part of Maryland's Total Cost of Care Model, which aims to reduce healthcare costs while improving quality by incentivizing preventive care and chronic disease management. MDPCP supports primary care practices with resources and support to enhance care delivery.
A CMMI state-level model where Maryland hospitals operate under all-payer global budgets with annual revenue limits, combined with care transformation incentives, making Maryland the only state with a hospital global budget system.
The negotiated ceiling price for drugs selected under the Medicare Drug Price Negotiation Program. CMS and manufacturers negotiate to set an MFP that applies to Medicare Part D (and later Part B) drugs, replacing the previous market-set price.
An entity that contracts with state Medicaid agencies or CMS to manage healthcare delivery and financing for enrolled populations, bearing financial risk through capitated payments and coordinating care through provider networks.
A CMMI model designed to gradually transition primary care practices from fee-for-service to prospective, population-based payments across progressive tracks, helping practices build VBC capabilities incrementally over time.
A primary care transformation initiative within Maryland's Total Cost of Care Model providing enhanced per-beneficiary payments to primary care practices for care management, aiming to reduce total cost of care through upstream primary care investment.
A CMMI expanded model offering structured lifestyle intervention services to Medicare beneficiaries with prediabetes, aiming to prevent type 2 diabetes through CDC-recognized programs delivering coaching on nutrition, physical activity, and behavior change.
MEAT is an acronym used in healthcare documentation and stands for Monitor, Evaluate, Assess, and Treat. It is a framework for ensuring comprehensive and accurate patient records, which are critical for quality care and appropriate reimbursement. MEAT criteria help healthcare providers document the necessary elements to justify medical necessity and support coding and billing processes.
A joint federal-state program providing health coverage to low-income individuals, pregnant women, elderly, and disabled populations. Spending reached $872 billion (18% of NHE) in 2023.
A state-imposed tax on healthcare providers (hospitals, nursing facilities, managed care plans) used to draw down additional federal Medicaid matching funds. CMS limits these taxes to 6% of net patient revenues to prevent states from inflating their federal match.
The process of verifying continued eligibility for Medicaid benefits. The post-pandemic "unwinding" of continuous enrollment led to significant disenrollment beginning in 2023.
The process of states resuming Medicaid eligibility redeterminations after the COVID-era continuous enrollment provision expired in 2023, resulting in millions of beneficiaries being disenrolled. Significantly impacts VBC organizations' attributed populations.
The process of translating healthcare diagnoses, procedures, and services into standardized codes for billing and documentation. Accurate coding is essential for risk adjustment and revenue optimization.
Medical Device Authorization is the process by which medical devices are reviewed and approved by regulatory bodies, such as the FDA, to ensure they meet safety and efficacy standards before being marketed. This process involves a rigorous evaluation of the device's design, manufacturing, and clinical data to protect public health. Authorization pathways may vary depending on the device's risk classification.
Medical devices are instruments, apparatuses, machines, or implants used in the diagnosis, prevention, monitoring, treatment, or alleviation of disease. They range from simple items like bandages to complex technologies such as pacemakers and MRI machines. Medical devices are regulated to ensure safety and effectiveness before they can be marketed and used in healthcare settings.
The percentage of premium revenue a health insurer spends on claims and quality improvement, as opposed to administrative costs and profit. ACA requires minimum MLRs of 80-85%.
The federal health insurance program for people 65 and older and certain younger people with disabilities. Spending surpassed $1 trillion (21% of NHE) for the first time in 2023.
Medicare Advantage & Part D Rate Setting involves the annual process where CMS releases the Advance Notice and Rate Announcement detailing payment methodologies and rates for Medicare Advantage and Part D plans. This process ensures that payments reflect changes in healthcare costs and utilization, and it includes updates to risk adjustment models and other payment policies. The goal is to maintain program sustainability while ensuring beneficiaries have access to high-quality care.
The CMS-administered program established by the Inflation Reduction Act allowing Medicare to negotiate prices for high-spend drugs directly with manufacturers. Negotiated Maximum Fair Prices take effect in designated Initial Price Applicability Years, starting with 10 drugs in 2026.
The Medicare Physician Fee Schedule (PFS) is a comprehensive listing of fees used to reimburse physicians and other healthcare providers for services rendered to Medicare beneficiaries. Updated annually by CMS, the PFS outlines payment rates for thousands of healthcare services and procedures, ensuring consistency and fairness in provider compensation. It plays a crucial role in the financial planning and operations of healthcare practices.
An independent congressional agency that advises Congress on issues affecting the Medicare program, producing influential reports and recommendations on payment rates, program design, and beneficiary access.
The medical technology industry, including manufacturers of medical devices, diagnostics, and equipment. EBITDA margins typically average 20-25%, with profit pools growing as procedure volumes recover.
Quantitative measures used to evaluate healthcare performance, spending, quality, and outcomes. Essential for benchmarking, accountability, and value-based payment arrangements.
A membership association for medical practice leaders providing benchmarking data, education, and advocacy on practice management, physician compensation, and operational performance in group practices.
An annual notice that Medicare Advantage plans must send between June 30 and July 31 to inform enrollees about supplemental benefits they have not used during the first six months of the plan year. Must be personalized for each enrollee, listing specific unused benefits such as dental, vision, hearing, fitness, over-the-counter allowances, and transportation. Introduced to improve benefit utilization and enrollee awareness.
Minimal Residual Disease (MRD) refers to the small number of cancer cells that may remain in a patient's body after treatment and could lead to a relapse. Detecting MRD is crucial for assessing treatment effectiveness and guiding further therapeutic decisions. Advanced diagnostic techniques, such as molecular and flow cytometry assays, are used to identify MRD with high sensitivity.
The threshold percentage by which an ACO's actual spending must fall below its benchmark before it can share in savings, designed to ensure measured savings reflect genuine performance rather than random variation in claims.
A program that adjusts Medicare payments to eligible clinicians based on performance across four categories: quality, cost, improvement activities, and promoting interoperability. Part of the Quality Payment Program under MACRA.
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 is a significant legislative act that introduced Medicare Part D, providing prescription drug coverage to Medicare beneficiaries. The MMA also established Medicare Advantage plans and made various changes to Medicare's structure and payment systems. It aimed to enhance access to medications and improve healthcare delivery for seniors.
Maintenance of Certification (MOC) is a process by which physicians and other healthcare professionals maintain their board certification through ongoing education and assessment. MOC ensures that practitioners stay current with medical advancements and continue to provide high-quality care. It typically involves periodic exams, continuing education, and quality improvement activities.
CMS Form 10611. Hospitals and Critical Access Hospitals must provide this notice to Medicare beneficiaries (including MA enrollees) receiving outpatient observation services for more than 24 hours. Informs them they are outpatients, NOT inpatients — which affects cost-sharing, SNF benefit eligibility, and financial liability. Required by the NOTICE Act (Section 1866E of the Social Security Act). OMB approved through February 2029.
The Medicare Plan Finder (MPF) is an online tool provided by Medicare to help beneficiaries compare and choose Medicare plans, including Medicare Advantage and Part D plans. It offers detailed information on plan costs, coverage options, and provider networks. The MPF aims to assist beneficiaries in making informed decisions about their healthcare coverage.
An entity that provides administrative and business support services to physician practices, allowing doctors to focus on patient care while the MSO handles billing, HR, and operations.
The Medicare Shared Savings Program (MSSP) is a program that encourages Accountable Care Organizations (ACOs) to reduce healthcare costs while meeting performance standards on quality of care. ACOs that succeed in lowering costs while delivering high-quality care can share in the savings achieved. MSSP aims to improve patient outcomes and reduce unnecessary spending in Medicare.
A program that helps Medicare fee-for-service providers become an ACO. Participating ACOs can earn shared savings payments when they lower healthcare costs while meeting quality standards.
Medication Therapy Management (MTM) is a service provided by pharmacists aimed at optimizing drug therapy and improving therapeutic outcomes for patients. It involves a comprehensive review of all medications a patient is taking, including prescription, over-the-counter, and herbal supplements, to ensure they are appropriate, effective, and safe. MTM is a critical component of value-based care, helping to reduce medication-related problems and improve patient adherence.
A strategy where Medicare, Medicaid, and commercial payers adopt consistent VBC incentives, quality measures, and reporting requirements, reducing provider burden and accelerating the transition from fee-for-service across all patient populations.
The leading national membership organization representing ACOs, advocating for policy changes that support accountable care and providing resources, education, and benchmarking data to ACO participants across all CMS programs.
A nonprofit organization that accredits health plans and certifies healthcare organizations, known for developing and maintaining HEDIS quality measures and PCMH recognition standards used widely in VBC programs.
The difference between premiums earned by private insurers and claims incurred, representing administrative costs, taxes, profits, and reserves. Totaled $362 billion (7.4% of NHE) in 2023.
The actual price paid for a drug after all rebates, discounts, and fees are applied. Significantly lower than the list price (WAC), though patients often pay cost-sharing based on list prices.
The regulatory requirement that health plan provider networks include sufficient numbers and types of providers to ensure enrollees can access care within reasonable time and travel standards, a key concern in MA and Medicaid managed care.
The official measure of total U.S. healthcare spending as defined by CMS, encompassing personal health care, government administration, insurance costs, public health activities, and investment. Reached $4.9 trillion (17.6% of GDP) in 2023.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is a part of the National Institutes of Health (NIH) focused on research related to the causes, consequences, prevention, and treatment of alcohol-related problems. NIAAA supports and conducts research to improve the understanding of alcohol use disorders and to develop effective interventions. It plays a key role in shaping public health policies and educational programs on alcohol use.
The National Institute of Allergy and Infectious Diseases (NIAID) is a division of the National Institutes of Health (NIH) that conducts and supports research to understand, treat, and prevent infectious, immunologic, and allergic diseases. NIAID's work is crucial in developing vaccines, therapies, and diagnostics for diseases such as HIV/AIDS, influenza, and emerging infectious diseases. It also plays a significant role in global health initiatives and pandemic preparedness.
The National Institutes of Health (NIH) is a part of the U.S. Department of Health and Human Services and is the primary federal agency for conducting and supporting medical research. NIH is composed of 27 Institutes and Centers, each with a specific research agenda, often focusing on particular diseases or body systems.
The National Library of Medicine (NLM), part of the National Institutes of Health, is the world's largest biomedical library. It provides a vast array of information services, including PubMed, a free search engine accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics.
Natural Language Processing (NLP) in healthcare refers to the use of computational techniques to analyze and interpret human language data, particularly in electronic health records. NLP can improve the efficiency of data extraction, enhance clinical decision support, and facilitate research by converting unstructured data into structured formats.
CMS Form 10123. A written notice that Medicare Advantage plans and certain providers must deliver to enrollees before terminating coverage for skilled nursing facility (SNF), home health agency (HHA), or comprehensive outpatient rehabilitation facility (CORF) services. Must be delivered at least 2 days before the proposed termination date. Triggers fast-track appeal rights to the Beneficiary and Family Centered Care QIO (BFCC-QIO). Updated in 2025 to extend appeal filing from 60 to 65 calendar days.
Nondiscrimination in healthcare refers to policies and practices that ensure individuals are not treated differently or unfairly based on characteristics such as race, gender, age, disability, or sexual orientation. These principles are enforced by laws such as the Affordable Care Act's Section 1557, which prohibits discrimination in health programs and activities receiving federal financial assistance.
A residential facility providing skilled nursing care and rehabilitation services. Spending grew 9.5% to $211.3 billion in 2023, though the sector faces severe labor shortages.
A CMS payment model that tested episode-based payments for chemotherapy treatment, providing enhanced payments for care coordination with shared savings opportunities.
The Office for Civil Rights (OCR) is a division of the U.S. Department of Health and Human Services responsible for enforcing federal civil rights laws, conscience and religious freedom laws, and the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules. OCR ensures that individuals' health information is protected while allowing the flow of health information needed to provide high-quality healthcare.
The period from January 1 through March 31 each year when beneficiaries already enrolled in a Medicare Advantage plan can switch to a different MA plan or disenroll from MA and return to Original Medicare (with the option to join a standalone Part D plan). Only one change is permitted during OEP. Not available to those in Original Medicare seeking to join an MA plan.
A continuous open enrollment period that allows Medicare beneficiaries who are institutionalized (residing in a skilled nursing facility, nursing facility, ICF/IID, or psychiatric hospital) to enroll in, disenroll from, or switch Medicare Advantage or Part D plans at any time. Unlike the calendar-year OEP, the OEPI has no quarterly or annual limits and remains available as long as the individual meets the institutional status criteria.
The Office of Family Assistance (OFA) is a division of the Administration for Children and Families within the U.S. Department of Health and Human Services. It oversees programs that provide assistance to needy families, including the Temporary Assistance for Needy Families (TANF) program, which aims to promote work, responsibility, and self-sufficiency.
The Office for Civil Rights (OCR) is a division of the U.S. Department of Health and Human Services responsible for enforcing civil rights laws and ensuring that individuals have equal access to healthcare services without discrimination. OCR also oversees the enforcement of the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules. It plays a critical role in protecting patient privacy and promoting equity in healthcare delivery.
The Office of Family Assistance (OFA) is a division within the Administration for Children and Families, part of the U.S. Department of Health and Human Services. It administers federal programs aimed at promoting family stability and economic self-sufficiency, including the Temporary Assistance for Needy Families (TANF) program. OFA works to improve outcomes for children and families by providing financial assistance and support services.
The Office of Head Start (OHS) is a division of the Administration for Children and Families within the U.S. Department of Health and Human Services. It oversees the Head Start program, which provides comprehensive early childhood education, health, nutrition, and parent involvement services to low-income children and their families. OHS aims to promote school readiness and support the development of young children from birth to age five.
The Office of Management and Budget (OMB) is a U.S. government agency that assists the President in overseeing the preparation of the federal budget and monitors the administration of executive branch agencies. OMB evaluates the effectiveness of agency programs, policies, and procedures, ensuring that they align with the President's priorities and comply with budgetary constraints. It plays a crucial role in shaping federal fiscal policy and resource allocation.
The Office of Head Start (OHS) is part of the Administration for Children and Families within the U.S. Department of Health and Human Services. It provides comprehensive early childhood education, health, nutrition, and parent involvement services to low-income children and families.
The HHS office responsible for protecting the integrity of healthcare programs through audits, investigations, and enforcement actions against fraud and abuse.
The Office of Inspector General (OIG) within the U.S. Department of Health and Human Services is responsible for protecting the integrity of HHS programs and the health and welfare of program beneficiaries. OIG conducts audits, investigations, and evaluations to prevent and detect fraud, waste, and abuse in HHS programs.
The Office of Management and Budget (OMB) is a U.S. government office that assists the President in overseeing the preparation of the federal budget and supervises its administration in Executive Branch agencies. OMB evaluates the effectiveness of agency programs, policies, and procedures, ensuring that they align with the President's policies and priorities.
The HHS office responsible for coordinating nationwide efforts to implement health information technology, establishing standards and certification criteria for EHR systems and overseeing interoperability policy.
The percentage of revenue remaining after operating expenses. Hospital operating margins rebounded to 5.2% in 2023 on average, though 39% of hospitals still had negative margins.
The administrative and business processes that support healthcare delivery, including billing, claims processing, authorization, and revenue cycle activities.
Medicare's payment system for hospital outpatient services, using APCs (Ambulatory Payment Classifications) to determine payment rates.
The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System are Medicare payment systems for outpatient hospital services and surgical procedures performed in ASCs, respectively. These systems establish predetermined rates for services, promoting efficiency and cost containment in outpatient care.
The initial decision made by a Medicare Advantage plan regarding whether to approve, deny, or partially deny a request for medical services, items, or Part B drugs. Must be made within 14 calendar days for standard requests (72 hours for pre-service requests) or 72 hours for expedited requests where delay could jeopardize life or health. An unfavorable determination triggers the Integrated Denial Notice (IDN) and the right to reconsideration.
The entities and structures that participate in the healthcare ecosystem, including providers, payers, government agencies, and intermediaries that facilitate care delivery and payment.
Healthcare expenses paid directly by patients, including deductibles, copayments, and coinsurance. OOP spending reached $506 billion (10% of NHE) in 2023, growing 7.2%.
Healthcare services provided to patients who are not admitted to a hospital, including clinic visits, same-day surgeries, and diagnostic tests. Outpatient revenue has grown faster than inpatient.
The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment system are Medicare payment methodologies used to reimburse hospitals and ASCs for outpatient services. OPPS covers hospital outpatient services, while ASC payment system applies to surgical procedures performed in ambulatory surgical centers. Both systems aim to control costs and ensure consistent payment rates for outpatient services.
A Medicare and Medicaid program providing comprehensive medical and social services to frail elderly individuals, typically through adult day health centers.
The Paperwork Reduction Act is a United States law designed to minimize the paperwork burden for individuals, businesses, and governmental entities. It aims to improve the efficiency of information collection by the federal government and enhance the quality of the information used in policymaking.
A model communications material that Medicare Advantage plans must send to enrollees after they receive covered services. Details the services provided, what the plan paid, what the enrollee owes, and the date of service. Unlike fee-for-service Medicare's MSN (Medicare Summary Notice), the Part C EOB is plan-specific and reflects the MA plan's cost-sharing structure.
Medicare prescription drug coverage offered through private plans. Can be standalone (PDP) or integrated with Medicare Advantage (MA-PD).
A notice that Part D prescription drug plans must provide to enrollees periodically (at least monthly when claims are processed). Shows each prescription filled, the drug cost, what the plan paid, what the enrollee paid, and the enrollee's progress toward the annual deductible, initial coverage limit, and catastrophic coverage threshold. Critical for tracking coverage gap (donut hole) status.
Patent extension in healthcare refers to the process of extending the duration of a patent beyond its original expiration date, often to compensate for time lost during the regulatory approval process. This extension can provide additional market exclusivity for pharmaceutical companies, impacting drug pricing and availability.
A Patient Safety Organization (PSO) is an entity that works to improve patient safety and healthcare quality by collecting and analyzing data on patient safety events. PSOs offer a protected environment for providers to report safety incidents, facilitating learning and prevention strategies without the risk of legal repercussions.
A payment strategy linking a portion of provider reimbursement to measurable performance on quality, efficiency, or patient experience metrics, creating financial incentives for improved outcomes rather than increased volume.
An intermediary that aggregates funds from sponsors, manages actuarial risk, and facilitates reimbursement to providers. Primary payers include private insurers, Medicare, and Medicaid.
The distribution of a provider's patients across different insurance types (commercial, Medicare, Medicaid, uninsured). A favorable payer mix with more commercial patients improves margins.
Activities ensuring that healthcare payments are accurate and appropriate, including identifying and recovering overpayments, preventing improper payments, and maintaining compliance with billing and coding regulations.
The various arrangements and methodologies used to compensate healthcare providers for services, ranging from traditional fee-for-service to value-based approaches that reward outcomes.
Third-party administrators that manage prescription drug programs for health insurers, processing claims, negotiating rebates, and determining formulary placement. The three largest PBMs (CVS Caremark, Express Scripts, OptumRx) process 80% of all claims.
A CMMI model offering primary care practices performance-based payments with flat, population-based payments replacing some fee-for-service billing, rewarding practices that reduce hospital utilization and improve quality outcomes.
A care delivery model where patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it.
Proportion of Days Covered (PDC) is a metric used to measure medication adherence by calculating the percentage of days a patient has access to their prescribed medication over a specified period. It is commonly used in pharmacy quality assessments to evaluate adherence to chronic medication regimens. A higher PDC indicates better adherence and is associated with improved health outcomes.
Prescription Drug Event (PDE) records are detailed data reports submitted by Medicare Part D plan sponsors to the Centers for Medicare & Medicaid Services (CMS). These records capture information about prescription drug claims, including the drug dispensed, cost, and beneficiary details. PDE data is used for program integrity, payment accuracy, and policy development in the Medicare Part D program.
In the context of pharmacy claims, a Prescription Drug Event (PDE) refers to the submission of detailed information about a prescription drug transaction under Medicare Part D. Each PDE record includes data such as the drug dispensed, quantity, cost, and beneficiary information, which is used by CMS for monitoring and reimbursement purposes. PDE data helps ensure the integrity and efficiency of the Medicare Part D program.
A standardized communications material that Medicare Advantage plans must provide to prospective enrollees with the enrollment form. Ensures beneficiaries understand important plan rules — including network restrictions, need for referrals, prescription drug coverage status, and that enrolling means leaving Original Medicare. Must be reviewed and signed before enrollment is processed.
A CMMI model testing global budgets for rural hospitals in Pennsylvania, providing predictable revenue to sustain essential services in rural communities while incentivizing quality improvement and care coordination.
Performance measures are standardized indicators used to assess the quality and efficiency of healthcare services provided by healthcare organizations and professionals. These measures are critical for evaluating outcomes, guiding quality improvement efforts, and determining reimbursement in value-based care models.
The performance period is a specific timeframe during which healthcare providers' performance is measured against established benchmarks to determine eligibility for incentive payments in value-based care models. This period is crucial for assessing improvements in care quality and efficiency.
The defined annual period during which a CMMI model or CMS program measures participant outcomes, spending, and quality performance for purposes of calculating shared savings, losses, or quality bonuses.
Person-centered care is an approach to healthcare that respects and responds to the preferences, needs, and values of the individual patient, ensuring that they guide all clinical decisions. This model emphasizes the importance of the patient-provider relationship and shared decision-making. It aims to enhance patient satisfaction and improve health outcomes.
The CMS payment system determining Medicare Part B reimbursement rates for physician and non-physician practitioner services, updated annually through rulemaking and serving as a foundation for payment in both FFS and many VBC arrangements.
The segment of healthcare focused on prescription drugs, including manufacturing, distribution, pricing, benefit management, and the complex flow of funds through the pharmaceutical supply chain.
The largest component of national health expenditures, representing direct spending for the treatment of individuals including hospital care, physician services, prescription drugs, and dental services.
A declaration by the HHS Secretary enabling emergency authorities and funding. The COVID-19 PHE ended in 2023, triggering Medicaid redeterminations and other policy changes.
Health coverage purchased from private insurers, either through employers or individual marketplaces. The largest single payer mechanism in the U.S., accounting for 30% of total healthcare spending.
The Public Health Service (PHS) is a division of the U.S. Department of Health and Human Services focused on protecting and advancing public health. It encompasses various agencies, including the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), and is responsible for implementing national health policies, conducting research, and providing essential public health services. PHS plays a vital role in disease prevention, health promotion, and emergency preparedness.
The trend of physicians becoming employees of hospitals, health systems, or corporate entities rather than owning independent practices. Fewer than 45% of physicians now own their practice.
The Principal Inpatient Diagnostic Cost Group (PIP-DCG) model is a risk adjustment methodology used by Medicare to predict healthcare costs based on beneficiaries' diagnoses. It categorizes individuals into groups with similar expected healthcare costs, allowing for more accurate payment adjustments to Medicare Advantage plans. PIP-DCG helps ensure that payments reflect the health status and anticipated resource needs of enrollees.
PIR, or Provider Incentive Reporting, refers to the process of collecting and analyzing data to assess the performance of healthcare providers in value-based care models. It aims to ensure that providers are meeting specific quality and efficiency benchmarks. This reporting is crucial for determining incentive payments and improving overall care delivery.
A written notice that Medicare Advantage or Part D plans must send to all enrollees when the plan is terminating its CMS contract or reducing its service area. Must be received by October 1, or at least 90 calendar days before the effective date of non-renewal. Must include information about alternative plans in the area and cannot include marketing for the organization's other products. Triggers a Special Enrollment Period (SEP) for affected enrollees.
In private equity healthcare investing, the initial large physician practice acquisition that serves as the foundation for rolling up smaller practices in a specialty.
A common healthcare payment metric that divides total costs by the number of members and months in the measurement period. Used extensively in capitation and risk-based contracts.
An approach that aims to improve the health outcomes of a defined group of individuals, including the distribution of outcomes within the group.
Healthcare services provided after an acute hospital stay, including skilled nursing facilities, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals. Post-acute spending is a major cost driver targeted by bundled payment models.
The Pharmacy Quality Alliance (PQA) is an organization that develops and implements performance measures to improve medication safety, adherence, and appropriate use. PQA's work is instrumental in enhancing the quality of pharmacy services and ensuring optimal patient outcomes.
In healthcare, PR often refers to Performance Reporting, which involves the dissemination of data regarding healthcare providers' performance on various quality and efficiency metrics. This transparency helps stakeholders make informed decisions and fosters accountability within the healthcare system.
The amount paid, typically monthly, to maintain health insurance coverage. Employer contributions to premiums grew 13% in 2023, a significant acceleration.
A refundable tax credit helping eligible individuals and families with low to moderate income afford health insurance purchased through the Health Insurance Marketplace.
Federal rules requiring hospitals and health plans to publicly disclose negotiated rates, allowed amounts, and cash prices for services, enabling consumers and employers to compare costs and creating competitive pressure on pricing.
Primary Care, often referred to as Medical Care Provider (MCP), is the day-to-day healthcare given by a healthcare provider. It acts as the first point of contact for patients and involves the provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal healthcare needs. Primary care is essential for continuous and comprehensive care, focusing on health promotion, disease prevention, and the management of chronic conditions.
A requirement that providers obtain approval from a health plan before delivering a service or prescribing a medication. A primary driver of administrative cost growth and provider burden.
Priority Review is a designation by the FDA that accelerates the review process for drugs and biologics that offer significant improvements in the treatment, diagnosis, or prevention of serious conditions. This designation shortens the FDA's review goal from the standard 10 months to 6 months. It aims to bring important new therapies to market more quickly.
Investment firms that acquire and consolidate healthcare businesses, particularly physician practices. Focus areas include dermatology, gastroenterology, ophthalmology, and cardiology.
Product approval in healthcare refers to the formal process by which a regulatory body, such as the FDA, evaluates and authorizes a new drug, medical device, or biologic for market release. This process ensures that the product is safe and effective for its intended use. Approval is based on evidence from clinical trials and other studies.
The total profits earned across all companies in a specific segment of the healthcare value chain. Understanding profit pools reveals where economic value is captured in the system.
A Program Information Report (PIR) is a document used by healthcare organizations to provide detailed data about their programs, including performance metrics, outcomes, and compliance with regulatory standards. It is often used for internal assessments and external reporting to stakeholders and regulatory bodies. The PIR helps in evaluating the effectiveness and efficiency of healthcare programs.
Program performance in healthcare refers to the measurement and evaluation of a healthcare program's effectiveness, efficiency, and quality in achieving its intended outcomes. It involves assessing various metrics such as patient satisfaction, clinical outcomes, and cost-effectiveness. Continuous evaluation of program performance is crucial for improving healthcare delivery and patient outcomes.
Formal government initiatives and structured arrangements designed to achieve specific healthcare policy objectives, such as expanding access, reducing costs, or improving quality.
The two-stage federal rulemaking process: a Proposed Rule solicits public comment on planned regulatory changes, and the Final Rule implements them after considering feedback -- the primary mechanism through which CMS updates payment systems and VBC programs annually.
A payment methodology where rates are set in advance based on predetermined criteria (such as DRG for inpatient or APC for outpatient), rather than being based on actual charges incurred, creating incentives for efficiency.
A notice that Medicare Advantage plans must send to affected enrollees when a network provider or facility is terminated from the plan's network. "Affected enrollees" are those currently receiving care from or who received care from the provider within the past 3 months. Must inform enrollees of their Special Enrollment Period (SEP) rights and Medigap guaranteed issue rights. CMS finalized that the SEP applies to all provider terminations, not just "significant" network changes.
A Patient Safety Organization (PSO) is a group that collects and analyzes data related to patient safety events to improve the quality and safety of healthcare delivery. PSOs provide a secure environment for healthcare providers to report and learn from safety incidents without fear of legal exposure.
The Physician-Focused Payment Model Technical Advisory Committee (PTAC) is an advisory body that reviews and evaluates physician-focused payment model proposals. PTAC provides recommendations to the Secretary of Health and Human Services on the implementation of these models to improve healthcare quality and efficiency.
Public comment is a process that allows individuals and organizations to provide feedback on proposed regulations, policies, or changes in healthcare programs. This process is essential for ensuring transparency and public participation in the decision-making process. Regulatory bodies often solicit public comments before finalizing rules to incorporate diverse perspectives and improve policy outcomes.
Government spending on epidemiological surveillance, vaccination programs, disease prevention, and other population-level health initiatives. A component of National Health Expenditures.
The Public Health Service (PHS) is a division of the U.S. Department of Health and Human Services focused on protecting and promoting public health. It encompasses various agencies, including the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). PHS plays a critical role in disease prevention, health education, and emergency response.
QBP, or Quality-Based Payment, is a healthcare payment model that links reimbursement to the quality of care provided, rather than the volume of services. This model incentivizes healthcare providers to improve care quality and patient outcomes. It is a key component of value-based care initiatives aimed at enhancing healthcare efficiency and effectiveness.
CMS's program that rewards high-value, high-quality Medicare clinicians with payment increases while reducing payments to clinicians who don't meet performance standards. Includes two tracks: MIPS and Advanced APMs.
The degree to which healthcare services meet established standards and improve patient outcomes. Quality measurement is foundational to value-based care and performance accountability.
Additional payments to Medicare Advantage plans or providers that achieve high quality ratings, typically based on Star Ratings or other quality measures.
Tools that help measure healthcare processes, outcomes, patient perceptions, and organizational structure. Used to assess and compare the quality of healthcare.
Risk Adjustment Data Validation (RADV) is a process used by CMS to ensure the accuracy of risk adjustment data submitted by Medicare Advantage organizations. RADV audits verify that the diagnoses submitted for risk adjustment are supported by medical record documentation. Accurate risk adjustment is crucial for appropriate payment and ensuring that plans are compensated fairly for the health status of their enrollees.
A score that predicts the expected healthcare costs for a patient based on their demographic information and diagnosed health conditions. Higher RAF scores result in higher payments from CMS.
RAPS, or Risk Adjustment Processing System, is a system used by CMS to collect diagnosis data from Medicare Advantage organizations to calculate risk scores for enrollees. These risk scores are used to adjust payments to plans based on the health status and demographic characteristics of their members. Accurate data submission through RAPS is crucial for ensuring appropriate funding and resource allocation.
A Rare Pediatric Disease is a serious or life-threatening condition affecting individuals primarily from birth to 18 years, with a prevalence of fewer than 200,000 cases in the United States. The FDA offers incentives, such as priority review vouchers, to encourage the development of treatments for these conditions. Addressing rare pediatric diseases is crucial for improving outcomes and quality of life for affected children.
RAS, or Risk Adjustment System, refers to the methodology used to adjust payments to health plans based on the health status and demographic factors of their enrolled populations. This system ensures that plans are adequately compensated for the risk profile of their members, promoting fairness and sustainability in healthcare financing.
The financial process that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance, including billing and collections.
REACH, or Realizing Equity, Access, and Community Health, is a model designed to address health disparities and improve access to care for underserved populations. It focuses on community-driven solutions and partnerships to enhance healthcare delivery and outcomes. This initiative is part of broader efforts to promote health equity and reduce systemic barriers in healthcare.
A CMS program (Hospital Readmissions Reduction Program) that penalizes hospitals with excess 30-day readmission rates for specified conditions, reducing Medicare payments by up to 3% and driving investment in discharge planning and care coordination.
Payments made by pharmaceutical manufacturers to PBMs and payers in exchange for favorable formulary placement and coverage. Rebates totaled approximately $334 billion in 2023.
The practice of PBMs sharing drug manufacturer rebates with their clients (employers, health plans) rather than retaining them. Many contracts now require 95%+ pass-through.
The retrospective process in bundled payment and ACO models where CMS compares actual total spending against benchmark or target prices, determining whether a participant receives shared savings payments or owes shared losses. Occurs semi-annually or annually.
The way physicians direct patients to specialists, facilities, or services. Vertically integrated systems can control referral patterns to keep care in-network and optimize margins.
Laws, rules, and policies that govern healthcare delivery, payment, and coverage. Regulatory frameworks shape market dynamics and stakeholder behavior across the healthcare ecosystem.
Regulatory review is the process by which government agencies assess the safety, efficacy, and quality of new healthcare products, such as drugs and medical devices, before they can be marketed. This process ensures that products meet established standards and are safe for public use. Regulatory reviews are essential for maintaining public trust and safeguarding health outcomes.
The Regulatory Review Period is the time taken by regulatory agencies, such as the FDA, to evaluate a new drug, device, or treatment for safety and efficacy before granting approval for market entry. This period is critical for ensuring that products meet necessary standards to protect public health. The length of the review can impact the time it takes for innovations to reach patients.
The amount a payer pays a provider for a specific service. Commercial rates are typically 200-300% of Medicare rates, making commercial patients more profitable.
In the context of healthcare, renovation refers to the process of updating or improving healthcare facilities to enhance patient care, safety, and operational efficiency. Renovations can include structural changes, technology upgrades, and improvements in patient flow and accessibility. These efforts are crucial for maintaining modern, effective healthcare environments.
Research in healthcare involves systematic investigation and study of materials and sources to establish facts and reach new conclusions, often aimed at improving patient care and outcomes. It encompasses clinical trials, observational studies, and other methodologies to advance medical knowledge and practice.
Responsible Fatherhood programs aim to promote the involvement of fathers in the lives of their children, supporting their emotional, educational, and financial well-being. These programs often provide resources and education to help fathers fulfill their parental responsibilities effectively.
The full financial lifecycle of a patient encounter, from scheduling and registration through service delivery, claims submission, and payment collection.
REZDIFFRA is not a recognized term in the context of healthcare policy or value-based care. It may be a misspelling or a term from another context. Please verify the spelling or provide additional context for accurate definition.
A clinic certified by CMS to provide primary care services in rural, underserved areas with enhanced Medicare/Medicaid reimbursement.
The financial exposure and uncertainty in healthcare, including actuarial risk borne by insurers and the contractual risk-sharing arrangements in value-based payment models.
Risk/Benchmark in healthcare refers to the process of assessing the financial risk associated with patient care and comparing it against established benchmarks to evaluate performance. This is crucial in value-based care models where providers are incentivized to manage costs while maintaining quality.
A methodology used to adjust payments based on the health status and expected costs of a patient population, ensuring that plans covering sicker patients receive appropriate compensation.
The process of categorizing a patient population into groups based on predicted healthcare utilization and cost, using clinical, claims, and social data to identify high-risk patients who would benefit most from intensive care management.
Risk-Based Contracts are agreements between payers and providers where payment is tied to the quality and efficiency of care delivered, with providers assuming financial risk for patient outcomes. These contracts are designed to incentivize cost-effective care while maintaining or improving quality.
ROI, or Return on Investment, is a financial metric used to evaluate the efficiency or profitability of an investment, calculated as the ratio of net profit to the cost of the investment. In healthcare, ROI is often used to assess the value of health interventions, technologies, or programs in terms of cost savings and improved outcomes. A positive ROI indicates that the benefits of an investment exceed its costs.
A private equity approach of acquiring multiple small physician practices to create a larger, more valuable consolidated platform that commands higher valuation multiples.
Use of digital technologies to collect health data from patients in one location and transmit it to providers in another location for assessment and recommendations.
A hospital located in a rural area, typically with limited resources and patient volume. Often operates with negative margins due to unfavorable payer mix and low economies of scale.
RYZNEUTA is not a recognized term in healthcare policy or value-based care. It may refer to a specific pharmaceutical product or a term from another context. Please provide additional context or verify the spelling for accurate definition.
A standardized document that Medicare Advantage plans must provide to prospective enrollees before enrollment. Summarizes the plan's most frequently used benefits and cost-sharing in an easy-to-compare format. Must include premium, deductible, copayment/coinsurance for common services, maximum out-of-pocket costs, and supplemental benefits. Works alongside the Pre-Enrollment Checklist.
A period outside the standard enrollment windows when Medicare beneficiaries can join, switch, or drop a Medicare Advantage or Part D plan due to qualifying life events. Triggers include moving out of a plan\'s service area, losing employer coverage, qualifying for Medicaid or LIS, plan contract termination, or residing in a FEMA-declared disaster area. Each SEP type has specific eligibility rules and timeframes.
SES, or Socioeconomic Status, is a measure that combines economic and sociological factors, including income, education, and occupation, to assess an individual's or group's social standing. In healthcare, SES is a critical determinant of health outcomes and access to care.
The SF-36 is a widely used health survey that measures quality of life across eight domains, including physical functioning, bodily pain, and general health perceptions. It is often used in clinical trials and health policy evaluations to assess patient-reported outcomes.
A payment arrangement where providers share in the cost savings achieved when actual healthcare costs come in below the target benchmark.
Shared Savings/Loss models are financial arrangements in value-based care where providers share in the savings achieved from efficient care delivery, or conversely, share in the losses if costs exceed benchmarks. These models incentivize providers to reduce unnecessary spending while maintaining quality care.
A CMMI initiative providing grants to states to design and test multi-payer payment and delivery reform strategies, supporting state-level healthcare transformation aligned with federal VBC goals.
A proposed policy that would require equal payment for the same healthcare service regardless of the setting (hospital outpatient department vs. physician office), eliminating facility fee arbitrage.
An inpatient facility that provides skilled nursing care, rehabilitation services, and other medical services to patients who need a higher level of care than can be provided at home.
CMS Form 10055. A specialized notice used by SNFs to inform Original Medicare Part A beneficiaries when the SNF believes Medicare Part A will not cover or will stop covering the resident's stay because it is no longer reasonable and necessary or is considered custodial care. Mandatory in its revised form since October 2024. For Part B items/services in the SNF, the standard ABN (CMS-R-131) is used instead.
CMS reports that allow skilled nursing facilities to preview their quality measure ratings and star ratings before public release, enabling facilities to identify potential errors and request corrections before the data is published on Care Compare.
A type of Medicare Advantage plan designed for specific populations: those dually eligible for Medicare and Medicaid (D-SNP), those with chronic conditions (C-SNP), or those in institutions (I-SNP).
The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health outcomes.
Pharmacies that dispense high-cost, complex medications requiring special handling, administration, or patient monitoring, such as biologics and oncology drugs.
The ultimate source of healthcare funding, including households (through premiums and taxes), private businesses, the federal government, and state/local governments. Distinct from payers who administer funds.
CMS quality rating system for Medicare Advantage and Part D plans, scored 1-5 stars. Higher ratings result in bonus payments and preferred marketing status.
A federal law prohibiting physicians from referring Medicare or Medicaid patients for certain designated health services to entities with which they have a financial relationship, with exceptions for VBC arrangements under specific regulatory safe harbors.
A coverage policy requiring patients to try less expensive medications before a plan will cover more costly alternatives.
Substance Use Disorder (SUD) is a medical condition characterized by an uncontrolled use of substances despite harmful consequences. It is a significant public health issue that requires comprehensive treatment approaches, including behavioral therapies and medications.
SUPD, or Statin Use in Persons with Diabetes, is a quality measure that assesses the percentage of diabetic patients who are prescribed statin therapy to reduce cardiovascular risk. This measure is used to evaluate the quality of care provided to diabetic patients.
SUPD (Statin Use in Diabetes) is a healthcare quality measure that evaluates the prescription of statins to diabetic patients to manage and reduce the risk of cardiovascular events. It is an important indicator of preventive care in managing diabetes-related complications.
In episode-based payment models like BPCI Advanced and CJR, the predetermined spending benchmark for a clinical episode against which actual Medicare expenditures are compared during reconciliation to determine shared savings or losses.
Medicare services for the first 30 days after hospital or SNF discharge, designed to reduce readmissions through medication reconciliation and care coordination.
Telecommunications Device for the Deaf (TDD) is a device that allows individuals who are deaf, hard of hearing, or speech-impaired to communicate over the telephone by typing messages instead of speaking. It is an essential tool for ensuring accessibility in healthcare communications.
A CMMI mandatory bundled payment model for surgical episodes including hip/knee replacements, spinal fusion, and coronary artery bypass grafting, succeeding CJR with broader episode types and mandatory participation in selected geographic areas.
Digital tools, systems, and innovations that support healthcare delivery, including electronic health records, telehealth platforms, and data analytics capabilities.
A CMMI model designed to improve maternal health outcomes by providing whole-person prenatal through postpartum care with enhanced payments, targeting states and providers serving populations with high rates of maternal morbidity and mortality.
A measure of all healthcare spending for a defined population over a specific period, including all services across all providers.
The original Medicare program (Parts A and B) administered directly by the federal government, as opposed to Medicare Advantage plans administered by private insurers.
The prices charged for transactions between related business units within a vertically integrated company. Used to optimize MLR and tax positions across insurance, PBM, and provider arms.
A notice that Part D plan sponsors must provide to enrollees during their first 90 days of coverage when a currently prescribed medication is not on the plan's formulary or is subject to utilization management restrictions. The plan must provide a temporary supply of the drug (typically 30 days) and notify the enrollee and prescriber to arrange a formulary alternative or file an exception request.
A registered nurse who takes temporary assignments at healthcare facilities, often in different geographic locations. Commanded premium wages ($150+/hour) during pandemic staffing crises.
Tribal Lead Agencies are designated entities within Native American tribes responsible for administering and managing specific federal programs, such as those related to healthcare, education, and social services. They play a critical role in ensuring that tribal members receive culturally appropriate services.
TRYVIO is not a recognized term in healthcare policy or value-based care. It may be a typographical error or a proprietary name not widely acknowledged in public healthcare literature.
Teletypewriter (TTY) is a device that enables individuals who are deaf, hard of hearing, or speech-impaired to send and receive typed messages over telephone lines. TTY is crucial for facilitating communication and ensuring accessibility in healthcare settings.
A payment arrangement where a provider or ACO shares in both savings when costs come in below a benchmark and losses when costs exceed it, requiring financial reserves and creating stronger incentives for cost management than upside-only models.
The process of evaluating risk and determining premiums for insurance coverage. Health insurers underwrite risk to set appropriate premium levels and maintain reserves.
A value-based contract arrangement where providers can earn bonuses for meeting quality targets or achieving cost savings, without penalty for missing targets.
The United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and prevention that systematically reviews evidence and develops recommendations for clinical preventive services. These recommendations are intended to guide healthcare providers in delivering evidence-based preventive care.
The extent to which healthcare services are used by patients. High utilization can indicate either appropriate access to care or potential overuse, impacting medical loss ratios and total costs.
Techniques used by payers and managed care plans -- including prior authorization, concurrent review, and retrospective review -- to evaluate the medical necessity and appropriateness of healthcare services before, during, or after delivery.
When actual healthcare utilization significantly exceeds actuarial predictions, pressuring insurer margins. Occurred in 2023 as patients returned for deferred elective procedures.
V22 does not correspond to a recognized term in healthcare policy or value-based care. It may refer to a version number or code not widely acknowledged in public healthcare literature.
V24 does not correspond to a recognized term in healthcare policy or value-based care. It may refer to a version number or code not widely acknowledged in public healthcare literature.
The updated CMS risk adjustment model being phased in for Medicare Advantage that removes certain HCC codes, adds others, and recalibrates condition weights, significantly impacting MA plan revenue and risk score calculations through 2025-2028.
The Vaccine Injury Compensation Program (VICP) is a federal program established to provide compensation to individuals who suffer injury or death as a result of receiving certain vaccines. It aims to ensure a stable vaccine supply by reducing the liability of vaccine manufacturers and providers. The program is funded by an excise tax on vaccines covered under the VICP.
The full sequence of activities involved in delivering healthcare, from funding sources (sponsors) through intermediaries (payers) to providers and manufacturers, each capturing a portion of value.
A healthcare delivery model in which providers are paid based on patient health outcomes rather than the volume of services delivered.
A CMS program and broader concept where a portion of provider payment is tied to performance on clinical processes, outcomes, patient experience, and efficiency measures, reducing payments for poor performers and rewarding top performers.
Value-Based Care (VBC) is a healthcare delivery model in which providers are reimbursed based on patient health outcomes rather than the volume of services provided. This approach aims to improve the quality of care while reducing healthcare costs.
A company providing technology, analytics, care management infrastructure, and operational support to help physician practices participate in value-based payment models, typically taking a share of generated savings. Examples include Agilon Health, Aledade, and Pearl Health.
The VBC Market comprises companies and organizations that develop, implement, and support value-based care models, focusing on improving patient outcomes and reducing costs. These companies often provide technology solutions, analytics, and consulting services to healthcare providers and payers.
Value-Based Purchasing (VBP) is a strategy used by purchasers of healthcare services to promote quality and value in healthcare. By linking provider payments to quality measures and outcomes, VBP aims to incentivize high-quality care and cost efficiency.
A CMMI model where Vermont aligned Medicare, Medicaid, and commercial payers under a single statewide ACO framework with shared quality and cost targets, one of the most ambitious multi-payer alignment experiments in the U.S.
When a company owns multiple stages of the healthcare value chain, such as a health insurer owning a PBM and physician practices. Examples include UnitedHealth/Optum and CVS/Aetna/Caremark.
In healthcare, a voucher is a certificate or authorization that allows individuals to access specific services or benefits, often as part of a government or insurance program. Vouchers can be used to promote access to care by subsidizing costs for eligible populations. They are commonly used in programs aimed at increasing healthcare access for underserved communities.
The VR-12 is a 12-item survey instrument used to measure health-related quality of life, particularly in older adults. It assesses physical and mental health status and is often utilized in Medicare and other health outcomes research to evaluate patient-reported outcomes. The VR-12 is a shorter version of the Veterans RAND 36 Item Health Survey (VR-36).
The list price at which manufacturers sell drugs to wholesalers, before any rebates or discounts. Often used as the basis for patient cost-sharing even though net prices are much lower.
Federal provisions allowing states to experiment with Medicaid (Section 1115) or ACA marketplace (Section 1332) program designs outside standard requirements, enabling state-level innovation in coverage, payment, and delivery reform.
The Wasteful and Inappropriate Service Reduction Model (WISeR) is a framework aimed at identifying and reducing unnecessary healthcare services that do not contribute to patient outcomes. By focusing on eliminating wasteful practices, WISeR helps improve the efficiency and effectiveness of healthcare delivery. This model supports value-based care initiatives by promoting the optimal use of resources.
Intermediaries that purchase drugs from manufacturers and distribute them to pharmacies, hospitals, and other dispensers. Typically receive a small discount (~2%) from WAC.
WISER (Wireless Information System for Emergency Responders) is a mobile application designed to assist first responders in hazardous material incidents. It provides critical information on chemical, biological, and radiological hazards to aid in decision-making during emergencies. WISER is developed by the National Library of Medicine to enhance the safety and effectiveness of emergency response operations.