Quiz 2 Flashcards
Patient-Centered Medical Home (PCMH)
Emphasis on the central role of primary care and care coordination, with the vision that every person should have the opportunity to easily access high-quality primary care in a place that is familiar and knowledgeable about their health care needs and choices.
Accountable Care Organization (ACO)
Emphasis on the urgent need to think beyond patients to populations, providing vision for increased accountability for performance and spending across the health care system.
Shared Savings Program
Rewarding providers by paying them a bonus that is explicitly connected to the amount by which they reduce the total cost of care compared to expected levels.
-Born of the Affordable Care Act
Capitation (Global Payment)
The provider is responsible for the costs of all care that a patient receives.
-The risk is on the provider.
Episode-of-Care Payment
Providers are paid a single payment for all services associated with a hospitalization or other episode of acute care.
National Committee for Quality Assurance (NCQA)
The U.S.’s largest credentialing organization.
-Offer PCMH designation to providers who achieve goals related to accessible, coordinated, and patient-centered care.
Pioneer ACO program
- Designed to show how particular ACO payment arrangements can best improve care and generate savings for Medicare
- Evaluate various risk-sharing agreements.
Medicare Shared Savings Program (MSSP)
Program designed to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce costs.
-Key component of Medicare delivery system reform initiative brought about by Affordable Care Act.
ACO Challenges
- Working across organizational boundaries.
- Building requisite data sharing networks
- Patient engagement in the care process
ACO Core Processes: Stratification
The ability to identify a patient or cohort at risk for a negative health event or preventable health care utilization.
1) Identify risk
2) Alert appropriate stakeholders
3) Timely intervention in the care process
ACO Core Processes: Care Management
Patient-centered management and coordination of care events/activities in multiple care settings by one or more providers.
-Aimed to help the most complex patients within a system.
ACO Core Processes: Managing Contracts and Financial Performance
- Estimating reimbursement and associated payment distributions.
- Carrying out predictive modeling for reimbursement contracts.
- Measuring performance against contracts and predicting profitability.
- Integrating with other key processes to share information.
ACO Core Processes: Measuring, Predicting, and Improving Performance
- Ramifications for failure; Reward for improvements
- Providers must forecast which patients are likely to become high-risk to begin earlier intervention.
- Retrospective monitoring: finding out what didn’t happen and why.
ACO Core Processes: Preparation and Automation
Transition to value-based payment models is dependent on providers adopting IT solutions for automation and supporting core processes.
Health IT Capabilities: Data
- Focus on information that powers clinical decision making
- Creating a holistic view of patients within a healthcare network:
1) Master Patient Indices
2) Record Locator Service
Health IT Capabilities: Revenue Cycle Systems
Must complement routine activities such as: patient registration, appointment scheduling, and patient billing administration.
Health IT Capabilities: Care Management Systems
Enable proactive surveillance, automation, coordination, and facilitation of services for different sub-populations.
-Automation allows care managers to handle 2x-3x more patients than possible with manual management.
Health IT Capabilities: Rules and Workflow Engines
Monitor process performance and alerts staff to missed steps, sequence issues, and delays.
-Workflow engines specialize in executing a business process.
Health IT Capabilities: Data Warehouse, Analytics, and Business Intelligence
Predictive analytics tools can help caregivers identify patients who are likely to present in the ER or be readmitted so they can tailor interventions and avoid penalties for excessive re-admissions.
Analytics
Facilitate proactive management of key performance metrics
Enterprise Data Warehouse
Fuels a wide range of analytic needs and provides intelligence to enable continual care process improvement initiatives.
Health IT Capabilities: Health Information Exchange (HIE)
Enables providers to obtain composite clinical picture of the patient regardless of where the patient is seen.
