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Key Definitions

​The Task Force on Pediatric Practice Change continues to actively assess the rapidly changing healthcare environment and is developing a series of resources to help prepare members on how to respond to these changes. The following evolving resource includes a glossary of key terms as they relate to practice change.

Phrase​Definition (direct quotes from sources)​​Citation
Population Health

The health status of a group of individuals, including the distribution of such outcomes within the group. The field of population health includes health status and out​​comes, patterns of health determinants, and policies and interventions that link these two.​

Kindig D, Stod​​dard G. What is Population Health? Am J Public Health. 2003; 93 (3): 380 – 383.

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Team-based Care

The provision of health services to individuals, families, and/or their communities by at least two health providers w​ho work collaboratively with patients and their caregivers, to the extent preferred by each patient, to accomplish shared goals within and across settings to achieve coordinated, high, quality care.

Mitchel P, Wyn​​ia M, Golden R, et al. Core Principles and Values of Effective Team-Based Health Care. Discussion Paper, Institute of Medicine, Washington DC, 2012.

 

Medical Home

The American Academy of Pediatrics (AAP) believes that the medical care of infants, children, and adolescents sho​uld be accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. It should be delivered or directed by well-trained physicians who provide primary care, and help to manage and facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a partnership of mutual responsibility and trust with them. These characteristics define the "medical home."

American Acade​my of Pediatrics. The Medical Home. Pediatrics. 2002; 110(1):184-186. Reaffirmed 2008.

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Medical Neighborhood

The medical neighborhood is defined as "the Patient-Centered Medical Home​​ (PCMH) and the constellation of other clinicians (including pediatric and surgical subspecialists) providing health care services to patients within it, along with community and social service organizations and state and local public health agencies.

Defined in this way, the PCMH and the surrounding medical neighborhood can focus on meeting the needs of the individual patient but also incorporate aspects of population health and overall community health needs in its objectives."

Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. Coordinating care in the medical neighborhood: critical components and available mechanisms. White Paper (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2). AHRQ Publication No. 11-0064. Rockville, MD: Agency for Healthcare Research and Quality. June 2011

Care Coordination

The deliberate coordination of patient care activities between ≥2 participants (including the patient) involved in a ​patient's care to facilitate the appropriate delivery of comprehensive health care services.

 

American Academy of Pediatrics. Patient and Family Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multipl​​e Systems. Pediatrics. 2014; 133(5): 1451-1460

 

Patient- and Family-Centered Care

The planning, delivery, and evaluation of health care that is grounded in a mutually defined partnership among patients, families, and providers that recognizes the importance of the family in the patient's life – and organized around the needs/wants of the patient.

 

American Academy of Pediatrics. Patient- and Family-Centered Care and the Pedia​​trician's Role. Pediatrics. 2012;129 (2):394-404.

 

 

Quality Improvement

Systematic actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The Instit​​ute of Medicine (IOM) "defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and population".

United Sta​​tes Department of Health and Human Services, Health Resources and Services Administration. Quality Improvement. HRSA.gov Web site.http://www.hrsa.gov/quality/toolbox/508pdfs/qualityimprovement.pdf. Accessed January 7, 2016.

Quality Measures

Tools to help quantify that a desired health care process or outcome is achieved or the extent that a desira​ble structure to support health care delivery is in place to ensure that care is: effective, safe, efficient, patient-centered, equitable, and timely.

Centers for Medicare and Medicaid Services. Quality Measures.  CMS.gov Website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html?redirect=/QualityMeasures/03_ElectronicSpecifications.asp. Last Updated April 17, 2015. Accessed January 7.

Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3 suppl):166–206

Community Integration

Supporting connections among health care providers and integration of th​​eir services with the social, cultural, and environmental influences on children's health within a community, including:

  • Recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces affect the health and functioning of children;
  • Synthesis of clinical practice and public health programs  to promote the health of all children within the community; and
  • A commitment to collaborate with community partners to advocate for and provide quality services equitably for all children.

American Academy of Pediatrics. Community pediatrics: navigating the intersection of medicine, public health, and social determinants of children's health. Pediatrics. 2013;131 (3):623-628.

 

*Accountable Care Organization

A group of physicians and other health care providers (often including hospitals) that voluntarily uni​​​​tes to accept risk and accountability for measuring and managing the overall quality of care and the total cost to payers of most or even all of the healthcare services rendered to a defined group of patients (i.e., a population) over a set time period.   

The original regulatory structure of an ACO was defined in the Patient Protection Affordable Care Act (ACA) and applied to groups of physicians, hospitals, and other healthcare providers that cared for Medicare beneficiaries.  More recently, the ACO concept has broadened to include groups that have accepted accountability for measuring and managing the quality and cost of healthcare services for patients insured by Medicaid or private payers.

Center for Health​​care Quality and Payment Reform. The Payment Reform Glossary, Center for Healthcare Quality & Payment Reform, First Edition. CHQPR Web site.http://www.chqpr.org/downloads/paymentreformglossary.pdf. Accessed January 7, 2016.

*Fee for Service (FFS) Payment

A defined payment for a specific service or services.   Services are usually identified by Current Procedural Terminology (CPT) codes.  For some s​​ervices that are not included in CPT codes, a payer may define a payer-specific code.  Payments are determined by a payer's fee schedule. Some combinations of services may be "bundled" according to CPT guidelines; for instance, a number of common procedures are "bundled" into CPT evaluation and management codes for critical care, meaning that they will not be paid in addition to the critical care CPT E&M payment.

 
*Value-Based Payment

A system where payment for some or all services will be variably adjusted upward or downward fro​​m a standard payment, based on performance using predetermined metrics intended to define quality of care and/or healthcare outcomes. 

Centers for Medicare and Medicaid Services. Value-Based Payment Modifier.  CMS.gov Website. https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html. Last Updated De​​cember 17, 2015. Accessed January 7, 2016.

*Risk-Based (Budget-Based) Payment

 

In risk-based arrangements, payers budget a fixed amount, based on actuarial estimates of costs and thereby offload risk to the participating providers.  Methods of payment can include capitation, bundled payments, and shared savings arrangements.  In ea​​ch case, the provider has incentives to deliver essential services efficiently and reduce unnecessary utilization of healthcare services; providers may be at financial risk if they do not meet objectives (downside) or share in savings if they achieve objectives (upside).  

American Academy of Pediatrics. Alternative Payment Models. AAP.org Web site. https://www.aap.org/en-us/professional-resources/practice-support/Pages/Payment-Models.aspx#sthash.LGwT91Q1.dpuf. Accessed Jan​​uary 7, 2016.

 

*Risk Adjustment

A process used in payment models which aims to minimize fiscal risk to a provider for factors that may influence cost or performance outcomes that are beyond the provider's control.  Under risk adjustment, payments may be modified based on  certain patient characteristics (e.g., age, sex, health status, and other demographic characteristics) that have a known actuarial impact on the cost of health services.  In models that use measures of quality of services or health outcome performance to modify payment, the expected measures can also be risk-adjusted for the population to establish meaningful goals.  Some risk adjustment includes other sociodemographic factors.

 
*Capitation

Payment based on the number (hence, per capita) of patients attributed to the provider(s), potentially adjusted for risk.   Capitation payments may be global (a fixed per capita payment covers all healthcare services over a set time period) or partial (a fixed per capita payment for a subset of services).  Certain services may be "carved out;" that is, paid​​ to other specific providers (e.g., mental and behavioral health providers) using fee-for-service or other types of payment models.

 
*Bundled Payment (Prospective Payment)

Health care providers (hospitals, physicians, other professional health care providers) share one payment for a specified range of services as opposed to paying each provider individually. In a bundled payment m​​ethodology, a single, "bundled" payment covers services delivered by two or more providers during a single episode of care or over a specific period of time. The intent of bundled payment is to foster collaboration among the multiple providers to coordinate services and control costs, thereby reducing unnecessary utilization. Bundled payments represent a shared risk between the payer and provider(s) and are considered to be the middle ground between FFS (in which the payer assumes the risk) and capitation (in which the provider assumes the risk).

American Academy of Pediatrics. Alternative Payment Models. AAP.org Web site. https://www.aap.org/en-us/professional-resources/practice-support/Pages/Payment-Models.aspx#sthash.LGwT91Q1.dpuf. Accessed ​​January 7, 2016

 

*Pay for Performance (P4P)

 

A payment model in which providers receive a base payment (using a negotiated fee-for-service or capitation methodology) which may be adjusted u​​pward (a reward) or downward (a penalty) based on provider performance with respect to one or more agreed benchmarks.

American Academy of Pediatrics. Alternative Payment Models. AAP.org Web site. https://www.aap.org/en-us/professional-resources/practice-support/Pages/Payment-Models.aspx#sthash.LGwT91Q1.dpuf. Accessed January 7, 2016

 

*Shared Savings

By coordinating care, providers and payers believe they can deliver quality care ​​at a cost that is below current budgeted amounts, and the resulting savings is shared between the payer(s) and providers. The degree of shared savings between the entities—how the savings is calculated and distributed—will be specified in the contractual arrangement.

American Academy of Pediatrics. Alternative Payment Models. AAP.org Web site. https://www.aap.org/en-us/professional-resources/practice-support/Pages/Payment-Models.aspx#sthash.LGwT91Q1.dpuf. Accessed January 7, 2016

 

*Withholds

 

The term "withhold" refers to a percentage of payments or set dollar amounts deducted from contractual payments, which are then typically placed in one or more "risk pools." Whether physicians involved ​​receive some or all of the retained monies will depend on specific, predetermined factors or events. These can include group performance with respect to quality and/or cost metrics.

American Medical Association. Withholds. AMA.org Website. http://www.ama-assn.org/ama/pub/advocacy/state-advocacy-arc/state-advocacy-campaigns/private-payer-reform/state-based-payment-reform/evaluating-payment-options/withholds.page. Accessed Janua​​ry 7, 2016.

*Consumer-Driven Health Care

 

Consumer-driven health care (CDHC), defined narrowly, refers to third tier health insurance plans that allow members to use Health Savings Acc​​ounts (HSAs), Health Reimbursement Accounts (HRAs), or similar medical payment products to pay routine health care expenses directly.  A high-deductible health plan (HDHP) minimizes annual premium payments by maximizing deductible, co-pay, and co-insurance responsibilities yet protects the beneficiary from catastrophic medical expense. This system of health care is referred to as "consumer-driven health care" because the consumer (beneficiary) has fiscal incentives that may influence what health care services to access.

American A​cademy of Pediatrics. High-Deductible Health Plans. 2014

Telehealth

The use of electronic technology to connect users for the purposes of health care delivery, education and/or administration. ​​Technologies can include: videoconferencing, websites, listservs, store-and-forward imaging, streaming media, and wireless communications.

Department of Health and Human Services. What is Telehealth.  
Telemedicine/Virtual Care

Asynchronous or real-time healthcare delivery interaction between a patient, and their physician or practitioner at the distant site using digital photos and/or audio and video equipment.

Center​​s for Medicare & Medicaid Services. Medicaid.gov Web site.https://www.medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/telemedicine.html.Accessed January 7, 2016.

mHealth

The generatio​​​n, aggregation, and dissemination of health information via mobile and wireless devices.

Healthcar​​e Information and Management Systems Society (HIMSS). mHealth. HIMSS Web site. http://www.himss.org/library/mhealth. Accessed January 7, 2016.

Telementoring

Using technology to provide long-distance training by con​necting experts from one organization to another at a different hospital, city, community, or continent.

 
Direct to Consumer Telemedicine 

The provision of telemedicine services directly to the consum​er without a prior physician-patient relationship.

 
Disruptive Innovations

Harnessing new ideas, new technol​​ogies, or new ways to exploit existing technologies to solve a problem not addressed in previous models.

Economist. What disruptive innovation means. January 2015.
Health Information Technology

Health Information Technology is a concept that encompasses an array of rapidly e​​volving technologies to store, share and analyze health information. The     HHS defines it as, "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making."

Brailer, D. (2004). The decade of health information technology. HHS Report, July, 2​​1.

 

Clinically integrated Network

A health care system (both inpatient and outpatient clinicians) working together, using evidence​​-based protocols and measures, to improve patient care, decrease cost and demonstrate value to the market.

 
Meaningful Use

A program directed by the Office of the National Coordinator (ONC) with specific me​​asures and objectives designed to improve healthcare delivery, integration and costs through the use of Electronic Health Records (EHR) and Health Information Technology (HIT) in a "meaningful" way. The program includes payment incentives for providers who participate in Medicare or Medicaid (patient volume thresholds required).

Meaningful Us​e Definition & Objectives. Healthit.gov Web site.https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives. Last Updated February 6, 2015. Accessed January ​7, 2016.

MIPS (Medicare Merit Based Incentive Payment System)

A program that combines parts of the Physician Quality Reporting System (PQRS), theValue Modifier ​​(VM or Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program based on: Quality, Resource use, Clinical practice improvement, Meaningful use of certified EHR technology.

Centers for Medicare and Medicaid Services. Th​e Merit-Based Incentive Payment System​​ (MIPS) & Alternative Payment Models (APMs). CMS.gov Web site. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed January 7, 2016.  

Health information network

Nationwide Health Information Network (NwHIN)—a set of standards, services,​​ and policies that enable the secure exchange of health information over the Internet.

Nationwid​​e Health Information Network ​(NwHIN). Healthit.gov Web site. https://www.healthit.gov/policy-researchers-implementers/nationwide-health-information-network-nwhin. Updated January 18, 2013. Accessed January 7, 2016.

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