Accountable Care Organizations (ACO)
An Accountable Care Organization (ACO) refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.
The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services: ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements; networks of individual practices of ACO professionals; partnerships or joint venture arrangements between hospitals and ACO professionals; hospitals employing ACO professionals; and other Medicare providers and suppliers as determined by the Secretary of Health and Human Services (HHS). In the proposed rule, the Secretary has made clear that certain critical access hospitals are eligible to participate in the Shared Savings Program. One example of an ACO is a Medicare Shared Savings Program (MSSP).
Admission, discharge, transfer (ADT)
ADT systems can be used an alert upon a patient’s admission to a healthcare facility, and provide follow through of the patient’s care upon discharge and transfer to another facility or home.
Healthcare Effectiveness Data and Information Set (HEDIS)
The Healthcare Effectiveness Data and Information Set is a tool used by more than 90 percent of health plans to measure performance on care and service. HEDIS consists of standard quality measures that involve an integrated system to improve accountability within the managed care industry through advancing quality of care for its members. HEDIS requirements are established by the National Committee for Quality Assurance (NCQA).
Health Information Exchange (HIE)
The sharing of patient information in the healthcare industry enables physicians, nurses, pharmacists and other health care providers appropriately access and (securely) share a patient’s vital medical information electronically. This method improves the quality, safety, timeliness and cost of care. Sharing of patient information among healthcare providers can help improve diagnoses, reduce readmission, avoid medication duplication, decrease duplicate tests, and more.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and QPP (Quality Payment Program)
These two program names are essentially the same. MACRA is now the law’s referred name, while the QPP is the new name for MACRA. The launch of MACRA by CMS ended the Sustainable Growth Rate formula, which threatened clinicians participating in Medicare with a significant payment cut. MACRA/QPP has two tracks to participate in: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs)
Michigan Urological Surgery Improvement Collaborative (MUSIC)
Blue Cross and Blue Shield of Michigan (BCBSM) created the Michigan Urological Surgery Improvement Collaborative (MUSIC). This professional Collaborative Quality Initiative (CQI) is built upon the principles of the successful multi-state Urological Surgery Quality Collaborative (USQC) pilot that launched in 2009 and involved multiple urology practices from Michigan, Indiana and Ohio. This expansion of the USQC pilot created a Michigan clinical registry that collects data on patient demographics, cancer severity (including pathological details from needle biopsies), utilization and outcomes for radiographic staging studies, and patterns of care for both local therapies (e.g., radical prostatectomy, radiation therapy) and systemic androgen deprivation therapy. Data is analyzed to determine the performance of each participating Michigan urology practice in comparison to peers. The MUSIC Coordinating Center also undertakes analyses designed to identify specific care components associated with better patient outcomes. Based on these analyses, MUSIC leadership develops strategies for both dissemination of this information to participating providers and the broader Michigan healthcare community, as well as implementation of best practices in local communities.
Organized System of Care (OSC)
An Organized System of Care (OSC) is a community of caregivers consisting of primary care practices, specialists, hospitals and other providers that measure performance, set goals, track progress, and coordinate care across the continuum for the primary care-attributed patient population. The OSC assumes responsibility for establishing shared information systems and care processes, and accepts accountability for delivering effective and efficient patient care over time and across settings of care.
OSC is a Blue Cross and Blue Shield of Michigan (BCBSM) program that is extended to Physician Organizations (PO) in the Physician Group Incentive Program (PGIP).
Patient Centered Model Home (PCMH)
The Patient Centered Medical Home (PCMH) is a health care model that strives to facilitate partnerships between individual patients and primary care providers, including caregivers and the patient’s family. The PCMH model is patient-centered, team-based, coordinated and focused on quality and safety for the patient. The primary care physician serves as the central coordinator of patient care, facilitating partnerships with other physicians, health care staff and the patient to ensure necessary care is received and long-term coordination of care is available across the care continuum. PCMH focuses on improving processes and outcomes in population management through gap reductions in care for chronic conditions along with utilization of preventative screenings.
Patient Centered Model Home Neighborhood (PCMH-N)
The Patient-Centered Medical Home – Neighborhood (PCMH-N) is a program that works in collaboration with the Patient-Centered Medical Home care model that encourages specialists to adopt practices and capabilities to support coordination with PCMH primary care physicians. A PCMH-N practice engages in processes that encourages timely consultations and referrals, enhanced access, high-quality care, and provide patient-centered care.
Physician Group Incentive Program (PGIP)
Since its inception in 2005, BCBSM’s Physician Group Incentive Program (PGIP) has supported and facilitated practice transformation using a wide variety of initiatives to reward physician organizations for improved performance in health care delivery. PGIP includes more than 40 POs from across the state of Michigan, representing 19,000 primary care and specialty physicians who are members of the BCBSM TRUST PPO and/or Traditional Networks. These physicians provide care to nearly 2 million BCBSM members.
PGIP encourages all payer collaboration, catalyzing all payer system development, rather than payer-specific system development. Through PGIP, BCBSM is helping to improve the quality of care for all Michigan residents. Patients throughout the state, regardless of payer, benefit from the improved care processes developed through the PGIP provider community. Developing systems of care which are used for all patients helps assure that providers don’t have to alter care processes based on whether patients have insurance, or which insurance they have. This is an important factor in ensuring that the best practices and care processes are reliably provided to all patients, all of the time. www.bcbsm.com/provider/value_partnerships/pgip/index.shtml
Physician Quality Reporting System (PQRS)
The Physician Quality Reporting System (PQRS) is a voluntary reporting program developed by the Centers for Medicare & Medicaid Services. PQRS serves to promote the reporting of quality information measures by eligible professionals through financial incentives.
Population Health Management (PHM)
Population health management has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” It is an approach to health that aims to improve the health of an entire population. One major step in achieving this aim is to reduce health inequities among population groups. Population health seeks to step beyond the individual-level focus of mainstream medicine and public health by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, resource distribution, etc. An important theme in population health is importance of social determinants of health and the relatively minor impact that medicine and healthcare have on improving health overall.
Practice Resource Team (PRT)
A field team consisting of registered nurses and practice transformation partners work closely with TPA staff and its member practices. A team of PRT staff are assigned to physician practices to provide support and expertise related to transformation processes needed to become a BCBSM Patient Centered Medical Home or a Patient Centered Medical Home Neighborhood; navigating requirements for a practice to be successful in pay for performance programs; and guidance to improve quality, cost and efficiencies in patient care.
Provider Delivered Care Management (PDCM)
The Provider Delivered Care Management (PDCM) is a healthcare model where care management is provided within the primary care physicians’ practice by trained care managers. PDCM was created based on studies that supported care management delivered in-person by care managers within practices are more effective than centralized care managers. PDCM is delivered by a highly qualified care manager along with a clinical team. The care manager works in the physician practice, or with the practice via their affiliated physician organization, to provide care that’s personalized and focused on the whole patient. In addition to R.N.s, clinical team members may include nutritionists, certified diabetes educators, M.S.W.s, or pharmacists. These health care professionals are directly affiliated with the patient’s primary care physician in order for service to be integrated and coordinated.
Resource Stewardship Initiative (RSI)
BCBSM created the Resource Stewardship Initiative (RSI) to promote the use of evidence-based medicine when making health care stewardship decisions. The RSI also encourages conversations between physicians and patients about appropriate and necessary care. The RSI focuses on appropriate use of services to improve quality and safety of patient care along with reducing healthcare costs.
St. John Providence Partners in Care (SJP PIC or PIC)
Partners in Care (PIC) is a unique and innovative partnership between The Physician Alliance (TPA) and St. John Providence Health System (SJPHS). With the formation of this unprecedented 50-50 partnership, the goals and incentives of our physicians and those of the health system are aligned. PIC will serve as the provider network to manage the ongoing care of more than a million patients in Wayne, Macomb, Oakland, Livingston and St. Clair Counties. Partners in Care will continue to serve as the contracting entity for traditional managed care contracts, as well as new and innovative contracting opportunities with insurers and employers to manage populations in the future.
The Physician Alliance (TPA)
The Physician Alliance, LLC (TPA) is one of Michigan’s largest physician organizations, serving more than 2,200 primary care and specialty physicians in southeast Michigan. TPA formed in 2011 when five local physician organizations merged to establish a high-performing network of physicians committed to evolving the care model strategy while remaining consistent with the principles of the Patient Centered Medical Home. Our physicians are committed to the delivery of coordinated, accountable, and clinically integrated health services. The physician membership is supported through public advocacy, educational services and collaboration with our stakeholders in Michigan healthcare. www.thephysicianalliance.org
Value-Based Reimbursement – (VBR)
Value-based reimbursement (formerly called the fee uplift) is a payment structure model in Blue Cross Blue Shield of Michigan’s Value-Based Partnership program that moves away from the fee for service structure model to a value based model where the focus is on the patient. This reimbursement model promotes an integrated system in managing patient populations where reimbursement is based on quality of care and improved patient outcomes. This model shifts the care delivery focus from volume to value based to deliver better care at a lower cost. test