There is no set definition for an ACO and it is likely that the various ACO models will continually evolve. The federal Centers for Medicare & Medicaid Services (CMS) defines an ACO as a group of doctors, hospitals, and other health care providers who come together voluntarily to deliver coordinated high-quality care to Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors, CMS said. Commercial health plans, hospitals, and physicians also are developing ACOs to serve patients outside of the Medicare and Medicaid programs and the goals are similar: delivery high quality, appropriate care while controlling the costs of care. An ACO is supposed to emphasize primary care and be accountable for the cost of care and the quality of care.
ACO investment model
A Medicare initiative for provider organizations in accountable care organizations (ACOs) that is designed to test the use of pre-paid shared savings to foster the development of new ACOs in rural and underserved areas and to encourage ACOs in Medicare’s Shared Savings Program to accept greater financial risk.
Organizations that participate in Medicare’s accountable care organization (ACO) investment model program (called AIM ACOs) can be physician practices, federally qualified health centers (FQHCs), rural health clinics (RHCs), critical access hospitals (CAHs) or other acute hospitals with no more than 100 beds.
ACO Transformation Track
This track is one of two under Medicare’s Community Health Access and Rural Transformation (CHART) Model for rural hospitals. Under this track, rural hospitals could become accountable care organizations under the Medicare Shared Savings Program to accept the financial risk for the total amount spent on Medicare beneficiaries. In exchange, these hospitals would get advanced shared savings payments rather than waiting until savings are generated. (See also: the Chart Model and the Community Transformation Track.)
Actual acquisition cost (AAC)
When a drug manufacturer sells a medication to a pharmacy, the AAC is the net cost the pharmacy pays. The AAC includes discounts, rebates, chargebacks and other price adjustments, but it excludes the pharmacy’s dispensing fees.
Health insurers make add-on payments to physicians, hospitals and other providers in addition to existing payment methods such as salary or fee-for-service payment. The add-on payments may be made for coordinating activities from other providers or may be made for hitting certain quality or cost targets (which would be pay-for-performance. Add-on payments can be made ex-post (meaning after the fact) or ex-ante (meaning before the fact).
In health care, the term “administrative costs” refers to the so-called back-end or back-office functions that are separate from delivering patient care. These costs include medical billing, negotiating with health insurers over unpaid bills, scheduling patient appointments, hiring and managing staff, and investing in quality improvement efforts.
Administrative services only (ASO)
Administrative services only (ASO) is an arrangement an employer makes with a third party to administer the employer’s health insurance benefits to its workers, family members, and retirees. Employers often use ASO arrangements because they are self-insured, meaning they assume the financial risk of providing health insurance benefits to workers. When they are self-insured, they do not need to contract with a health insurer to provide health insurance to their workers. Many self-insured employers use third-party administrators (TPAs) in ASO arrangements and they also contract with health insurers as ASOs. As ASOs, health insurers process claims and make payments and let the employers’ workers, families, and retirees use the insurers’ physician and hospital networks. TPAs usually don’t have networks of providers and so they just process claims and make payments.
Admissions per 1,000
Health insurers use the admissions per 1,000 (or sometimes admissions/1,000) metric to show the number of hospital admissions for each 1,000 persons covered under a health insurance plan in a given time. In this way, insurers may be able to measure and compare the disease burden of certain populations.
Advanced alternative payment models (Advanced APMs)
Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress allowed physicians to earn incentive payments by participating in Advanced APMs. The federal Centers for Medicare & Medicaid Services defines APMs such as Comprehensive ESRD Care (CEC) accepting upside and downside (two-sided) financial risk, Comprehensive Primary Care Plus, Next Generation ACO Model, certain Medicare shared savings programs, an Oncology Care Model accepting two-sided risk, a Comprehensive Care for Joint Replacement Payment Model, and the Vermont Medicare ACO Initiative.
Advance Beneficiary Notice of Noncoverage (ABN)
An ABN is a notice that a hospital, physician or other provider gives to a Medicare beneficiary before delivering the health care service in question, stating that Medicare may deny payment for the service. If a Medicare member does not get an ABN before getting the health care service, and Medicare denies the payment, then the consumer may not have to pay for the service. If, however, a consumer gets and signs an ABN, the consumer is likely to be responsible for the service if Medicare denies payment.
Advance premium tax credits (APTCs)
help consumers lower their monthly health insurance premium payments when buying health insurance on the Affordable Care Act (ACA) marketplaces. The tax credits are based on each consumer’s estimated annual household income and household size. Consumers can choose to have all, some or none of their credits paid directly to their health insurer. (See also: IRS Form 8962.)
Affordable Care Act (ACA)
Officially known as Patient Protection and Affordable Care Act, the ACA was signed into law on March 23, 2010. The main provisions of the law include a mandate for employers with 50 or more employees to provide health insurance for all full-time employees and family members or pay a penalty and a mandate for individuals to buy health insurance coverage or pay a penalty. The law also calls for subsidies for low- and moderate-income Americans to help them buy insurance and for state-based health insurance exchanges. These provisions go into effect on Jan. 1, 2014 (except for the employer mandate, the implementation of which is delayed until Jan. 1, 2015). The law is designed to help an estimated 32 million Americans gain insurance coverage by 2019.'
All or nothing contracting
When health insurers negotiate with large hospitals or health systems or with large physician groups, the providers sometimes insist on “all or nothing contracts” in which the insurer must contract with all members of the organization, meaning all hospitals in an affiliated group or all hospitals and facilities in a health system. Health policy experts consider such contracts to be anti-competitive in nature.
The allowed amount is the maximum that a health insurer will pay for covered health care service. After the insurer pays the allowed amount, the insured member usually would be responsible for the balance of the bill unless other insurance coverage is available. The allowed amount also may be called the eligible expense, the payment allowance or the negotiated rate. See also Balance billing.
Alternate delivery system
Health insurers consider an alternate delivery system to be one of several kinds of facilities that deliver more lower-cost care than the insurer or patients would get in a hospital.
Alternative payment models (APMs)
The federal Centers for Medicare & Medicaid Services says physicians participating in alternative payment models would be eligible for financial rewards under the Medicare Access and CHIP Reauthorization Act of 2015 if they work in certain settings such as medical homes and in the Medicare Shared Savings Program. CMS makes a distinction between APMs and Advanced APMs. An APM would be a medical home or an accountable care organization with Medicare as a payer or in which physicians or other eligible clinicians play a core role in implementing the payment methodology. Also, the organization should aim to improve quality and cut the cost of services.
Ambulatory care sensitive condition
ACSCs are those for which good outpatient or primary care could prevent the need for hospitalization, or for which early intervention could prevent complications or more severe disease. Medicare and policy makers use rates of hospital admissions for ACSCs to assess the effectiveness of primary care.
Ambulatory payment classification (APC)
The APC is a coding system that Medicare requires hospitals to use when billing for services provided to Medicare and Medicaid patients. Every procedure or medication prescribed has its own unique code that hospitals use when seeking payment.
Some health insurers set yearly limits on what they will pay for individuals and families, either in total costs or for services such as prescriptions, dental care, or hospitalizations. After an insured person reaches the limit, he or she must pay all such costs for the rest of the year.
Arbitration or independent dispute resolution
Under the federal No Surprises Act of 2020, the first step in resolving disputes over surprise bills is negotiations between the insurer and the provider. If negotiations fail, the insurer and provider may elect to use the federal independent dispute resolution (arbitration) process in which an arbitrator would select an amount after reviewing the amounts the parties submit.
A new designation for physicians who have finished medical school but have not yet been matched to a residency program.
A policy the Massachusetts health insurance exchange uses to prevent coverage interruptions among low-income enrollees. Rather than disenroll people who fail to make a premium payment, the policy automatically switches them to an available free plan until they actively cancel or lose eligibility.
Average manufacturer price (AMP)
When a drug retailer or wholesaler buys a medication directly from a manufacturer, the AMP is the average price paid. Congress created the AMP to calculate rebates for the Medicaid program in 1990 and is available to the public.
Average sales price (ASP)
The average sales price is what all purchasers pay to drug manufacturers. ASP includes practically all discounts but is available only for medications covered under Medicare Part B.
Average wholesale price (AWP)
The AWP is what pharmacies pay to buy drugs from wholesalers.
This occurs when a hospital, physician or other health care provider sends a bill to a managed care patient after the patient’s health insurer has paid its share. The patient owes the balance. By law, providers cannot balance-bill Medicare patients. Thirteen states have passed laws to protect managed care patients from exorbitant balance billing, which occurs when an out-of-network provider charges a patient an out-of-network rate, usually higher than the rate in-network providers charge, according to the Kaiser Family Foundation. Some out-of-network charges are extremely high even though the patient believed he or she was getting care in network. In-network doctors sometimes will ask out-of-network doctors to assist in a procedure and the patient gets billed for whatever the out-of-network provider charges. The health insurer may pay the out-of-network doctor an in-network rate or nothing at all, leaving the out-of-network doctor to charge the patient the remaining amount.
The federal Centers for Medicare and Medicaid Services makes base payments and supplemental payments in the Medicaid program. Base payments include fee-for-service or capitated payments and are specifically tied to the care that health care providers deliver to individuals. (See also: supplement payments.)
When used in reference to health insurance, the concept of behavioral hazard defines the behavior that some insured individuals may exhibit when forced to pay copayments of deductibles when seeking physician or hospital care. Economists fear that when insured persons need care and yet must pay for such care they may forego certain recommended treatments. A patients on cholesterol-lowering medication may not have any symptoms, for example, but does not want to incur the expense of making a copayment for the medication and thus skips this prescribed treatment. Economists believe that higher levels of cost sharing worsen the problem.
Behavioral Risk Factor Surveillance System (BRFFS)
The CDC conducts the BRFFS to collect state data about U.S. residents regarding their health-related risk behaviors, chronic health conditions and use of preventive services. The CDC says the BRFFS is the largest continuously conducted health survey system in the world.
The Affordable Care Act has two definitions for the term benchmark plan. In one definition, a benchmark plan is the second-lowest-cost silver plan available in the federal Marketplace in a certain area. The price of this plan is used to calculate premium subsidies and may vary from one part of a state to another, depending on the rating area and plan availability. The second definition of benchmark plan is that it is the one plan that each state designates as the standard for essential health benefits (EHBs). Under the ACA, states are responsible for designating benchmark plans and health insurers in each state use the benchmark plan when creating their own EHB-compliant health plan options.
This occurs when specialty pharmacies ship a drug directly to a patient, who then takes the medication to the provider’s office for administration. See also white bagging.
Most health insurers pay providers under fee-for-service arrangements. If a physician sees a patient in the office, the physician bills the patient’s insurer for that time. If a patient needs heart surgery in a hospital, the hospital bills the insurer for the operation, hospital stay, supplies and other costs. The cardiologist, anesthesiologist, and other providers all bill the insurer as well. The patient also may be billed.
Bundled payment, however, is a fundamentally different form of payment. Under bundled payment, physicians, hospitals, and other providers assume the financial risk for delivering an episode of care. For heart surgery, the episode would be some period before the surgery, usually 30 days, and sometime after the surgery, usually 90 days. For a chronic condition such as asthma, diabetes, or congestive heart failure, a physician would bill the insurer for one year’s worth of care for each patient under a bundled payment arrangement. Most bundled payment programs are for acute care episodes, such as hip or knee replacement surgery, but many are for patients with chronic conditions. Insurers pay physicians and hospitals working under bundled payment arrangements a set fee. The providers usually are fully responsible for any costs above that fee and can share any savings if costs are below the fee. Physicians and hospitals also are responsible for any potentially avoidable complications, such as if a surgery patient gets an infection. Bundled payment thus aligns the insurers’ incentives to control costs and shifts financial risk to providers and providers who can share in any savings. See also Warranteed payment, Episode payment for a procedure, and Condition-based payment.
A process that physicians and other providers use when a patient needs a specialty drug that the provider will administer to the patient. The physician or provider will buy the drug, store the medication in the office and then administer the drug to a patient usually in an office or other clinical setting. After the provider has purchased and administered the medication, the provider will bill the health insurer for the drug and the administration fee.
Obstetricians and other physicians will perform a Caesarean section, also known as C-section or caesarean delivery, to deliver one or more babies when the providers fear that the mother or baby or both are at risk. For health insurers, a Caesarean section is a complication that costs more than a normal vaginal delivery. Reducing the Cesarean-section delivery rate is often cited as a goal of the nation’s health system because of the perceived health, economic and societal benefits derived from vaginal deliveries.
When a health care provider receives a fixed payment for each patient under his or her care, regardless of whether the provider’s patient receives many or few health care services, this payment is called capitation or a capitated fee. An annual capitated payment covers all services for a year. The word “capitation” has a negative connotation among insurers and so they sometimes refer to annual or capitated payments as global payments or a global budget.
Case Mix Index (CMI)
Calculation that the federal Centers for Medicare and Medicaid Services uses to reflect the clinical complexity, diversity and resource needs of all the patients in a hospital. A higher CMI indicates a more complex and resource-intensive case load, meaning the patients in this hospital are sicker than those in a hospital with a lower CMI.
Centers for Medicare & Medicaid Services (CMS)
Part of the Department of Health and Human Services, this federal agency runs Medicare, Medicaid and the Children’s Health Insurance programs. It now includes centers, or offices, responsible for key elements of health reform, such as the federal Center for Medicare & Medicaid Innovation.
In August 2020, the federal Center for Medicare and Medicaid Innovation (CMMI) announced the Community Health Access and Rural Transformation (CHART) Model by giving rural hospitals a capitated payment for improving care quality and patient outcomes. The program has two tracks: the Community Transformation Track and the ACO Transformation Track. (See also: Community Transformation Track and ACO Transformation Track.)
Chief experience officers
As health insurers focus on star ratings from Medicare and their member-satisfaction scores, they have begun to hire experience officers whose job is to ensure that all members are satisfied with the benefits and medical care they receive. Health plans know that the loss from getting no bonus under the star ratings program can affect income by more than $1 million in a year given that Medicare pays no bonus for ratings of three or lower (on a five-point scale). The job of the chief experience officer (or CXO) is to ensure that the health insurer is making member satisfaction a top priority, just as luxury brands such as the Four Seasons hotels and Lexus automobiles do for their customers.
Children’s Health Insurance Program (CHIP)
The federal CHIP program provides health coverage to nearly 8 million children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage. Signed into law in 1997, CHIP provides federal matching funds to states to provide this coverage.
Any information recorded on the forms physicians, hospitals and other providers use to submit claims for payment health insurers. Claims data differ from clinical data (see separate entry). Two types of information are recorded in claims data. First are procedure codes that describe the specific services a patient gets. These codes are recorded using the American Medical Association’s Current Procedural Terminology (CPT) codes to report medical procedures and services to public and private health insurers. Second are diagnosis codes that describe the patient’s health issue being treated. Providers in the United States use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). By Oct. 1, 2015, providers will change to ICD-10-CM, which providers use in most other countries.
When an insured patient pays a copayment for a prescription that exceeds the total cost of the drug to their insurer or the insurer’s pharmacy benefit manager (PBM), pharmacies and PBMs often don’t pass along that difference to consumers. When that happens, the pharmacy or PBM is said to “claw back” that difference.
This describes a patient’s condition and the services provided and are recorded in the patient’s medical chart, an electronic health record or a clinical data registry. The two types clinical data are the services a patient receives and the health problems of the patient. Generally, clinical data have information about services and health problems than are contained in claims data and may include services ineligible for payment and health problems, such as a comorbid condition, that the provider did not treat explicitly.
Clinical decision support (CDS) systems
Health insurers use CDS systems to give clinicians and other providers patient- and condition-specific information about the treatment protocols insurers want physicians and others delivering care to follow. The systems are designed to alert providers at appropriate times at the point of care. Such systems are designed to improve the quality of care, enhance patient outcomes, avoid errors (particularly adverse events related to prescription drugs, and make care delivery more efficient. Physicians complain that such systems can be intrusive and inflexible.
Commercial determinants of health (CDoH)
The World Health Organization defines commercial determinants of health as “factors that influence health which stem from the profit motive.” Health policy researchers use the term CDoH to focus attention on the role of corporations to affect the environment and in making tobacco products, alcoholic beverages, highly processed food and beverages, and other harmful products that are drivers of non-communicable diseases (NCDs). (See also social determinants of health or SDoH.)
Community Transformation Track
This track is one of two under Medicare’s Community Health Access and Rural Transformation (CHART) Model for rural hospitals. Under this track, Medicare, Medicaid, and other payers could shift to capitated payment instead of using the fee-for-service or cost-based payment systems. (See also: Chart Model and ACO Transformation Track.)
Complex and Chronic Care Improvement Program (CCIP)
CMS uses the CCIP to promote management of patients who have chronic conditions and are enrolled in a Medicare Advantage plan. Health insurers use CCIPs to improve the care and outcomes for enrollees with chronic conditions by slowing disease progression, preventing complications and comorbidities, reducing preventable emergency room visits and inpatient stays, improving patients’ quality of life, and cutting costs.
Complexity of care charges
Emergency rooms often charge fees based on the complexity of care needed for each patient. These fees usually are ranked on a scale from 1 being the lowest complexity to 5 being the highest complexity. Rarely are patients aware of these fees at the time of the visit. Instead, these fees are listed on bills the patient or the patient’s insurer will get days or weeks later.
Comprehensive medication management (CMM)
This is a whole-person approach that is similar to medication therapy management but, as the name implies, can be more comprehensive. CMM is designed to help patients manage their prescription drugs, over the counter medications, and dietary or other supplements. Usually a pharmacist will conduct a CMM and will focus on the patient’s clinical and personal goals of therapy, rather than relying solely on the knowledge of the currently prescribed medications as a baseline for interventions. While the term “comprehensive medication management” is sometimes used interchangeably with medication therapy management, not all experts agree that the terms are interchangeable.
Comprehensive protections against balance billing and surprise bills
Many states are working on or have passed laws to protect consumers from balance billing or surprise medical bills, but not all these laws are considered to be comprehensive in how they protect consumers. The Commonwealth Fund considers the following elements necessary to protect consumers comprehensively: Protections must extend to both emergency room and in-network hospital settings; the laws must apply to all types of insurance, including HMOs and PPOs; the laws must protect consumers from extra provider charges and from balance billing, and the laws must adopt an adequate payment standard regarding how much the insurer pays the provider or a process to resolve payment disputes between providers and insurers.
Comprehensive risk-based plans
Comprehensive risk-based plans or managed care organizations (MCOs) are the most common type of Medicaid managed care arrangement. States using this arrangement will pay a qualified health plan a fixed per member per month (PMPM) payment to provide a defined set of health services to plan enrollees through a network of participating providers. If expenditures exceed total income, the health plan is responsible for absorbing the losses.
Concierge medicine is a method of care in which an individual physician or group practice of physicians give patients longer office visits and more time and attention than patients get in a typical doctor-patient arrangement. The doctors also respond quickly to requests for care. Usually, a patient would pay a monthly, quarterly, or annual fee for concierge care and other fees for individual services.
A copay is a fixed fee that an individual would pay for each health care service, such as $15 for primary care and $50 for specialist care. Copays or copayments vary from plan to plan. Co-insurance is a percentage that the patient pays for health care services and would be paid in addition to a copay. Both a copay and co-insurance count toward a patient’s annual out-of-pocket limit. Copays sometimes are paid to in-network providers while co-insurance is paid to out of network providers, but these arrangements vary from plan to plan.
Under the Affordable Care Act, Congress called for the Consumer Operated and Oriented Plan Program (Co-ops), that would serve as qualified nonprofit health insurers that would competitive health plans in the individual and small group markets. These nonprofit organizations can be formed at national, state or local levels and can include doctors, hospitals, and businesses as member-owners to offer insurance through the ACA marketplaces.
Under this form of bundled payment an insurer would pay a single amount for all services and procedures needed to treat a particular patient condition or combination of conditions for a certain period of time (usually one year). The insurer may make the payment in monthly installments, as it would under capitated payment. In fact, condition-based payment is similar to capitated payment for one patient with one or several conditions. The physician gets one payment to cover all costs for that patient’s condition for one year. A patient with diabetes, for example, would need certain services over a year, such as exams and blood tests, and these services would be included in the payment. If the patient’s actual costs after one year are higher than what the physician receives in payment, the physician would need to pay that higher amount.
Consumer-directed health plan (CDHP)
The National Health Insurance Survey defines a CDHP is an HDHP that is linked to a special tax-advantaged account that a consumer uses to pay for medical expenses. These tax-advantaged accounts are sometimes called health savings accounts (HSAs), health reimbursement accounts (HRAs), personal care accounts or personal medical or choice funds. Any unspent funds in these accounts are carried over to subsequent years. These accounts are different from flexible spending accounts.
Most Americans who have health insurance have a cost-sharing arrangement with their health insurer because the insured individual pays a part of the cost of health care services and the insurer pays the other part. Also, Americans with employer-sponsored health insurance typically share the cost of individual and family premiums with their employers.
This occurs when a hospital or other provider charges an insured patient more than it charges an uninsured or underinsured patient for the same health care service. In effect, those patients who have health insurance cover the financial loss providers incur when they delivering care to those who do not have insurance or who are underinsured.
Approximately 2.5 million poor uninsured adults have fallen into what health policy experts called the ‘coverage gap’ that resulted from state decisions not to expand the Medicaid programs in 14 states (as of March 2019). These individuals earn too much to qualify for Medicaid, but not enough to be eligible for premium tax credits allowed when buying health insurance on the ACA Marketplace.
Critical Access Hospital
A Critical Access Hospital is a hospital with fewer than 25 acute inpatient beds in a rural area and distant from other hospitals. The federal Centers for Medicare & Medicaid Services designates facilities as critical access hospitals and pays them under a system in which they are reimbursed for services plus a small margin for profit. Most larger hospitals are paid through the Medicare Inpatient Prospective Payment System.
An insurance deductible is an amount an insured individual or family would owe for health care services before a health insurance plan would begin to pay. An annual deductible of $500, for example, would mean that an individual would need to pay $500 out of pocket for all health care services before an insurance company would start covering health care costs. Deductibles are paid before an individual pays his or her co-insurance amount, which is almost always higher than the deductible. The deductible and co-insurance both count toward an individual’s out of pocket maximum per year.
Defined benefit vs. defined contribution
When a health plan, whether through a private employer or a government program such as Medicare or Medicaid, promises specified benefits (even if the costs can fluctuate, benefits are guaranteed), it's called a defined benefit. Under Medicare and Medicaid, the government must spend what’s necessary to provide benefits for everyone enrolled in these programs. Beneficiaries may need to share in paying for some costs, but the benefit is not capped. Most private health insurance plans still have defined benefit plans in which the employer pays a certain percentage of the premium, and the employee pays the rest.
But more employers today are adopting defined contribution plans in which they a pay limited, set, or fixed amount toward health coverage, whether through a voucher or another form of payment. Beneficiaries may have their choice of health plans, but the contribution is fixed. That means the government or employer has a fixed financial liability. The development of the state-based insurance exchanges has accelerated the growth in defined contribution plans because they allow employers to pay a set amount for each employee’s care and employees then shop for the best insurance coverage on the exchanges.
Direct contracting is an arrangement between a purchaser and a provider to deliver health care services for a select group of patients, usually health plan members or employees, family members and retirees of one or more employers. The health plan or the employer pays the providers directly for each service the provider delivers to the patients. Often, purchasers make direct contracts with the best providers for certain treatments such as joint replacement or cardiac care.
Direct and indirect remuneration (DIR)
Direct and indirect remuneration (DIR) fees are the result of a loophole in Medicare regulations that allow health insurers to claw back fees paid to pharmacies more than half a year after a pharmacy fills a prescription for a Medicare member. Health insurers take back the fees based on a pharmacy’s poor performance on quality measures, according to the National Association of Chain Drug Stores (NACDS). These quality measures may be unknown, unpredictable, inconsistent and outside of a pharmacy’s control, NACDS has said.
Direct primary care
Direct primary care (DPC) is a form of a bundled capitation payment model in which a primary care doctor or group practice of primary care doctors charges a monthly, quarterly, or annual fee to a patient to cover all or most of the services the primary care practice would normally provide, such as office visits, laboratory testing or other care management services. The patient would not necessarily need to enroll in a health plan or group health insurance. Instead, the patient might have coverage for catastrophic care. The patient would not be charged a separate fee for individual services the doctor or group practice provides.
Double burden of disease
The double burden of disease is a term researchers and public health officials use to describe the coexistence of undernutrition and obesity or diet-related non-communicable chronic diseases. In 2014 the WHO declared that the double burden of diseases was an important public health issue.
Hospitals, physicians, or other health care professionals have downside risk if they could incur costs that are greater than the payments they receive. See also: Upside risk.
Health insurers offer embedded deductibles when providing family coverage. When a family has an embedded deductible, the family has a deductible and each family member has an individual deductible that is much lower than the total family deductible. After an individual meets his or her deductible, the health plan pays for that person's covered medical services, even if the family had not met its deductible. An embedded deductible can be advantageous for family if one family member has unusually high covered medical expenses. When that family meets his or her deductible, the insurer begins to pay for that person’s expenses even if the family has not yet met its deductible.
Employee welfare benefit plan
The federal Department of Labor defines an employee welfare benefit plan as one that an employer or employee organization would establish to buy insurance for employees and their family members to cover the costs of medical, surgical, or hospital care or to cover benefits to cover sickness, injuries from an accident, disability, or other benefits such as unemployment, vacation costs, training or other benefits as described in the Labor Management Relations Act of 1947.
Many Americans who are employed full time get health insurance for themselves and their family members through their employers. The employers generally pay for most of the cost of the insurance while workers pay a share of the total expense through premiums, copayments and deductibles. That share has been rising as employers have shifted more costs to workers as health insurance costs have risen. A report, The Kaiser Family Foundation and Health Research & Educational Trust 2012 Employer Health Benefits Annual Survey, shows what employers have paid since 1988 and how those costs have risen.
Employer-group waiver plans (EGWPs)
EGWPs (pronounced egg-whips) are customized health plans under the Medicare Advantage program that are developed exclusively for employers and union groups that use these plans to provide supplemental coverage for retirees beyond the standard benefits typically offered under Medicare Advantage plans. The federal Centers for Medicare and Medicaid Services determined that EQWPs were required because otherwise Medicare rules would hinder their development.
The employer mandate is a key part of the Affordable Care Act. It requires companies with more than 50 employees to provide health insurance to workers and their family members or face a penalty. Disagreements over whether the mandate was constitutional were the basis for many lawsuits challenging the Affordable Care Act. In a significant ruling in June 2012, the U.S. Supreme Court upheld the mandate in the ACA. The employer mandate was originally scheduled to take effect on Jan. 1, 2014, but the Obama administration decided in June 2013 to delay implementation of the employer mandate until Jan. 1, 2015.
Episode payment for a procedure
Under this form of bundled payment, an insurer makes a single payment for all services associated with delivering a procedure including those services needed before the procedure (usually 30 days) and a specific period after the procedure (usually 90 days). The payment includes services to correct preventable complications after the procedure, such as the need to care for an infection. In the case of any surgery requiring rehabilitation services, such as physical therapy, those services would be covered in full and the patient would not need to pay an additional fee.
The Employee Retirement Income Security Act of 1974 (ERISA), pre-empts state law, thwarting state efforts to regulate health insurance that self-insured employers offer to their workers. Self-insured employers cover 57 percent of all Americans who have health insurance. Courts have long upheld the concept of ERISA pre-emption, saying that ERISA allows self-insured employers to be exempt from state regulations that apply to traditional health insurers.
ESRD Seamless Care Organizations (ESCOs)
ESCOs are specialty focused accountable care organizations that participate in a federal program for Medicare beneficiaries who have end-stage renal disease (ESRD). In 2015, the federal Centers for Medicare and Medicaid Services started an alternative payment initiative called the Comprehensive ESRD Care (CEC) Model to provide better care for beneficiaries with ESRD. In this program, the participating dialysis facilities, nephrologists and other providers can form specialty-focused ACOs called ESCOs that assume financial responsibility for the quality of care they deliver to ESRD patient and for the spending for these patients under Medicare Part A and Part B.
Essential health benefits
Essential health benefits are a set of benefits created under the Affordable Care Act that will ensure that a plan covers comprehensive services. All plans, inside and outside of the state-based exchanges, will need to meet these minimum requirements in order to offer coverage on the exchanges. Some insurers will decide not to participate on the exchanges rather than offer essential health benefits for all exchange participants.
Evidence-based hospital referral
Refers to one involving a patient with a high-risk condition who is referred to and then treated at a hospital with those characteristics shown to be associated with better outcomes, which include a combination of patient outcomes, evidence-based processes of care, and criteria to show that the hospital has treated a sufficient number of patients (or has patient volume) to be proficient in delivering such care.
Physicians and hospitals define evidence-based medicine as the use in daily medical decision making of the best available scientific research and practices with proven effectiveness and that integrates the best research evidence with clinical expertise and patient values.
Exchanges or health insurance exchanges
The exchanges are new marketplaces in which individuals and small businesses can purchase health insurance under the Affordable Care Act. Some states are developing their own exchanges (such as Covered California) and others have refused to develop exchanges, which means the federal government will establish the exchanges in these states. States can have one exchange for small business and another for individuals, or they can merge them.
Excluded services are those that a health insurer deems not to cover under the terms of its contract with an insured individual. If a service is excluded from coverage, the insured person would need to pay the full amount for the care received. Cosmetic services are an example of care that is often excluded under health insurance contracts.
Hospitals sometimes charge a facility fee if an outpatient visits a doctor in a clinic that the doctor does not own. For example, if a hospital owns the clinic, then a hospital may charge a facility fee if a patient visits the doctor in the hospital-owned clinic. Hospitals also charge facility fees simply as a way to increase charges to patients, such as those outpatients who visit an emergency room. Facility fees can range from $10 up to several hundred or, in some cases, several thousand dollars. Many insurance plans do not cover facility fees or cover only a portion of these fees.
Under the Affordable Care Act (ACA), employees who have employer-sponsored health insurance can qualify for premium subsidies if their employer requires them to spend more than 9.83% of their household income on the company’s health plan premium. This percentage creates what’s called the family glitch because household income is based on the cost of the employee-only coverage, not the premium required to cover the worker’s dependents. Therefore, if the worker’s payment for self-only coverage is less than 9.83% of household income, the employee and all dependents are ineligible for financial assistance under the ACA, even if the cost of adding dependents to the employer’s plan would exceed 9.83% of the family’s income.
Family income level
Under the Affordable Care Act, the federal government uses family income levels to set subsidies for health insurance bought on the federal or state marketplaces. The categories of family income are based on the ratio of the family’s income in the previous calendar year to the appropriate poverty threshold (given the family’s size and number of children), as defined by the U.S. Census Bureau.
Federal poverty level
A term often used to define the federal poverty guidelines. The federal Department of Health and Human Services says the term “federal poverty level” (or FPL) is ambiguous and should be avoided. Instead, HHS recommends using the term federal poverty guidelines, which HHS publishes each year in the Federal Register. The guidelines are used to determine financial eligibility for certain federal programs such as subsidies for health insurance.
Flexible spending accounts (FSAs)
Some employers offer FSAs to allow employees to set aside pretax dollars of their own money for their use throughout the year to pay for out-of-pocket health care expenses. Any funds remaining in an FSA account at yearend returns to the employer following a short grace period.
A formulary (also called a drug list) is a list of prescription drugs that a health insurer or pharmacy benefit manager will cover under any insurance plan offering prescription drug benefits. Drugs not listed on a formulary are not covered, requiring consumers to pay the full retail price. Health insurers and PBMs usually place certain formulary drugs on tiers in which the lower tiers require the lowest copayments and higher tiers require higher copayments.
Global payment is a form of capitated payment in which health insurers pay physicians, hospitals and other providers a set fee for each person under care. The fee is usually paid on a per-member-per-month basis as a fixed monthly payment. The physicians, hospitals, and other providers would form a network to share the funds and provide all care to the health plan members the insurer would assign. If all care after one year is lower than what the providers are paid, they can share in the savings. If all care is higher than what they are paid, the providers would need to cover those costs from their own funds or from a stop-loss insurance policy. Critics have charged that global payment, like capitation, encourages providers to stint on care delivery. While providers may gain in the short term from delivering less care than members need, they may lose out over time if patients need more expensive care later. To ensure that members get the best, most appropriate care, some health insurers pay providers extra if they achieve certain quality goals, such as ensuring that all patients get appropriate health screenings, for example.
Group model HMO
A group model health maintenance organization (HMO) is one that contracts with a single multispecialty medical group to provide care to the HMO’s members, or one that owns a multispecialty group of physicians. The group practice may work exclusively with the HMO, or it may provide services to non-HMO patients as well. The HMO may pay the medical group a negotiated, per capita rate and then the group would distribute these funds among physicians, usually as salary. Examples of group-model HMOs include Group Health Cooperative in Washington State and Kaiser Permanente in California and other states.
Health care common procedure coding (HCPC)
Physicians, hospitals and other health care providers use this five-digit numbering system to standardize professional and outpatient billing for some medical services.
Health care tax deductions
The IRS allows taxpayers to deduct medical expenses, such as copayments, deductibles, coinsurance, hospital and physician bills and medical care-related transportation costs, as long as the total spending on such expenses exceeds 7.5% of the taxpayer’s adjusted gross income.
Health insurance unit (HIU)
consists of an adult, a spouse and any dependent children who would need commercial health insurance or a health plan from a public source such as the Affordable Care Act’s health insurance marketplaces. Researchers use the HIU when analyzing health insurance coverage. The term HIU was developed to aid researchers in reconciling the differences between the way federal surveys (such as the U.S. Census) define a family with the way health insurers define a family.
Before the Affordable Care Act (ACA) became effective in January 2014, states offered health insurance coverage to individuals through high-risk pools to those who had pre-existing conditions and lacked health insurance. The pools were often underfunded, which limited the choice of health plans and made coverage costly. Under the ACA, individuals with insurance through high-risk pools could get health coverage on the exchanges with subsidies based on income or off-exchange without subsidies.
Hospital Referral Regions (HRRs)
The Dartmouth Atlas Project defines hospital referral regions as regional health care markets for tertiary medical care. Each of the nation’s 305 HRRs contains at least one hospital that performs major cardiovascular procedures and neurosurgery. HRRs are geographically contiguous and have a minimum population of 120,000 people.
Hospital service areas (HSAs)
The Dartmouth Atlas Project defines local health care markets for hospital care as HSAs. Each of the 3,436 HSAs in the United States is a collection of ZIP codes whose residents receive most of their hospitalizations from the hospitals in that area. Most HSAs contain only one hospital.
Occurs in health care when companies acquire or merge with other similar companies. For example, when a health system acquires a hospital or when individual physicians join large physician groups or when one physician group joins another. (See also vertical integration.)
Health maintenance organizations (HMOs)
An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with. HMOs typically have a closed network of hospitals, physicians, and other providers, meaning members must choose one of these providers and cannot get care from another provider without a referral. A member who gets care outside of the network without a referral may be asked to pay the full cost of that care.
Health savings accounts (HSAs)
An HSA has tax advantages because the funds contributed (usually by an employer) are not subject to federal income tax when they are deposited. Also, any unspent funds in the HSA can carry over from year to year, and the owner can take her or her HSA funds from one job to the next. Federal tax rules limit what expenses the owner can cover with HSA funds to what the government calls qualified medical expenses. When the funds are used to pay for qualified medical expenses there is no federal tax liability. Other names for HSAs include health reimbursement accounts (HRAs), personal care accounts or personal medical or choice funds. HSAs are different from flexible spending accounts.
High-deductible health plans (HDHPs)
In 2015 and 2016, the National Health Insurance Survey of the federal Centers for Disease Control and Prevention defined an HDHP as a private health plan with an annual deductible of at least $1,300 for self-only coverage or $2,600 for family coverage. The deductible is adjusted annually for inflation. For 2013 and 2014, the annual deductible was $1,250 for self-only coverage and $2,500 for family coverage. The survey makes a distinction between an HDHP and a consumer-directed health plan or CDHP.
High out-of-pocket costs
When evaluating employer-sponsored insurance coverage, a household’s spending on out-of-pocket costs includes expenditures for deductibles, copayments and coinsurance for prescription drugs; physician and dental visits; and other care such as surgery, eyeglasses, contact lenses, and medical supplies (but not over-the-counter medical items). If these costs equal 10% or more of the household’s annual income and are not covered by the household’s employer-provided health insurance, they are considered high, according to the Commonwealth Fund, which tracks these costs. For families earning less than 200% of the federal poverty level, then a household’s out-of-pocket costs would be high if they equal 5% of annual income.
High premium contributions
When evaluating employer-sponsored coverage, a household’s contributions to the employer’s health insurance premium costs are defined as low or high relative to the household’s income. A household’s premium contributions are considered high if the total annual amount the household pays for its employer-sponsored health insurance premiums equals 10% or more of annual household income, according to the Commonwealth Fund, which tracks these costs.
Home Health Value-Based Purchasing (HHVBP) Model
Refers to a CMS Innovation program designed to improve the quality and delivery of home health care services to Medicare beneficiaries by provide financial incentives to encourage home health providers to deliver better quality care more efficiently, to study potentially new quality and efficiency measures for appropriateness and to enhance the current public reporting process. The program began in 2016 for all Medicare-certified home health agencies in nine states. Changes in payment to these agencies will rise or fall over five years (2018 through 2022) based on their performance against certain quality measurers, CMS said.
Hybrid health care
This refers to practices that offer both telehealth and in-person treatment. These practices may use video conferencing for patient monitoring and text messaging for appointment scheduling and follow-up. Some patients may be managed remotely, face-to-face or both.
The International Classification of Diseases, Ninth Revision, Clinical Modification, will replace the ICD-9-CM codes in the United States on Oct. 1, 2015. There are 68,000 ICD-10 codes and they provide more specific information on the patient’s diagnosis than ICD-9 codes provides. , which are seven-position alphanumeric codes that et has been expanded from five positions (first one alphanumeric, others numeric) to seven positions. The codes use alphanumeric characters in all positions, not just the first position as in ICD-9 in part because the ICD-10 cods are a combination of diagnoses and symptoms, meaning fewer codes are needed to describe a condition fully.
IRS Form 8962
Some consumers buying health insurance on the Affordable Care Act marketplaces will be offered advance premium tax credits (APTCs) to lower their monthly insurance payments. Those consumers can choose to receive all, part, or none of the APTC each month. Those who choose to get all or part of the APTC each month must file IRS Form 8962 on their federal income tax returns to reconcile the amount of APTC paid against estimates made during enrollment of income and tax credits the consumers would need that year. (See also: advance premium tax credits.)
Part of the Affordable Care Act, this mandate requires individuals to have health insurance, or face a penalty. Dispute over whether the mandate was constitutional was the basis for lawsuits challenging the ACA. In a significant ruling in June 2012, the U.S. Supreme Court upheld the mandate in the ACA.
Inpatient Prospective Payment System
The federal Centers for Medicare & Medicaid Services uses the Inpatient Prospective Payment System (IPPS) to pay for health care services delivered in most large acute care hospitals for inpatient stays. Under the IPPS, a hospital is paid a case rate for each patient, meaning the hospital receives a single payment for the patient’s entire stay. The payment is based on the patient’s diagnosis.
Lab-developed tests (LDTs)
The FDA defines a laboratory developed test as “an in vitro diagnostic test (meaning it can detect diseases, conditions or infections) intended for clinical use and designed, manufactured and used within a single laboratory.”
Learning health care system
The Institute of Medicine says achieving higher quality care at lower cost will require an across-the-board commitment to transform the U.S. health system into a "learning" system that continuously improves by systematically capturing and broadly disseminating lessons from every care experience and new research discovery. Incremental upgrades and changes by individual hospitals or providers will not suffice, the IOM said.
Before the Affordable Care Act became effective in January 2014, many health insurance plans limited what insurers would pay throughout an individual’s life. After an insured person reached this lifetime limit, the individual was responsible for paying for all of their health costs. The ACA prohibited lifetime limits on benefits beginning in 2010, the year the law passed.
Limited benefits plans
are a type of health insurance coverage that limits coverage only for certain specified health care services or treatments or provides coverage for health care services or treatments only up to a specific dollar amount or a limited period.
The Medicaid and CHIP Payment and Access Commission (MACPAC) is an advisory committee on established in 2009 and then expanded and funded in the Affordable Care Act of 2010. MACPAC reviews state and federal policies and makes recommendations to Congress, to the federal Department of Health and Human Services and to the states on matters related to Medicaid and children’s access to care.
are those required that state or federal law requires all health insurance policies provide to insured individuals.
In 36 states, the federal Department of Health and Human Services runs the Marketplace for consumers enrolling in health insurance under the Affordable Care Act. There are 14 states and the District of Columbia operating state-based marketplaces (SBMs). The Marketplace and the SBMs are the only sites where consumers can buy comprehensive health insurance that fully complies with the requirements of the ACA. (See also: state-based marketplaces.)
Maternal mortality ratio
Maternal mortality ratio is reported as the number of maternal mortality deaths per 100,000 live births when such a death is defined as while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancy and from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. The federal Centers for Disease Control and Prevention and the World Health Organization use this ratio when making international comparisons.
Maximum allowable cost lists (MAC lists)
Pharmacy benefit managers used MAC lists to determine what to charge employers for drugs and how to pay pharmacies. Not available to the public, these lists allow PBMS, such as CVS, Express Scripts and OptumRx, to charge employers higher rates, pay pharmacies lower rates, and then pocket the difference.
This is a term the federal Centers for Medicare & Medicaid Services (CMS) uses to describe the ideal use of electronic health record (EHR) systems. Certified EHRs should be used to reduce health disparities and improve quality, safety, and efficiency; to engage patients and family; to improve population, public health, and care coordination; and to maintain privacy and security of patient health information, CMS said. Under meaningful use, CMS has been paying physicians and hospitals to adopt, implement, upgrade, or demonstrate meaningful use of certified EHRs. Physicians can get as much as $44,000 from Medicare and $63,750 from Medicaid for installing and using certified EHR systems. Hospitals can qualify for EHR incentive payments of $2 million or more, CMS said. The goals of CMS’ meaningful use program include improving clinical outcomes, population health, transparency and efficiency, the agency said. The meaningful use program is designed to support physicians and hospitals in installing certified EHR systems in three stages. Stage 1 was in 2011-12 and involved data capture and sharing, stage 2 is in 2014 and is designed to improve clinical processes, and stage 3 will be in 2016 when meaningful use will help providers improve patient and population health outcomes.
Medicaid best-price rule
Medicaid’s best-price rule requires that state Medicaid programs pay the lowest price at which a drug is sold, meaning the reported best price must reflect all discounts, rebates, and other pricing adjustments. This price is the benchmark that the government uses to make sure that state Medicaid programs receive the lowest price for which a drug is being offered to any purchaser.
Medical device excise tax
The medical device excise tax is a 2.3 percent sales tax on medical devices that went into effect on Jan. 1, 2013, to help pay to implement the Affordable Care Act. The tax applies to non-retail medical devices such as X-ray equipment, MRI machines, surgical instruments and pacemakers. It does not apply to products such as glasses, contact lenses or hearing aids. The effective tax rate is about 1.5 percent, because device makers pay the tax and can claim a deduction for those payments on their federal tax returns. Repealing the tax would reduce federal revenue by about $20 billion over 10 years, according to the Congressional Budget Office. Device makers won a significant victory in 2015, when Congress voted to suspend the tax for two years, through the end of 2017. Bills in the U.S Congress to repeal and replace the ACA call for eliminating the tax.
Medication therapy management
Health insurers and health systems use medication therapy management (MTM) to ensure that patients, particularly the elderly, are taking appropriate medications. Under MTM, a pharmacist, physician, or other provider will review all medications a patient takes because patients often take many different drugs prescribed by different providers. During this review, a provider may find that one medication conflicts with another and so could cause an adverse reaction. Experts estimate that medication-related problems and mismanagement cause 1.5 million preventable adverse events occur annually, which can lead to injury and death. (See also, comprehensive medication management.)
Medicare cost plans
Medicare cost plans are similar to Medicare Advantage plans in that commercial health insurers sell these plans offering coverage to consumers that supplements original Medicare coverage. Medicare cost plans allow beneficiaries to use out-of-network hospitals, physicians, and other providers and offer more flexibility in choosing a Medicare Part D prescription drug plan. Medicare cost plans are available only in certain areas of the country.
The Medicare and Medicaid programs make payments under the DSH program to help the so-called DSH hospitals that serve a significantly disproportionate number of low-income patients. States receive an annual DSH allotment to cover the costs of DSH hospitals that provide care to low-income patients that are not paid by other payers, such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) or other health insurance. Under federal law, this annual allotment includes requirements to ensure that the payments to individual DSH hospitals are not higher than the uncompensated costs, according to the Kaiser Family Foundation.
Member hospital referral region
On billing and other forms, a code represents each health insurance member’s hospital referral region (MHRR). The region is a plan member's regional market for tertiary medical care based on the Hospital Referral Regions as identified in the Dartmouth Atlas Project.
Merit-based incentive payment system (MIPS)
Physicians who participate in MIPS could earn a performance-based payment adjustment. Physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists also could participate in MIPS. Once he or she decides to participate in MIPS, the physician or other provider could will earn a performance-based adjustment to his or her Medicare payment based on submitting practice-specific data on quality of care to Medicare patients and on delivering data on the evidence-based care the practice delivers. Also, physicians can get an incentive payment for demonstrating the delivery of high-quality, efficient care supported by technology by submitting information in certain categories. Payments will start in 2019 based on data submitted in 2017. Physicians and other providers will get performance improvement incentive payments of 4 percent to 9 percent or more depending on several factors and could see their Medicare payments could decline by 4 percent to 9 percent. MIPS combines three financial incentive programs for physicians into one system. The three incentive programs being eliminated are the Physician Quality Reporting System, the electronic health record (EHR) incentive program and the value-based payment modifier established under the Affordable Care Act.
Minimal essential coverage
To meet the individual mandate requirement under the Affordable Care Act, a health insurance plan must meet the minimal essential coverage standard. Individuals seeking to avoid the penalty for not having insurance must be enrolled in a plan that qualifies as minimum essential coverage, which is sometimes called qualifying health coverage. Health insurance plans that offer minimal essential coverage are those offered on the federal and state Marketplace; plans that employers offer, Medicare and Medicaid plans and plans offered under the Children’s Health Insurance Program.
When used in reference to health insurance, the term moral hazard is used to describe how a person’s behavior changes once that person is insured against losses. When fully covered for all physician and hospital care, for example, a person may be inclined to overuse the health care system, thus driving up costs. This concept is what drives some employers and health plans to require insured individuals to pay copayments and deductibles on the theory that such payments will make consumers consider whether they truly need the care they are seeking. Health care economists believe the counterpart to moral hazard is behavioral hazard.
When assessing a hospital’s mortality rate, researchers will evaluate the rate of patient deaths (mortality) as a ratio comparing patients' actual mortality to their expected mortality, according to the Mayo Clinic. The ratio of observed-to-expected mortality is a risk-adjusted measure created from observed mortality (the rate of patient deaths in the hospital each quarter) to the expected mortality (which is the expected average of hospitalized patient deaths with a particular illness or condition that are beyond the hospital’s control, such as age, gender and other medical problems.
Most favored nation clauses
When negotiating with hospitals, health systems and large physician groups, health insurers sometimes will require the providers to sign agree to the inclusion of “most favored nation” clauses in contracts. Under such clauses, insurers require providers not to set lower rates for other insurers.
Multiple-employer welfare arrangement (MEWA)
A MEWA is a system for marketing health and welfare benefits to employers for their employees. Also known as a multiple employer trust (MET), a MEWA allows a group of employers to combine their contributions in a self-contributing benefits plan for the benefit of workers and their family members. MEWAs allow smaller companies to offer employee benefits outside of the government-run health insurance exchanges by sharing risk and became popular as a result of the Patient Protection and Affordable Care Act (ACA).
National Drug Code
Prescription drugs sold in the United States are identified using a three-segment number called the National Drug Code (NDC) that the FDA, the pharmaceutical industry, and insurers use to identify and classify drugs. The Drug Listing Act of 1972 requires drug companies to provide the FDA with a list of all drugs sold to that each prescription drug in common use has an NDC number. The FDA publishes the listed drugs in the NDC Directory which is updated daily.
In the individual and small group insurance marketplaces under the Affordable Care Act, many health plans are expected to offer several so-called “narrow networks” of physicians, hospitals, and other providers. These narrow networks may not include the premier hospitals, physicians, or other providers in a region but these providers may provider care at lower costs. Note that although health plans may offer narrow networks, the plans must still satisfy ACA requirements about coverage and access.
Health plans make a distinction between in-network coverage and out-of network coverage. When health plans contract with doctors, hospitals, clinical laboratories, and other health care providers, they designate these providers as being “in network.” These providers then charge patients lower rates than they would charge if they were out of network. Out-of-network providers almost always charge patients more and health plans often require patients to pay higher deductibles or coinsurance or both to see out-of-network providers.
Insurers, consumer advocates and insurance regulators evaluate the adequacy of a physician or hospital network based on the ability of the network’s providers to achieve certain standards in the way they deliver services to the patients who are required or encouraged to use the network. The most basic standard of adequacy is to have at least one provider in the network who can deliver each service that a patient could potentially need under the insurance plan or payment arrangement. Adequacy requirements often include a maximum distance a patient must travel to receive care from a network provider who can deliver the services patients need and the quality of care the network physicians and hospitals deliver. The National Association of Insurance Commissioners has proposed revisions to the Network Adequacy Model Act that states would follow when considering network adequacy laws. The federal Centers for Medicare & Medicaid Services also has proposed to expand the federal network adequacy standards that health and dental plans must meet to be certified as qualified health plans (QHPs). Under the CMS proposal, the federal rules would largely subsume the NAIC’s efforts because states would be need to strengthen their standards or meet the federal rules. CMS is expected to issue a final rule in the spring of 2015.
The federal Center for Medicare and Medicaid Innovation announced a demonstration program for next-generation ACOs that will have multiple payment options, including capitation, and that requires hospitals, physicians, and other providers to accept virtually full performance risk and some insurance risk for a population of Medicare beneficiaries. Performance risk is the risk that providers assume for factors under their control, such as causing an infection in a patient during treatment. Insurance risk results from factors related to a patient’s health status or other factors that are beyond a provider’s control of a provider, such as the risk that patients will have more serious health problems than an average group of patients.
Non-claims costs are what health insurers pay for cost containment strategies, claims adjustment, sales department salaries and benefits, fees and commissions for agents and brokers, taxes and general administrative expenses.
NCDs are often called lifestyle diseases because their origins stem from behaviors humans can control such as poor diet, physical inactivity and alcohol and tobacco use. Health researchers say commercial interests push the use of alcohol, sugar, soft drinks, tobacco and other harmful products on consumers, creating behaviors called socially constructed choices. NCDs are responsible for about two-thirds of all global deaths annually, and about 80 percent of such deaths are in low- and middle-income countries, leading some researchers to consider them to be among the most pressing contemporary challenges to human health.
Health insurers offer non-embedded deductibles when providing family coverage. A non-embedded deducible means the total family deductible must be paid before the insurer will paying for covered medical expenses for any individual member. Health plans sold on the government exchanges set a limit on family deductibles at $13,700 in 2016. The problem with a non-embedded deductible is that families without children (meaning when a two members of a family share a family plan) may be better served with individual plans and individual deductibles. Non-embedded deductible plans can cause one member of the two-member family to spend thousands of dollars that would have been covered under an embedded deductible or under an individual plan. In 2016, the federal government moved to require all plans to eliminate non-embedded deductibles.
Non-emergency weekend admission restriction
Most health insurance plans will not pay for care or will limit payment for members who get treatment for a condition that is not emergent if the treatment would require admission on a weekend.
A non-participating provider is an out of network physician, hospital, or other health care provider that can charge whatever the market will bear for their services. Non-participating providers are sometimes called non-par. Out of network providers may be a source of surprise medical bills because patients may believe the provider is in network and thus subject to charging only the insurer's allowed amount. If possible, insured patients should confirm with their insurance company that a provider is in fact in network or not before getting services. (See also participating provider.)
Non-preferred drugs are usually brand-name medications (although in rare instances, there are non-preferred generic drugs). As a result of not being preferred, these drugs carry the highest copayment, and may require a patient to pay more in the form of coinsurance. Usually non-preferred drugs are higher-cost medications that have recently come on the market and an alternative and lower-cost medication is available.
Observed-to-expected (O/E) mortality ratio
The observed mortality rate is divided by the expected mortality rate to create the observed-to-expected mortality (O/E) ratio. A lower score is better, the Mayo Clinic has a target of 0.71. An O/E ratio equal to 1.5 means the hospital's mortality rate is higher than expected; an O/E ratio of 1.0 means the rate is equal to what’s expected; an O/E ratio of 0.75 means the hospital's mortality rate is 25 percent lower than expected; and an O/E rate of 0.50 means the facility’s mortality rate is 50 percent lower than expected.
Opioid non-directive laws
State legislatures in at least four states have passed laws allowing patients to insert directives into their medical records saying they refuse physicians’ prescriptions for opioids. Massachusetts was one of the first states to pass such a rule known as a voluntary non-opioid directive which goes into the patient’s medical record and requires any treating physician to follow the non-prescribing instructions even if the patient is incapacitated. It can be withdrawn only if a patient’s healthcare proxy is present or is available to medical personnel on site. These directives encourage discussions between physicians and patients about the risks of opioids and promote education of physicians and patients about inappropriate use of such medications.
Outcomes-based risk sharing agreements (OBRSAs)
Contracts between pharmaceutical companies and health insurers that are designed to control the rising cost of drugs while requiring drug manufacturers to prove that their medications produce positive patient outcomes. Under these contracts, health insurers will pay for performance in exchange for guarantees from pharma companies that medications will keep patients out of the hospital, reduce hospital length of stay or avoid surgery or other costs.
This occurs when a patient goes out of network for care. Sometimes bills from out-of-network providers can be much higher than what in-network providers charge. Often, the patient is fully responsible for the high charges even though the patient did not specifically choose the out of network provider. When a patient has a medical emergency and calls 911, for example, an ambulance will take the patient to the nearest hospital or facility equipped to handle such cases. That hospital or facility may not be in the patient’s network. In 2011, America’s Health Insurance Plans (AHIP), a trade group, reported that 88 percent of claims were paid on an in-network basis and 12 percent were paid out-of-network. AHIP also reported that out-of-network charges can be much higher than other charges, some running as much as 95 times higher.
Out-of-pocket limit (or out-of-pocket cap or maximum)
This limit is the most a consumer would pay during a policy period (usually a year) before health insurance would begin to pay 100 percent of the allowed amount of a bill. Some states require health plans to set out-of-pocket limits on copayments for certain high cost medications. California, Delaware, Louisiana and Maryland, for example, limit the amount an insured person would pay for a month’s supply of drugs. California’s cap applies to all covered drugs, some states apply caps only to specialty drugs.
A participating provider is a physician, hospital, or other health care provider that a health insurer has designated as being in-network in the insurer's health insurance plan. A provider may be in-network in one, several, or all of a health insurer's plan offerings.
In-network providers have contracts with the health insurer that allow them to charge certain amounts for their services but not more than the allowed amount. Typically, the insurer will pay most (or all) of the bill and the insured patient will pay the remaining amount. Participating providers should be listed in the health insurer's directory of in-network providers but these directories are notoriously inaccurate and often out of date. If possible, insured patients should confirm with their insurance company that a provider is in fact in network or not before getting services. (See also non-participating provider.)
A statutorily imposed liability that occurs when a hospital capable of providing the necessary medical care transfers a patient to another facility or simply turns the patient away because of the patient's inability to pay for services. Hospitals that knowingly, willfully, or negligently fail to comply with legislation prohibiting this practice are subject to various monetary penalties as well as suspension of their Medicare provider agreements. How affordability of health care varies by income among people with employer coverage
Pharmacy gag orders
Under the contracts pharmacies have with pharmacy benefit managers, neither side can disclose the actual amounts pharmacies pay or how much PBMs claw back. Such gag orders prevent pharmacists and PBMs from telling consumers if they are being overcharged for their medications.
Physician Quality Reporting System (PQRS)
This is a reporting program from the federal Centers for Medicare & Medicaid Services (CMS) for physicians and other providers. Previously, it was known as the Physician Quality Reporting Initiative (PQRI). It uses a combination of financial incentive payments and payment adjustments to promote reporting of quality information by what CMS calls eligible professionals (EPs). While the program is designed to reward physicians for meeting certain quality goals, physicians and other providers complain that filing the necessary documentation is sometimes not worth the time and expense because some high-paid specialists consider the payments to be modest compared with their annual income. In 2012, for instance, the rewards totaled about 0.5% of Medicare’s annual payment to physicians. Beginning in 2015, however, the program will result in lower payment for those EPs who do not report data on quality measures for their professional services.
A Pioneer ACO is a provider organization participating in a demonstration program that the federal Center for Medicare and Medicaid Innovation established that uses a shared savings payment model with different rules than those for provider organizations participating as ACOs in Medicare’s Shared Savings Program. The federal Department of Health and Human Services says the Pioneer ACO Model is designed for health care organizations and providers that already were experienced in coordinating care for patients across care settings and thus allows those providers to move more rapidly from a shared savings payment model to a population-based payment model.
Pharmacy benefit rebates
In an effort to control the cost of prescription drugs, pharmacy benefit managers negotiate price rebates with drug manufacturers and say they pass these rebates along to consumers. The drug manufacturers provide these rebates in exchange for getting their medications listed on the PBM or insurer’s formulary. While these rebates are legal, the agreements behind them are opaque and so researchers and journalists often do not know what percentage of the rebates the PBMs retain and what percentage goes to plan sponsors and consumers.
Political determinants of health
Health policy and politics have such a strong influence on the social conditions that generate health outcomes that the social determinants of health should be referred to as the political determinants of health, according to Daniel Dawes, the director of the Satcher Health Leadership Institute at the Morehouse School of Medicine. In a book, Dawes argued that the common aspects of social determinants, such as housing, transportation, education and access to care, are the result of political decisions. (See also social determinants of health and the commercial determinants of health.)
Polygenic risk score
Polygenic risk score is a mathematical formula based on genetic test results that sums up the cumulative effect of many different gene variants believed to play a role in the risk of a disease or condition.
Health insurers pay physicians, hospitals or groups of health providers on the basis of a population being covered such as a group of patients enrolled with one employer or a group of a patients in a geographic area. Usually, population-based payments include bonuses or penalties based on whether the providers hit or miss certain quality or cost targets.
Post-hospital syndrome (PHS)
After being discharged from a hospital, some patients face a period in which they are susceptible to disease and have an elevated risk for adverse events that can lead to a hospital readmission or death. Clinicians use the term post-hospital syndrome (or posthospital syndrome) to describe this time of increased vulnerability.
An authorization from a health insurer to a patient for a hospital admission before the patient is admitted. If the patient’s needs are not emergent, failing to get a preadmission certification could mean the insurer would require the patient to pay for the entire hospital bill and other related charges.
Health insurers often require patients to get any necessary diagnostic testing done before a non-emergency hospital admission.
Pre-authorization or prior approval
Health insurers sometimes require physicians or patients to get pre-authorization for expensive diagnostic tests or procedures. Failing to get pre-authorization (or prior approval) can mean the patient would need to pay the entire bill rather than only the patient’s cost-sharing portion.
A preferred drug is usually a brand-name medication that a health insurer has clinically reviewed and approved for use based on its proven clinical value and cost effectiveness. Usually, for brand-name preferred drugs there is no generic equivalent. Preferred drugs cost less than non-preferred drugs.
Pregnancy-associated mortality is a death while pregnant or within one year of the end of pregnancy, regardless of cause and considered to be the starting point for any analysis of maternal deaths. Pregnancy-associated mortality is different from a pregnancy-related death, according to the federal Centers for Disease Control and Prevention’s Maternal Mortality Review Committee. (See also: pregnancy-related mortality.)
Pregnancy-related mortality is a death during pregnancy or within a year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy or the aggravation of an unrelated condition by the physiologic effects of pregnancy. The federal Centers for Disease Control and Prevention (CDC) uses this term to report U.S. maternal mortality trends. (See also: pregnancy-associated mortality.)
Premium deficiency reserve (PDR)
This is the amount an insurer would need if the expected premiums to be collected would not cover future claims and expenses. Expressed as a financial liability on financial statements, a PDR is a reserve amount that insurers are required by law to set aside to ensure that they can pay policyholders’ claims.
Premium rate review
Premium rate review is the process state insurance departments use to review and accept (and in some cases, revise and reject) health insurers’ rate requests. What insurers propose in the spring is what they want to charge consumers for premiums for policies to be sold on the exchanges starting in the fall. The rates are preliminary because they are subject to state and sometimes federal review and approval. Insurance premium rates are only a part of what goes into what health insurance costs for individual consumers. Additional costs include deductibles and copayments (which together are called coinsurance). When states have ineffective review processes, officials from the federal Department of Health and Human Services review the filings but only state officials can tell insurers to revise rates.
Premium surplus is the amount of money that insurers report as profit or reserved capital and calculated by subtracting costs for paying medical claims, quality improvement and non-claim costs from premiums collected. It’s one of the numbers the federal Department of Health and Human Resources uses to calculate each insurer’s medical loss ratio.
Price transparency refers to a trend to provide consumers with the cost of the individual services of health care, such as a physician visit, a diagnostic test, or a hospital procedure. With such price information, consumers can make informed health care choices. Programs designed to promote health care price transparency usually involve publishing prices from different providers to allow consumers to compare prices from one provider against that of another. The price should include the total cost to the consumer and include any discounts providers offer. The best price transparency efforts provide the actual price that a consumer would pay and ideally should provide information on what the consumer would pay in the form of an insurance deductible, copayment, co-insurance. Some states require providers to offer this information.
The term “private equity” is used to describe investment companies or actual investments by private investment companies that invest in businesses that turn a profit or have strong cash flow or both. Often, these investors will take an equity interest in the company they invest in, meaning they will own a share of the business or a percentage of profits. Private equity investors are primarily or exclusively interested getting a return on their investment (ROI). Most such private capital invested in health care will seek the easiest path to getting an ROI. Therefore, they will typically invest in companies that are getting fee-for-service payment and that have few competitors, such as those businesses that specialize in emergency-room staffing, anesthesia and that run ambulance services, expert say.
Private health insurance
The federal government defines private health insurance as that which an individual would get through a comprehensive private insurance plan, including those available from a health maintenance organization (HMO) or a preferred provider organization (PPO). Individuals usually get these plans through an employer or they purchase them directly from a commercial health insurer, or through local or community programs or the federal or state health insurance marketplaces or via a state-based exchange.
Used in some payment models when an insurer or other payer sets the payment amount for a physician, hospital or other provider for delivery of health care services before the services are delivered. The amount of payment does not change depending on the actual cost of delivering the service except if there are unusual or extenuating circumstances that are beyond the providers’ control. Prospective payment is designed to control costs and is used in bundled payment programs, and Medicare uses this form of payment for some inpatient care. See also retrospective payment.
Prospective payment system
A method of Medicare payment based on a fixed and predetermined payment amount for care delivered to a group of patients based on Medicare’s classification for each particular service (such as diagnosis-related groups). The federal Centers for Medicare and Medicaid Services uses different prospective payments for acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities. See also prospective payment for bundled payment.
Prospective payment for bundled care
Prospective payment is often used for bundled care. In bundle payment arrangements, a provider receives the payment from an insurer or other pay and then pays other providers involved in delivering care in the bundled. For example, a bundle for knee replacement surgery would require a surgeon, other surgery team members, an anesthesiologist, and a rehab team. The lead provider would pay these other providers from the prospective payment amount from the insurer. If the total cost of the knee replacement is less than the prospective payment, the lead provider can keep all of that amount or share it with other team members. If the total cost is higher than the prospective payment, the lead provider might absorb that loss or share it with other providers.
Early versions of bills to reform health care in 2009 and 2010, included a public option, which would be like a government-run health insurer that would serve to increase competition, particularly in those states where competition was limited. In the final version of the bill that became the Affordable Care Act, there was no public option in part because some conservative Democrats objected to the idea. At the time, supporters of the public option said it would have countered the adverse effect of limited competition and helped to contain costs.
Quality-adjusted life year (QALY)
A measure used to quantify the value of treatment. QALYs measure the time a patient lives and the quality of that patient’s life after receiving a treatment. One year in perfect health equals one QALY. Health economists and researchers used QALYs to quantify the health benefits of particular treatments, such as a medication. Some of Europe’s health systems use QALYs to decide which drugs to cover.
Qualified health plans (QHPs)
are certified health insurance plans under the Affordable Care Act that meet certain criteria allowing them to be offered in the federal and state health insurance marketplaces. QHPs must meet certain requirements, including providing at least the minimum essential health benefits and limiting cost-sharing (meaning the maximum amounts plans can charge for deductibles, copayments and other out-of-pocket costs).
QHP-eligible uninsured population
is a number that federal health authorities calculate based on the number of uninsured individuals ages 0 to 64 who have certain family incomes that meet the income criteria under the Affordable Care Act.
Beginning in 2012, the federal Medicare program has cut what it pays hospitals if the hospitals have high readmission rates within 30 days after discharge for six patients with any of six conditios: those admitted for heart attacks, heart failure, pneumonia, chronic lung disease, hip or knee replacements or coronary artery bypass graft surgery. The penalties may have been instrumental in bringing down the rate of readmissions, as Kaiser Health News reported: “Between 2007 and 2015, the frequency of readmissions for conditions targeted by Medicare dropped from 21.5 percent to 17.8 percent, with the majority of the decrease occurring shortly after the health law passed in 2010…” The penalties eliminated an incentive hospitals had to discharge patients quickly and then charge Medicare more when those patients were readmitted.
Employers and health plans sometimes set a certain price limit when reimbursing employees or plan members for health care services. This limit is known as the reference price. Any employee or plan can shop for a health care service and pay whatever rate the provider or hospital charges, but the employer or health plan will not reimburse the employee or plan member any amount above the reference price. In this way, reference pricing may affect what the employee will pay and will sometimes help to drive down costs. The employee can pay more than the reference price but will not be reimbursed above the limit.
During the first three years under the Affordable Care Act (2014 through 2016), the law calls for a temporary reinsurance program for those health insurers that have enrolled higher-cost individuals (meaning those who have pre-existing conditions or poor health status). Designed to stabilize premiums, the reinsurance program will transfer funds to individual insurance plans that have higher-cost enrollees. To pay for the program, the federal Department of Health and Human Services (HHS) will collect a reinsurance fee from health insurers and third-party administrators of self-insured group health plans. The administrators are expected to pass along these fees to employers that hire administrators to manage their health insurance plans. In the first year of the program, HHS expects to collect and distribute $12 billion based on need. In 2015, HHS will collect and distribute $8 billion, and in 2016, it will collect and distribute $5 billion in reinsurance fees.
For hospital care, researchers at the RAND Corporation have used two kinds of hospital prices for reports on what commercial health insurers pay for inpatient and outpatient care: relative and standardized prices. The relative price of a hospital service, which RAND defines as the ratio of the actual allowed amount that a commercial health insurance company would pay divided by the allowed amount that Medicare would pay for the same service at the same hospital. Relative prices incorporate all of Medicare’s adjustments for case mix, wages, inflation, medical education, and the volume of uncompensated or disproportionate-share services provided. (See also: standardized prices.)
Relative value units (RVUs)
The federal Medicare program makes payments to physicians based on their relative value units (RVUs), which reflect a relative level of time, skill, training and intensity for each particular service when treating patients. A visit with a well patient would be assigned a lower RVU than an invasive surgical procedure. Commercial health insurers typically follow Medicare’s example and so may base payments on RVUs as well. Physicians used the Current Procedural Terminology (CPT) coding system for each patient encounter. Each CPT code has three components (work RVU, practice expense RVU, and professional liability insurance RVU), and the sum of the three components is the total RVU for each CPT code. (See RBRVS.)
Resource based relative value scale (RBRVS)
In 1992, the federal Medicare program introduced the Resource-based Relative Value Scale (RBRVS) system to describe and quantify physicians’ work and to pay for each physician service. The RBRVS incorporates three components of physician services: the actual work the physician performs, the physician’s practice expense, and the physician’s professional liability insurance expense. A relative value unit (RVU) is assigned to each component. (See RVU.)
Perhaps the most common form of payment and is used for fee-for-service payment. In this arrangement, a provider delivers care, totals the costs for such care and bills the insurer. Health policy experts say this form of payment provides an incentive for providers to deliver more care regardless of need, thus driving up costs. See also prospective payment.
As health insurers develop new methods of payment to replace fee-for-service arrangements, they have found new ways to pa implement a prospective payment model is to make preliminary payments to the provider on some other basis, then sum the preliminary payments made, compare the total to the prospective payment amount, and make a transfer of funds (the Net Payment Reconciliation Amount) between the provider and the payer so that the provider has received only the prospective payment amount. This process is called “retrospective reconciliation,” since it reconciles the preliminary payments against the prospective payment amount so that the actual total payments to the provider equal the prospective payment. For example, in order to implement a multi-provider bundled payment or an episode payment, each provider might continue to bill and be paid for services under the standard fee-for-service system, but then all of those payments would be totaled and compared to the prospective payment amount; if the total is less than the prospective payment, the difference would be paid to the providers, and if the total is greater than the prospective payment, the providers would have to refund the difference to the payer. (Alternatively, the payer could create a withhold on the provider’s fee-for-service payments, and then return all or part of the withhold if the fee-for-service payments are below the prospective payment amount.)
The risk adjustment program under the ACA is permanent and designed to reinforce rules that prohibit risk selection. As a permanent program, it is unlike the reinsurance and risk corridor provisions under the Affordable Care Act, which are temporary and run only from 2014 through 2016. Under the risk adjustment program, the federal Department of Health and Human Services will pay health insurance companies that disproportionately enroll higher-risk populations (such as those individuals who have chronic conditions and poor health status). Payment will be made after the plan year and before June 30 of the following year. Only those plans that are non-grandfathered individual and small group market plans will be affected. Grandfathered plans are those that existed in March 2010 and thus do not need to meet the requirements of the ACA. Insurers canceled many of these plans in 2013.
The ACA’s temporary risk corridor program runs from 2014 through 2016 and applies to qualified health plans in the individual and small group markets. Designed to stabilize health insurance premiums by protecting against inaccurate rate-setting, the risk corridor program works in conjunction with the medical loss ratio (MLR) rules, which specify that qualified health plans must spend 80 percent of premium income on delivering health care to enrollees and on improving quality. If insurers do not spend 80 percent of premium income on care delivery and quality improvements, they must issue a refund to enrollees. The risk corridor program works by allowing the federal Department of Health and Human Resources to collect fees from insurers that have costs that are less than 3 percent of the target amount under the MLR rules and use those funds to reimburse plans that have costs that exceed 3 percent of the MLR rules.
Risk for payers
In insurance, payers (meaning health plans or health insurers) take on financial risk when they accept a fixed premium payment from an employer, labor union, or other group of members in exchange for a promise to pay for all health care services for the members of the group even if those cost exceed the total revenue received in premium income.
Risk for providers
Providers (meaning hospitals, physicians or other health care professionals) take on financial risk when they agree to provide all health care services for a group of employees or a union for a fixed fee even if costs exceed the total fee. Usually, the providers are paid monthly and costs are totaled at year end. If costs exceed the payment, the providers need to pay the difference. If costs are below the payment, they keep the difference.
The risk pool is a group of individuals who get health insurance from one source. Those who get their insurance on a state’s online Marketplace under the Affordable Care Act is an example of a risk pool. If a risk pool is segmented, such as by underwriting, then an insurer would separate high-risk (or high-cost) individuals from low-risk members and may charge more—as they did before the ACA was implemented in 2014—for those deemed to be high-risk members. Another way to segment the risk pool is to use a high-risk pool. When a risk pool is segmented, premiums fall for those who have low risks and rise for those who have high health risks.
Health insurers assign a numeric value to patients when adjusting payment based on the level of illness in a population. The risk score indicates the relative level of illness and thus a level of spending required for that patient. In such risk-adjustment systems, physicians and other providers get paid more when caring for patients who are sicker than other patients.
Health insurers use risk stratification to adjust payments based on differences in patient characteristics. Health plans assign patients to two or more categories based on their level of illness characteristics that influence the costs of care and then adjusting the payment for patients based on the category to which the patients are assigned. The diagnosis-related group (DRG) system that the federal Centers for Medicare & Medicaid Services uses to pay hospitals is an example of a risk-stratification system based on clinical risk.
Ryan White HIV/AIDS Program
Enacted in 1990, this program is the largest federal program specifically for people with HIV/AIDS and serves more than half of all those who have the diagnosis. Under this safety-net program, people who lack health insurance or who have gaps in their insurance coverage get HIV outpatient care and treatment. Most clients of the program are low-income, male, people of color and sexual minorities, according to the Kaiser Family Foundation. The program is named for Ryan Wayne White of Kokomo, Ind., who had hemophilia and became infected with HIV from a contaminated blood treatment. After being diagnosed with HIV in December 1984, White was expelled from middle school because of his infection. He died in 1990.
Second surgical opinion
Health insurers often require patients to get the opinion of a second doctor after one physician has recommended that a non-emergency or elective surgery. When a second opinion is required, the insurer may not pay or may reduce what it would pay if the member does not get a second opinion. Usually, health plans will require that such opinions come from board-certified specialists who have no personal or financial interest in the patient’s outcome.
A physician who is not a primary-care provider but is another kind of specialist physician such as a cardiologist, neurologist or oncologist. Some health insurers consider all non-PCPs to be secondary care providers. Before making an appointment to see a second provider, insured patients should confirm that the provider is in-network and that the patient's PCP sent a referral to that secondary providers.
Section 1115A of the Social Security Act was added as part of the Affordable Care Act to establish the Center for Medicare and Medicaid Innovation (CMMI) to test payment models. Such payment models include those for which there is evidence that they address a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures, the act says. Also, there must be a focus on models expected to reduce costs while preserving or improving the quality of care patients receive.
A self-insured employer or purchaser (also called a self-funded employer or purchaser) sets funds aside in order to assume the financial responsibility of paying claims for health care services for its employees, employees’ family members and retirees. Self-funding is different from purchasing health insurance policies from a health insurance company for each employee in that the employer is at risk for all claims and so could suffer a loss or make a profit depending on the level of health care spending for employees each year. If losses are too high, employers have coverage (called stop-loss insurance) beyond a set amount that they buy from insurance companies. An estimated 149 million Americans have employer-sponsored coverage and most of those individuals are covered under self-insured plans.
A self-pay patient pays a provider for his or her entire charge for a service from the patient’s own funds, rather than relying on an insurer or other third-party payer to pay for all or part of the provider’s charge for the service. If the patient has health insurance and a deductible, the patient may pay for a service out of the patient’s own funds, but the patient may only have to pay the payment amount that his or her insurer negotiated for that service.
Shared decision making (SDM)
A provision in the Affordable Care Act encourages greater use of shared decision making. SDM is a process some health plans and provider groups use to help patients and physicians make health care decisions together. Designed to take into account the best scientific evidence and patients’ preferences, SDM is most useful important when a patient is considering preference-sensitive options, such as surgery or watchful waiting care. If more than one option is appropriate, patients should be allowed to consider the advantages and disadvantages of each one. Too often, however, patients make decisions without having all the information they need or fully understanding their options. Also, physicians often make decisions for patients without explaining all the disadvantages of certain procedures or treatments.
Shared savings is a form of pay-for-performance that health plans and the federal Centers for Medicare & Medicaid Services use as an incentive for physicians, hospitals and other providers under contract to improve health care quality and efficiency. In a shared savings program, an insurer will share the savings with a provider or a group of providers if the providers keep costs below a certain benchmark spending level. Shared savings programs are a precursor to shared-risk programs.
Shared risk programs are a form of pay for performance that health plans and the federal Centers for Medicare & Medicaid Services use when contracting with physicians, hospitals and other providers. Recognizing that physicians, hospitals and other providers may feel a potential financial loss more powerfully than they feel a potential gain, some health policy experts believe shared-risk programs could present stronger incentives to providers to manage care appropriately than shared savings programs do. Under a shared-risk program, the providers would have some loss of funds when spending exceeds an established target. Capitated payment, in which a provider receives a set amount to deliver care to each patient each month, is a form of shared risk. If the provider’s costs exceed what the health plan pays, the provider would suffer a financial loss. Other forms of shared risk include the loss of a bonus payment if the provider fails to achieve certain levels of quality or efficiency.
A shared-savings accountable care organization (ACO) is a Medicare initiative for physicians, hospitals, and other health care providers seeking to form an ACO in which the providers would be held accountable for the quality and cost of care and for the patients’ experience of care. When they form the ACO, the physicians and hospitals would be assigned Medicare beneficiaries who previously were part of a fee-for-service Medicare program. The shared savings program has two participation options (called tracks) that allow ACOs to choose different levels of financial risk.
The Small Business Health Options Program (SHOP) will provide insurance coverage for businesses in every state beginning in November 2014. Originally, the SHOP exchanges were scheduled to open in November 2013, but the opening was postponed when the federal Department of Health and Human Services needed to fix the individual health exchange system. Before the SHOP exchanges open, small employers can purchase health care for workers through brokers, HHS said. When the SHOP exchanges open, they will serve employers with as many as 100 employees. This number may be increased in the years ahead, HHS said. By design, the SHOP exchanges will offer a variety of plans, although the choices will be limited in the first year in some states.
Single-payer health care
Single-payer national health insurance is a system in which a single public agency would organize health care financing and replace private health insurers. The delivery of care would remain largely unchanged and private health insurers may have a role providing supplemental health insurance to those who wanted to purchase such coverage in addition to the insurance offered under the single-payer model. Some proponents refer to single payer as “Medicare for all” because a single-payer insurance program could be offered through the Medicare program. But the public agency that becomes the single-payer does not necessarily need to be the Medicare program. Proponents say the goal of the ideal single-payer system would be universal coverage, meaning the program would offer coverage to all residents of the United States for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.
Social determinants of health (SDoH)
The federal Office of Disease Prevention and Health Promotion defines SDoH as conditions in the environment in which people are born, live, learn, work, play, worship and age that affect health, functioning, and quality-of-life outcomes and health risks. Resources that enhance the quality of life, such as the availability of high-quality health care services, including primary care, can influence population health outcomes significantly. Other such resources include safe and affordable housing, access to education, public safety, the availability of healthy foods, local emergency and other health services and environments free of life-threatening toxins. (See also the AHCJ core topic Social Determinants of Health.)
Specialty pharmaceuticals are a fast-growing category of costly medications developed for specific chronic and genetic conditions. These drugs may include bioengineered proteins, complex molecules, or be derived from blood. These pharmaceuticals often are injected or infused, require additional patient education and close monitoring of the patient’s clinical response by a physician or other provider. They also may require member-specific dosing, medical devices to administer the medicine or special handling and delivery.
These process expensive drugs for patients with difficult conditions and often deliver medications by mail. The National Association of Specialty Pharmacy says these state-licensed pharmacies focus solely or largely on providing medications for patients with serious health conditions such as bleeding disorders, cancer, cystic fibrosis, hemophilia, hepatitis C, HIV/AIDS, hormone deficiencies, multiple sclerosis, rheumatoid arthritis, and those who have or need organ transplants.
Spontaneous vaginal delivery
A spontaneous vaginal delivery is a natural process that usually does not require significant medical intervention. Such a delivery at term has long been considered the preferred outcome for pregnancy.
Staff model HMO
A staff model health maintenance organization (HMO) is a type of closed-panel HMO, meaning patients can receive services only through certain physicians, such as those who are employees of the HMO. The physicians see patients in the HMO’s own facilities and get paid a salary from the HMO. Sometimes, a staff-model HMO will contract with physicians to supplement its employed staff, but the employed physicians deliver most of the care to the HMO’s members.
For hospital care, researchers at the RAND Corporation have used two kinds of hospital prices for reports on what commercial health insurers pay for inpatient and outpatient care: relative and standardized prices. RAND defines standardized prices as the average allowed amount per standardized unit of service, using Medicare’s relative weights. Standardized prices eliminate the cost of medical education and other Medicare adjustments and can be difficult to interpret because they require two sets of weights, one for inpatient care and another for outpatient services. (See also: relative prices.)
State-based marketplaces (SBMs)
Outside of the 36 states that use the federal marketplace at www.healthcare.gov, consumers in 14 states and the District of Columbia can enroll in health insurance under the Affordable Care Act (ACA). The federal marketplace and the SBMs are the only sites where consumers can buy comprehensive health insurance that fully complies with the ACA’s requirements. Those 14 states are California, Colorado, Connecticut, Idaho, Maryland, Massachusetts, Minnesota, Nevada, New Jersey, New York, Pennsylvania, Rhode Island, Vermont and Washington state. (See also: The Marketplace.)
Under subrogation, health insurers reserve the right to pursue a third party that causes one of its policyholders to file a claim. In most subrogation cases, the individual’s insurer will pay its insured member’s claim and then seek reimbursement from the third-party’s insurance company. If an insured member is in an auto accident, for example, the member’s health insurer may require the member’s auto insurer to pay some or all the claims for care.
In the Medicaid program, the federal Centers for Medicare and Medicaid Services makes supplement payments that are not specifically tied to the care that health care providers deliver to individuals but are used to offset any remaining costs of care that providers have for Medicaid enrollees. (See also: base payments.)
Surprise medical bills
Surprise medical bills are those that arise when a patient who has health insurance receives care from an out-of-network provider without previous notice. Such inadvertent care delivery arises in emergencies when a patient has no chance to select an emergency room, treating physicians, or ambulance providers who are in-network. Or, a surprise medical bill can result when a patient gets care from an in-network provider (at a hospital or ambulatory care facility) but a non-network provider is asked to participate in the patient’s care and the patient is not informed. Such non-network providers often are anesthesiologists, radiologists, pathologists and surgical assistants, among others. In some cases, out-of-network subcontractors may operate entire departments, such as the emergency room or the anesthesiology service within an in-network hospital. When services are out-of-network, the patient usually owes more in the form of a deductible and copayment than he or she would owe if services were in-network. Sometimes, a surprise medical bill comes in the mail following a health care service after the patient’s insurer has paid the physicians, hospital or other providers. When the patient is asked to pay the amount remaining after the insurer has paid, such notices are called balance billing.
A third-party administrator (TPA) is an organization that pays claims for a self-insured (or self-funded) employer or other purchaser, but does not assume any direct financial risk related to the cost of those claims. The TPA pays the claims and then the self-insured employer pays the TPA for the actual cost of the claims plus an administrative fee. See also Administrative Services Only (ASO). One difference between a TAP and an ASO is that the TPA usually does not have a network of providers as ASOs do.
With tiered cost-sharing, insurers rank physicians, hospitals and other provides based on measures of cost and quality and list the lowest-cost and highest quality providers on the lowest tiers. What patients would pay in terms of cost-sharing would depend on which providers they choose. For providers whose costs are high-cost or whose quality scores are low, patients would pay more in cost sharing. Tiered cost sharing is most common in pharmacy benefits where the lowest-priced medications are usually generics and have the lowest or no copayment amount. The most expensive drugs are on the highest tiers and require the highest copayments.
In a tiered network, health insurers offer financial incentives to encourage health plan members to choose providers in the lowest-cost tiers. In a tiered network, all providers are generally considered to be in-network but with different cost-sharing requirements. The cost-sharing incentives are designed to get consumers to choose low-cost, high-quality physicians and hospitals. Ideally, insurers say, the lower-cost providers would offer the best quality and would be listed in the lowest-cost tiers.
Traditional health plan
A traditional health plan is defined as a private health plan that has an annual deductible that is less than the high-deductible health plan threshold that the federal government sets each year.
The term “two-sided risk” refers to arrangements that physicians, hospitals, and other providers have with health insurers in which the insurer will pay the provider for reaching certain pre-determined targets for cost control or quality improvement or both and the insurer will require the provider to pay the health insurer if the provider fails to reach certain goals. See also “upside risk” and “downside risk.”
Universal health insurance coverage is a goal of the most ambitious health insurance reform plans, particularly single-payer initiatives. The individual mandate under the Affordable Care Act seeks to achieve universal coverage. One of the aims of universal coverage would be to eliminate medical bankruptcy, which many families face in the United States. Even families with the best health insurance coverage from the largest employers face high deductibles and need to pay a portion of the premium and costs for out-of-network care.
Unnecessary care of overtreatment is a common problem in the U.S. health care system and health insurers have had little success in preventing it. For a report on unnecessary care, the Lown Institute surveyed physicians and found that a majority (64.7 percent) of respondents estimated that at least 15 percent to 30 percent of care is unneeded and on average, doctors said 20.5 percent of care is unnecessary. The surveyed doctors estimated that 22.0 percent of prescription medications, 24.9 percent of tests, and 11.1 percent of procedures in their specialties were unnecessary. Among the most popular causes overtreatment were fear of malpractice (84.7 percent of respondents) and patient demands or requests (59 percent). Financial factors, meaning the incentive to get paid more for doing more, was a significant factor as well.
Usual, customary and reasonable (UCR)
This rate is the amount paid for a certain medical service, and it often varies geographically. It is based on what providers usually charge, and health plans use it to determine their “allowable” payments. Sometimes, health plans will pay a hospital, physician, or other provider what it determines to be the UCR rate and then let the provider bill the patient for the balance or remaining amount. Such balance billing often is allowed for out-of-network care but may not be allowed when a member visits an in-network provider.
Hospitals, physicians, or other health care providers have upside risk if they will be paid more for services they deliver than the costs they will incur. In other words, there is no downside risk because the provider will almost certainly achieve a positive profit margin and thus the risk is due to the uncertainty about whether there will be a margin and how large it will be.
Health insurers conduct utilization review (or UR) to evaluate the appropriateness of care that physicians or other providers recommend for to patients. Almost all elective procedures require utilization review before an insurer will agree to pay for the procedure. UR should be done before the procedure but insurers will do it during and after services are rendered. In these latter two instances, the insurer could deny payment for the service, leaving the patient to pay the full amount.
Value-based insurance or value-based insurance design (V-BID)
A methodology for identifying clinically beneficial screenings, lifestyle interventions, medications, immunizations, diagnostic tests and procedures, and treatments for which copayments or coinsurance should be adjusted or eliminated because of their high value and effectiveness when prescribed for particular clinical conditions. (Source: Center for Value-Based Insurance Design at the University of Michigan.)
Value-based purchasing (VBP) is distinct from value-based insurance design (V-BID) in the VBP is designed to reward health care providers for delivering value instead of volume. In fact, VBP is a strategy used to shift away from fee-for-service payment (often referred to as payment for volume) to payment for value - hence the idea of shifting from volume to value. VBP also is a form of pay for performance. The critical element in any VBP or P4P program is how value is defined. Health plans use a variety of methods to define value, usually quality metrics such as patient satisfaction or a physician’s ability to meet or exceed certain patient care guidelines. The federal Centers for Medicare & Medicaid Services has a VBP program called the Physician Quality Reporting System (PQRS), which uses a combination of incentive payments and adjustments to promote the reporting of quality information. CMS also has the Hospital Value-based Purchasing initiative and the Readmissions Reduction Program. For more information on these programs, see this report by Kaiser Health News.
Occurs in health care when one company in the supply chain acquires or merges with another company along the chain. For example, vertical integration occurs in health care when a physician groups aligns with non-physician partners such as hospitals, universities, medical schools or health plans. UnitedHealthcare’s acquisition of DaVita Medical Group is an example because the health insurer bought a physician group. (See also horizontal integration.)
Virtual primary care
Virtual primary care is a term used to describe telemedicine-enabled visits with primary care physicians. Some health systems are contracting with companies that provide virtual primary care. These providers say that are in-network and will coordinate care with other provides as needed. The care can be provided via video- and voice-enabled telemedicine systems in patients’ homes, workplaces, or anywhere an internet connection is available.
This form of bundled payment offers a higher rate of payment to physicians and other providers who deliver high-quality care for a procedure or service, and no additional payment if more services are needed to correct errors and avoidable complications resulting from the original procedure. If a patient has knee replacement surgery, for example, and gets a surgical-site infection following the procedure, the patient would not be charged for the additional care required to eliminate the infection. A warranteed payment gives a provider the resources he or she would need to deliver the best care and also to generate more income than he or she would get under bundled payment without a warranty, according to a definition in a report from the Center for Healthcare Quality & Payment Reform. The provider then can distribute the additional funds to other participating providers.
White bagging (also called clear bagging)
This occurs when specialty pharmacies sell drugs to a physician or other provider and then ships those medications to the provider for administration to a patient. See also brown bagging.