Glossary

Posted on March 4, 2010 by in Uncategorized

Spencer Healthcare Strategists knows that navigating health reform can be an arduous task. That’s why we provide this handy glossary, which links directly from hot button terms on our blog. Here, we break down the legalese, medical jargon, and political hype to help you understand what we’re really talking about: Making health reform work for you.

ACO: An acronym for “accountable care organization.” The active collaboration of multiple health care providers (facilities and professionals) to accept responsibility for and oversight of the regimented cost of care for a given patient population.

Anti-Kickback Statute (AKS):  The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. §1320a-7b.  AKS prohibits individuals or entities from knowingly and willfully offering, paying, soliciting or receiving anything of value to induce referrals of items or services covered by any federal health care program, and imposes criminal penalties on violators (both the offeror and offeree).

Comparative Effectiveness Research (CER):  Conducting and synthesizing systematic research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions for the purpose of informing patients, providers, and payers about which interventions are most effective for which patients under specific circumstances.

Diagnosis Related Group (DRG): The classification of hospital patients based on their diagnoses, treatments, and other criteria. Hospitals are paid the same for each case in the same DRG, regardless of the actual treatment provided.

Evidence-Based Medicine: Use of current best clinical evidence to make decisions about care of individual patients.

Fee-For-Service: The traditional, pre-health reform payment model by which Medicare and insurance companies compensate medical providers based solely on the type and quantity of services delivered to patients. No consideration is given to the quality or degree of care provided.

HIE: An acronym for “health information exchange.” The process by which health care organizations – such as regional care centers, hospitals, or community health facilities – use the Internet to digitally to share health care information.

HIT: An acronym for “health information technology.” Technological advances in digitized medical care, such as electronic medical records, computerized physician order entry, and automated dispensing machines.

HMO: An acronym for “health maintenance organization.” A United States health care model based on maintaining the number of patients cared for by regulating the types of services provided and the doctors that provide them. The model requires patients to choose a primary care physician who delegates and recommends all care given to the patient. The caregiver is compensated based on a fee-for-service model; doctors receive better reviews if they see more patients.

Medical Home: An approach in which patients, especially those with chronic illnesses, are cared for by a primary care physician heading a team that might include behavioral experts and dietitians.
Medicaid: State-federal health program for the low-income and disabled. Provides acute and long-term care to about 60 million people.
Medicare: Federal health program for people 65 and older, the disabled, and persons with end-stage renal disease. Part A provides inpatient-hospital coverage; Part B, outpatient coverage (including physician services); Part C, inpatient and outpatient expenses, administered through private plans called Medicare Advantage, and Part D, stand-alone prescription drug coverage
Never Event: Medical errors that can be prevented and should never happen in a hospital, as determined by the National Quality Forum. The group lists 28 such events, including, for example, operating on the wrong body part.
Pay-For-Performance: The health care payment model suggested by health care reform advocates. The system compensates care providers based not on the type or quantity of services delivered, but on the quality and degree of care provided.
PHO: An acronym for “physician hospital organization.” A network of hospitals and physicians that organizes with primary HMOs, insurance plans, or providers to provide patients with standardized care.
PPACA: An acronym for the Patient Protection and Affordable Care Act, P.L. 111-148, as amended by the Health Care and Education Reconciliation Act.
PPO: An acronym for “preferred provider organization.” A subscription health care service that relies on a network of health care providers to negotiate with insurance providers to offer low-cost health care to the physicians’ or insurance providers’ clients.
Prospective Payment System (PPS): Used by Medicare to pay for several types of services including inpatient, outpatient and skilled nursing services. Rates are linked to diagnoses rather than the actual costs of the care given.
Resource-Based Relative Value Scale (RBRVS): Method used by Medicare to reimburse physicians. The cost of providing service is divided into three categories—physician work, practice expense and professional insurance. The payment is determined by multiplying the costs by a conversion factor set by the CMS.
Stark Law:  The statute may be found at 42 U.S.C. 1395nn, and its implementing regulations at 42 C.F.R. 411.350 to 411.389.  Named after its Congressional sponsor, Rep. Fortney (“Pete”) Stark (D-CA),  the Stark Law prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies.  The law also prohibits the entity that provides the service from presenting or causing to be presented claims to Medicare for those referred services.
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About Laura J. Bond

Laura Bond has more than 20 years expertise on regulatory compliance, contract analysis, and reimbursements. Laura assists clients in strategically addressing hospital-physician relationships, medical staff issues, and other business concerns of hospitals, physicians, and communities. Contact Laura at lbond@shstrategists.com or 913-327-5127.
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