Qualified Clinical Data Registry – QCDRs are one of the reporting mechanisms physicians and group practices can use to report MIPS performance measures. Under MACRA, QCDRs must meet certain criteria in order to be eligible to submit data on behalf of providers.
Further reading –
Physician Quality Reporting System – PQRS is a quality reporting program that encourages individual eligible professionals and group practices to report information on the quality of care to Medicare. PQRS gives participating providers and group practices the opportunity to assess the quality of care they provide to their patients, helping to ensure that patients get the right care at the right time. It is one of the Medicare reporting programs that is being moved into MIPS.
Further reading –
Comprehensive Primacy Care Initiative – CPCI was a four-year multi-payer initiative designed to strengthen primary care. The initiative was a multi-payer collaboration that paid population-based care management fees and had shared savings opportunities to participating primary care practices to support the provision of a core set of five “Comprehensive” primary care functions. These five functions are: (1) Risk-stratified Care Management; (2) Access and Continuity; (3) Planned Care for Chronic Conditions and Preventive Care; (4) Patient and Caregiver Engagement; (5) Coordination of Care across the Medical Neighborhood. Ob-gyns were not permitted to participate unless they were in a multispecialty practice.
Further reading –
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/
Center for Medicaid and Medicaid Innovation – This division of CMS is responsible for overseeing Advanced APMs and other demonstrations, along with testing and evaluating new payment and delivery system reforms.
Further reading –
Certified Electronic Health Record Technology – CEHRT meets the data standards established by the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology to qualify for the EHR Incentive Program.
Further reading –
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Certification.html
Delivery System Reform Incentive Payment – DSRIP initiatives, which are part of broader Section 1115 demonstration waiver programs, provide states with significant funding to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries. DSRIP waivers are not grant programs – they are performance-based incentive programs. The concept is that states undertake initiatives expected to save Medicaid funds and then use the available savings for new investments in delivery system reform. To obtain DSRIP funds, eligible entities, including hospitals and other providers and/or provider coalitions, must meet certain milestones or performance metrics. While the exact structure and requirements of DSRIP initiatives vary, there is often a focus on meeting process-oriented metrics in the early years of the waiver, such as metrics related to infrastructure development or system redesign, and a focus on more outcome-oriented metrics in later years.22 For example, infrastructure related metrics might pertain to implementation of chronic care management registries or enhanced interpretation services. System redesign metrics might relate to expansion of medical homes or physical and behavioral health care integration. Outcome measures might address clinical care improvements or population health.
Further reading –
Managed Long-Term Services and Supports – MLTSS refers to risk-based arrangements for the delivery of Medicaid long-term services and supports, which often include institutional and home and community-based services (e.g., adult day care), enabling Medicaid beneficiaries to live independently in their homes and communities rather than receive care in an institution.7 Some MLTSS programs provide only long-term services and supports (e.g., operate as PHPs), but, in other arrangements, MLTSS are provided through comprehensive MCOs.
Further reading –
https://www.medicaid.gov/medicaid/managed-care/ltss/index.html
Prepaid Health Plan – As distinct from an MCO, a PHP is a non-comprehensive health plan that provides only certain services, such as dental services or non-emergency medical transportation.4 Most PHPs are paid on a risk, or capitated, basis. There are several types of PHPs:
Prepaid Ambulatory Health Plan (PAHP): A PAHP is a non-comprehensive prepaid health plan that provides only certain outpatient services, such as dental services or outpatient behavioral health care, and does not cover any inpatient services.5
Prepaid Inpatient Health Plan (PIHP): A PIHP is a non-comprehensive prepaid health plan that provides only inpatient hospital or institutional services, such as inpatient behavioral health care, and does not have a comprehensive risk contract.6
Further reading –
https://www.michigan.gov/documents/RevisedPlanforProcurementFinalVersionSenttoHCFA_7983_7.pdf
Risk-based Managed Care – MCOs are health plans that contract with states to provide comprehensive Medicaid benefits to enrolled Medicaid beneficiaries for a pre-set per-member-per-month (PMPM) premium, or capitation payment.3 This arrangement is known as risk-based managed care because MCOs are at financial risk for the Medicaid services specified in their contracts. States develop and oversee their own Medicaid managed care programs, subject to federal requirements. MCOs must meet federal and state-specific requirements that address matters such as: protocols for enrollment, disenrollment, and member support; ensuring an adequate provider network and access to care; grievances and appeals, and collection and reporting of data. Although MCOs are at financial risk for comprehensive Medicaid benefits, many states “carve out” certain services from their MCO contracts, such as prescription drugs or behavioral health services. These carved-out benefits may be provided and financed under a separate contract with a prepaid health plan (see definition below) or on a FFS basis. Alternatively, some MCOs may subcontract with prepaid health plans to provide such benefits.
Further reading –
https://en.wikipedia.org/wiki/Medicaid_managed_care
Primary Care Case Management – PCCM is a model of Medicaid managed care that is outlined in the Medicaid statute. In PCCM programs, state Medicaid agencies contract with primary care providers to provide, locate, coordinate, and monitor primary care services for Medicaid beneficiaries who select them or are assigned to them by the state.1 2 In effect, the primary care provider – usually a physician or a physician practice, but sometimes a nurse practitioner, physician assistant, or other provider – serves as a beneficiary’s “medical home” for primary and preventive care. Under their contracts with primary care providers, states pay them a small monthly case management fee in addition to regular FFS payments; unlike in risk-based managed care (see definition below), providers do not assume any financial risk under this model. States set requirements for the participating primary care providers, such as minimum hours of operation at each location, specific credentials or training, and responsibility for referrals to specialists. State staff carry out, or contract out, administrative functions related to PCCM (e.g., network development and credentialing). “Enhanced” PCCM refers to PCCM programs that include additional services and responsibilities to strengthen care coordination.
Further reading –
https://www.cga.ct.gov/2009/rpt/2009-R-0216.htm
