Glossary In Progress: Health Reform Terms For Coming 2012 Debate


Very soon, the topic of health reform is going to get white-hot again in Massachusetts. Legislative leaders will reveal their plans for the next stage, the part left out of the landmark 2006 law: How to cut costs. Gov. Deval Patrick laid out his own blueprint last February, and now, at long last, this next political shoe will drop.

To prepare you and ourselves, we at WBUR are gathering a glossary of terms that it will help to know in the coming debate. We entreat you to improve on our definitions and write in suggestions for more. And most of all, we need a catchy title for what's coming. Health reform, part two or 2.0? Health reform 2012? There's Romneycare and Obamacare, but Devalcare or Patrickcare just don't sound right, especially for the coming legislative initiatives.

One thing we do already know: We're going to use the Twitter hashtag #mahealthcosts for relevant tweets, and invite you to do the same.

ACO — Accountable Care Organization -- An accountable care organization is a collection of hospitals, doctors, and other care providers that coordinate among themselves to provide high-quality, efficient care to a patient within the bounds of a single payment. Consumers, at some point you will likely be asked to sign up for one of these. This is a really important decision because it means you're making a commitment to get most or all of your care from within this group. Here's a fuller explanation in cartoon form: "What The Heck Is An ACO?"

AQC — Alternative Quality Contract — The global payment model created by Blue Cross Blue Shield of Massachusetts. Other major insurers now offer their own global payment contracts.

Bundled and episode-based payments — "Providers are reimbursed for clinically defined episodes of care – that is, a lump sum payment is made to providers in different settings for caring for one patient who has undergone, say, a major procedure."(From the Massachusetts Hospital Association's new guide to health reform, "Completing the Journey.")

Capitation — Very unpopular in the 1990s. From Wikipedia: "Capitation is a method of paying health care service providers (e.g., physicians or nurse practitioners) a set amount for each enrolled person assigned to that physician or group of physicians, whether or not that person seeks care, per period of time. Generally these providers are contracted with a type of health maintenance organization (HMO) known as an independent practice association (IPA). The HMO contracts with the providers to have the latter take care of patients enrolled in the HMO. Most often, payment for such a service is under the capitation system."

EMRs and EHRs — Electronic Medical Records, also known as Electronic Health Records — Computerized patient medical records, replacing ancient paper files. Can allow all a patient's doctors to share information better, and also be used to assess and improve care. Caution: Some patients worry about privacy.

Fee for service — Right now we pay doctors and hospitals a separate fee for each service they provide. The trouble is that this system creates incentives to do as much as possible, for as much money as possible.

Global payments — Capitation redux. Health care on a budget. In this version, doctors and hospitals, in theory, get paid more when they can prove their patients are healthier. Health insurers pay them a set annual fee per patient depending on the patient's condition. If the doctors don't meet that budget, they're on the hook for some of that loss. If they stay under the budget, they get to keep some of the surplus. They can also get bonuses for high quality.

GSP+ — Gross State Product plus — As lawmakers debate how much to allow health costs to rise, they use terms like GSP plus one or GSP minus one. What they mean is, for example, if the state's economy (or GSP) grew by 4% in a given year, health costs could be allowed to grow at GSP plus 1, or 5%; or by GSP minus one, or 3%. The idea is to tie the growth of health care costs to the growth of the state's overall economy.

Limited Networks — Health insurance plans that limit where patients can go for treatment. They are cheaper because insurers negotiate volume discounts with certain medical providers.

Medical Home — Also known as Patient-Centered Medical Home — The general definition is the place where you get your primary care; and the idea is that your home person or clinic will understand everything about what you need and help you find it. The definition is in flux because some patients' main provider might be, say, their psychiatrist if they have mental illness or their endocrinologist if they have diabetes.

P4P — Pay for Performance — When doctors and hospitals get paid for meeting quality measures.

PMPM — Per member per month — When insurers decide how much to pay providers under a global budget, then they have to figure out how much it's going to cost to take care of each patient. They adjust the budget if you're older and sicker, and come up with a cost per member per month. For example, a health middle-aged person might be assessed at perhaps $400 per month. PMPM can vary significantly depending on where a patient gets care.

PCP — Primary Care Provider — Your primary doctor or other care provider, including nurse practitioners and others. Some have proposed requiring all Massachusetts residents to have one, because it's such a critical entry point to the health care system, both in terms of getting care and tracking costs.

Price Disparities — Catchphrase for the fact that some hospitals and doctors get paid four to eight times as much as others for the same tests and procedures.

Tiered coverage — Think drug prescription co-pays, but apply that same kind of generic-vs.-brand price gap to all medical care. A tiered health insurance plan allows you to go to a more expensive hospital, but you pay more out of pocket — sometimes a lot more.

Readers, what are missing? Please post in the comments below...

This program aired on April 30, 2012. The audio for this program is not available.

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Carey Goldberg Editor, CommonHealth
Carey Goldberg is the editor of WBUR's CommonHealth section.



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