Catalyst for Payment Reform

CPR’s Payment Reform Definitions

Click here for New York specific payment reform definitions.

Attribution:  Refers to a statistical or administrative methodology that attributes a patient population to a provider for the purpose of calculating health care costs/savings or quality of care scores for that population. “Attributed” patients can include those who choose to enroll in, or do not opt out of, an accountable care organization (ACO), patient centered medical home (PCMH), or other delivery models in which patients are attributed to a provider with a payment reform contract.  For the purposes of CPR’s Scorecards, attribution is for Commercial (self-funded and fully-insured) lives and Medicaid beneficiaries only.

Bonus payments based on measures of quality and/or efficiency: Payments made that reward providers for performance in quality and/or efficiency relative to predetermined benchmarks, such as meeting pre-established performance targets, demonstrating improved performance, or performing better than peers.  Bonus payments can include programs that pay providers lump sum payments for achieving performance targets (quality and/or efficiency metrics).  Bonus payments can also include payments tied to a provider’s annual percentage increase in FFS payments based on their achievement of performance metrics.  Bonus payments do NOT include Medicaid health home payments or payments made to PCMH’s that have received NCQA accreditation (see “non-visit function”), or payments made under shared-savings arrangements that give providers an increased share of the savings based on performance (see “shared savings).

Bundled payment: Also known as “episode-based payment,” bundled payment means a single payment to providers or health care facilities (or jointly to both) for all services to treat a given condition or to provide a given treatment. Providers assume financial risk for the cost of services for a particular treatment or condition as well as costs associated with preventable complications.

Commercial market: Commercial business includes self-funded and fully-insured large group, small group, individual, state employee/retiree business, and exchange business. Commercial spending includes medical, behavioral health, and pharmacy to the extent possible.  Dental and vision services are excluded.

Condition-specific capitation: A fixed dollar payment to providers for the care that patients may receive for a specific condition (or set of conditions) in a given time period, such as a month or year. Non-specified conditions remain reimbursed under fee-for-service or other payment method.

Dollars paid: Claims and incentives that were paid to providers (including individual physicians, IPAs, medical groups, and/or inpatient and outpatient facilities) for services delivered to health plan participants in the past year, during the 12-month reporting period, regardless of the time period when the claim or incentive payment was/is due. (i.e., regardless of when the claim was received, when the service was rendered, or when performance was measured). For example, incentive payments that were paid in calendar year 2017 for performance in calendar year 2016 should be reported.  Claims for 2016 services that are in adjudication and not yet paid during the reporting period should not be included.

Episode-based payment: See definition for “Bundled Payment”.

Full capitation with quality: A fixed dollar payment to providers for the care that patients may receive in a given time period, such as a month or year, with payment adjustments based on measured performance (quality, safety, and efficiency) and patient risk. Includes quality of care components with pay-for-performance. Full capitation on top of which a quality bonus is paid (e.g. P4P) is considered full capitation with quality.

Full capitation without quality: A fixed dollar payment to providers for the care that patients may receive in a given time period, such as a month or year. Payments may or may not be adjusted for patient risk and there are no payment adjustments based on measured performance, such as quality, safety, and efficiency.

Limited network:  A product, within a health plan’s portfolio of offerings, that contains a network of providers with fewer providers (hospitals, specialists and/or PCPs) than the health plan’s broadest network.

Medicaid market: The Medicaid market segment includes a health plan’s business with a state to provide health benefits to Medicaid eligible individuals. Responses to the survey will reflect dollars paid for medical, behavioral health, and pharmacy benefits (to the extent possible). Data submitted for this survey should exclude the following: health care spending for dual-eligible beneficiaries, health care spending for long-term care (LTC), and spending for dental and vision services.

Member support tools: Tools (e.g. online) that provide transparency including but not limited to quality metrics, quality information about physicians or hospitals, benefit design information, out-of-pocket costs associated with expected treatment or services, average price of service, and account balance information (e.g. deductibles).

Non-FFS-based payment: Payment model where providers receive payment not based on the FFS payment system and not tied to a FFS fee schedule (e.g. bundled payment, full capitation).

Non-visit function: Includes but is not limited to payment for outreach and care coordination/management; after-hour availability; patient communication enhancements, health IT infrastructure and use. May come in the form of care/case management fees, medical home payments, infrastructure payments, meaningful use payments, and/or per-episode fees for specialists.  For the purposes of this data collection, health home payments and payments for NCQA accreditation for achieving PCMH status made under the Medicaid program are classified as non-visit functions.

Partial capitation: A fixed dollar payment to providers for specific services (e.g. payments for high-cost items such as specific drugs or medical devices, like prosthetics) that patients may receive in a given time period, such as a month or year. Non-specified services remain reimbursed under fee-for-service.

Past year (in definition for dollars paid): Means calendar year 2016 or the most current 12-month period for which the health plan can report payment information.  This is the reporting period for which the health plan should report all of its data.  See also definition of “Reporting Period.”

Payment reform: Refers to a range of health care payment models/methods that use payment to promote or leverage greater value for patients, purchasers, payers, and providers.

Plan members: Health plan’s enrollees or plan participants. For the purposes of this data, plan members will be counted by number of months each unique member was covered by health plan during the reporting period.

Primary care providers: A primary care provider is a generalist clinician who provides care to patients at the point of first contact and takes continuing responsibility for providing the patient’s care. Such a provider must have a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine.  For the purposes of this data collection, PCPs are not specialists.  See definition of “specialists.”

Providers: Physicians, non-physician clinicians (e.g. nurse practitioner), IPAs, medical groups, and inpatient or outpatient facilities (e.g. hospitals), including ancillary providers.

Quality/Quality components: A payment reform program that incentivizes, requires, or rewards some component of the provision of safe, timely, patient-centered, effective, efficient, and/or equitable health care.

Reporting period: Reporting period refers to the time period for which the health plan should report all of its data.  Unless otherwise specified, reporting period refers to calendar year (CY) 2016.  If, due to timing of payment, sufficient information is not available to answer the questions based on the requested reporting period of calendar year 2016, the health plan may elect to report for the time period on the most recent 12 months with sufficient information and note the time period.  If this election is made, ALL answers should reflect the adjusted reporting period.

Shared risk: Refers to arrangements in which providers accept some financial liability for not meeting specified financial targets.  It may also include arrangements in which providers accept some financial liability for not meeting specified quality targets.  Examples include: loss of bonus; baseline revenue loss; or loss for costs exceeding global or capitation payments; withholds that are retained and adjustments to fee schedules. For the purposes of this data collection, shared risk programs that include shared savings as well as downside risk should only be included in the shared risk category.  Shared risk programs are based on a FFS payment system and for the purposes of the CPR Scorecard, shared risk does not include bundled payment, full capitation, or partial or condition-specific capitation.

Shared risk contract: A payment arrangement contract between a health plan and a provider (see definition of provider) where the provider has agreed to a shared risk payment method (see definition of shared risk) for the care, or a subset of the care, they provide to health plan members.  For the purposes of this survey, the number of contracts should be counted; not the number of providers covered by the contract.  For example, a shared risk contract is counted as one contract whether it covers multiple providers (e.g. a group practice) or a single provider.

Shared savings: Provides an upside-only financial incentive for providers or provider entities to reduce unnecessary health care spending for a defined population of patients, or for an episode of care, by offering providers a percentage of any realized net savings.  “Savings” can be measured as the difference between expected and actual cost in a given measurement year, for example. Shared savings programs can be based on a FFS payment system.  Shared savings can be applied to some or all of the services that are expected to be used by a patient population and will vary based on provider performance.

Specialists: Specialist clinicians have a recognized expertise in a specific area of medicine.  For physicians, they have undergone formal residency and/or fellowship training programs and have passed the specialty board examination in that field.  Examples include oncologists, ENTs, cardiologists, OB-GYNs, renal care specialists, etc.  Nurse practitioners and physician assistants working in a non-primary care setting are also considered specialists. For the purposes of this data collection, specialists are not primary care providers. See definition of “primary care providers.”

Status-Quo payments: Includes all payment not tied to quality, including legacy FFS- payments, which is a payment model where providers receive a negotiated or payer-specified payment rate for every unit of service they deliver without regard to quality, outcomes or efficiency. For the purposes of the CPR Scorecard, Diagnosis Related Groups (DRGs), case rates, and per diem hospital payments are considered status-quo payments. Full capitation without quality, ora fixed dollar payment to providers for the care that patients may receive in a given time period, such as a month or year, is also categorized as a status-quo payment. In this model, payments may or may not be adjusted for patient risk, and there are no payment adjustments based on measured performance, such as quality, safety, and efficiency.

Total Dollars: The total estimated in- and out-of-network health care spend (e.g. annual payment amount) made to providers in calendar year (CY) 2016 or most recent 12 months.