CARVE-OUTS

Examples of Carve-Outs

  • Transplant service
  • Burn treatment services
  • Other high cost services
  • Out-of-area emergency
  • Mental health and Substance abuse
  • Vision
  • Dental

Refers to a set of medical services that are carved out of the basic arrangement.  In terms of plan benefits, may refer to a set of benefits that are carved out and contracted for separately; for example, mental health/ substance abuse services may be separated from basic medical-surgical services.  May also refer to carving out a set of services from a basic capitation rate with a provider (e.g., capitating for cardiac care but carving out cardiac surgery and paying case rates for that).  Medical services commonly carved out from managed care contracts (exempt from capitation) include out-of-area emergency, out-of-network services in plans that allow members to use not-network providers, mental health substance abuse, vision and dental care.

CONTINUOUS QUALITY IMPROVEMENT (CQI) PROGRAM

Utilizes standards and has defined goals of ongoing increases in the level of quality of care given and outcomes. The CQI program may include the establishment of credentialing standards, regular review of practice patterns, study of clinical outcomes, routine utilization review and case management. These may be mandated by third party payors or developed by health care delivery group.

CONTINUUM OF CARE

A comprehensive set of health services ranging from preventive and ambulatory services to acute care to long-term and rehabilitative services. Continuum of care involves coordinating the mix of services that each patient may require. Primary care tends to be the point of access for most patients. If the patient is well, then the health system would ideally place that person along a track geared toward promoting and maintaining wellness. If the patient has one or more chronic illnesses, then the system would ideally enlist tools and techniques to manage those conditions across sites and providers of care. Such a system provides consistency and continuity of care, while encouraging patients toward responsibility for improving or maintaining their health, independence and well-being.

GATEKEEPER

Usually Primary Care Physicians are the “gatekeeper” who serve as the patient’s initial contact for medical care and referrals. He or she decides on what tests to order, when consultation and hospitalization is needed and whether or not to carry out consultant’s recommendations. In the original gatekeeper systems used by HMOs and many PPOs, the patient cannot self-refer to specialists.

MID-LEVEL PRACTITIONER

Physician’s assistants, clinical nurse practitioners, nurse midwives and the like.  Non-physicians who deliver medical care, generally under the supervision of a physician but for less cost.

PRIMARY CARE PHYSICIAN (PCP)

Practitioners who treat a variety of health problems across all patient age groups and who frequently serve as the patient’s first point of contact with the health care system. Typically, Primary Care Physicians include family practitioners, general internists, general pediatricians, and in some cases, obstetricians and gynecologists. PCP’s are the means by which patients gain access to and navigate through a health care system. Often, Managed Care Organizations establish their own criteria for who may provide primary care. Three general approaches may be used to define the category of primary care physicians: by specialty, by historical practice, and by willingness to provide primary care services.

AFFORDABLE CARE ACT:

FRONTIER HEALTH PROFESSIONAL SHORTAGE AREA

The term ‘frontier health professional shortage area’ means an area  with a population density less than 6 persons per square mile within the service area; and with respect to which the distance or time for the population to access care is excessive.  (124 STAT.591)

HEALTH CARE TEAM

A health care team collaborates with local primary care providers and existing State and community based resources to coordinate disease prevention, chronic disease management, transitioning between health care providers and settings and case management for patients, including children, with priority given to those amenable to prevention and with chronic diseases or conditions identified by the Secretary of health and Human Services.  (124 STAT.514)

HEALTH LITERACY

The term ‘health literacy’ means the degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions.  (124 STAT.591)

PATIENT CENTERED MEDICAL HOMES

Medical homes, are defined as a mode of care that includes personal physicians; whole person orientation; coordinated and integrated care; safe and high-quality care through evidence informed medicine, appropriate use of health information technology, and continuous quality improvements; expanded access to care; and payment that recognizes added value from additional components of patient-centered care.  (124 STAT.514)

PHYSICIAN COMPARE

“Physician Compare” is an  Internet website with information on physicians enrolled in the Medicare program and other eligible professionals who participate in the Physician Quality Reporting Initiative.  (124 STAT.967)

PRIMARY CARE

The term ‘‘primary care’’ in reference to “patient-centered medical home” means the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

PRIMARY CARE PRACTITIONER

The term “primary care practitioner” means an individual who is a physician and has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or is a nurse practitioner, clinical nurse specialist, or physician assistant; and for whom primary care services accounted for at least 60 percent of the allowed charges for such physician or practitioner in a prior period as determined appropriate by the Secretary of Health and Human Services.  (124 STAT. 652)

PRIMARY CARE PROVIDER

The term “primary care provider” means a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing a sustained partnership with patients, and practicing in the context of family and community, as recognized by a State licensing or regulatory authority, unless otherwise specified in this section.  (124 STAT. 650)

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