Class 5: Vocabulary
BENCHMARKING or CLINICAL BENCHMARKING
Benchmarking is a management tool available to health care organizations for achieving breakthrough performances in both patient care and support areas. Benchmarking promotes and depends on a learning oriented organization meaning an organization that systematically collects, integrates and disseminates information. Clinical Benchmarking is the use of clinical data and process analysis to identify best outcomes. For example, one hospital or provider compares its care patterns with those of hospitals or providers that achieve better results and modifies its processes accordingly.
CASE MANAGEMENT
A process whereby covered persons with specific health care needs are identified and a plan which efficiently utilizes health care resources is formulated and implemented to achieve the optimum patient outcome in the cost effective manner. A systematic approach to identifying potentially serious illness/injuries, assessing potential opportunities to coordinate their care, developing treatment plans that improve quality, and managing the patients’ total care to ensure optimum outcomes in the most appropriate health care setting.
CASE MANAGER
An experienced professional (ex. nurse, doctor, or social worker) who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate healthcare.
CONCURRENT REVIEW
A method of reviewing patient care, during hospital confinement, to validate the necessity of current care and explore alternatives to inpatient care. Refers to utilization management that takes place during the provision of services. Also an assessment of hospital admissions, conducted by trained managed care staff via telephone or on-site visits during a covered person’s hospital stay, to ensure appropriate care, treatment, length of stay and discharge planning.
CONTINUOUS QUALITY IMPROVEMENT (CQI)
A continuous process that identifies problems in healthcare delivery, tests solutions to those problems and constantly monitors the solutions for improvement. Continuous Quality Improvement for the health care industry is complementary to the process of TQM, of getting everybody involved in the process of working together to improve the process and outcomes of the health care intervention.
CRITICAL PATHWAYS or DISEASE MANAGEMENT or BEST PRACTICES or CARE-MAPPING or OUTCOMES MANAGEMENT or POPULATION BASED CARE
Critical Pathways and Disease Management and Best Practices and Care-Mapping and Outcomes Management and Population Based Care are processes that are coming to mean roughly the same thing. It calls for doctors to discard their old, autonomous way for making decisions and substitute new group-tested “recipes” for treating common conditions ranging from asthma to diabetes. The aim is to take the best of what is learned in epidemiology and research exploring the results of various treatments, then export that knowledge to everyday practice, while measuring and attempting to improve the results. It implements a philosophy of continuous quality improvement and is an attempt to plot out the day-by-day process of health care delivery for a standard patient admitted with a specific diagnosis.
DISEASE MANAGEMENT
Approach to controlling defined illness or injury by integrating all components of health care in order to produce the best total patient outcomes at the most effective cost (not necessarily cost savings); that is usually utilized with patients who suffer from serious and/or chronic illnesses.
HEDIS
Healthplan Employer Data information Set. Developed by the NCQA with considerable input from the employer and managed care communities. HEDIS is an ever-evolving set of data reporting standards. HEDIS is designed to provide some standardization in performance reporting for financial, utilization, membership and clinical data so that employers and others can compare performance among plans.
JOINT COMMISSION (formerly JCAHO)
Joint Commission for the Accreditation of Healthcare Organizations. A not-for-profit organization that performs accreditation reviews primarily on hospitals, other institutional facilities, and outpatient facilities. Most managed care plans require any hospital under contract to be accredited by the Joint Commission.
LENGTH OF STAY (LOS)
The number of days that a member stayed in an inpatient facility.
MEDICALLY NECESSARY
A service or treatment which is appropriate and consistent with diagnosis, and which, in accordance with accepted standards or practice in the medical community of the area in which the health services are rendered, could not have been omitted without adversely affecting the member’s condition or the quality of medical care rendered.
NCQA
National Committee on Quality Assurance. A not-for-profit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also developed HEDIS standards.
OUTCOMES OF CARE
The end results of medical care, as indicated by recovery, disability, functional status, mortality, morbidity or patient satisfaction. Outcomes Measurement is the process of systematically tracking a patient’s clinical treatment and responses to that treatment using generally accepted outcomes measures or quality indicators. Outcomes may mean different things to different people and can be looked at from a quality perspective, measuring end results in terms of properly adjusted mortality and morbidity measurements. Outcomes can be based on pure utilization statistics such as lengths of stay or readmission rates. Outcomes can be measured by like comparisons for total costs of care. From the patient’s perspective, outcomes can be based on both the functional and perceptual benefits resulting from the health car intervention.
PHYSICIAN PROFILING
Improvements in care are based on the assumption that there are variations in health care delivery with variations in health care outcomes. Physician Profiling compares physicians on selected criteria and may be used for educational purposes to share information with physicians in a non-adversarial manner to encourage interest and participation in designing positive alternatives for change. Variations may be attributable to the fact that some patients are really sicker than others. Severity of illness can be adjusted by applying any of several severity adjustment software packages currently on the market. The second source of variation is the physician. What does the physician do in the way of ordering diagnostic and therapeutic procedures? Do physicians order a lot of tests because they equate quality with quantity? Do they have a preference for heavy utilization of all the latest, most expensive technologies? How do they utilize consultants? Physician behavior is a key issue when looking at variations in patient care.
PRECERTIFICATION
Process of reviewing requested services for medical necessity, appropriateness, level of care needed, and plan benefit prior to delivery of service. Also known as preadmission certification, preadmission review and precert. The process of obtaining certification or authorization form the health plan for routine hospital admissions (inpatient or out-patient). Often involves appropriateness review against criteria and assignment of length of stay. Failure to obtain precertification often results in a financial penalty to either the provider or subscriber.
PROSPECTIVE REVIEW
A method of reviewing possible hospitalization, prior to admission, to determine necessity of confinement, outpatient alternatives and estimated length of stay.
QUALITY ASSURANCE (QA)
A formal set of activities to assure the quality of services provided. Quality Assurance is the same as quality management and includes quality assessment and corrective actions taken to remedy any deficiencies identified through the assessment process. See QA Programs in class 2.
RETROSPECTIVE REVIEW
A method of determining medical necessity and/or appropriate billing practice for services which have already been rendered. A method of review which occurs after health care has been provided and sometimes after reimbursement has been issued. This type of review is used to review situations in which it is believed there may have been inadequate data on which to base a decision about Utilization Management programs, possibly choose to vary reimbursement as a result of the review, or to monitor expenditures in areas which were not selected for intensive review.
TOTAL QUALITY MANAGEMENT (TQM)
Total Quality Management is a managerial innovation and calls for continuous and relentless improvement in the total process that provides care, not simply in the improved actions of individual professionals. Improvement is based on both outcomes and process. TQM places primary emphasis for problem characterization on the system rather than the individual.
UTILIZATION
The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Usually expressed as the number of services used per year or per 100 or 1,000 persons eligible for the service.
UTILIZATION MANAGEMENT (UM) or UTILIZATION REVIEW (UR)
Systematic means for reviewing and controlling patients’ use of health services and providers’ use of health care resources. Usually involves data collection, review and/or authorization, especially for services such as a specialist referrals and emergency room use, and particularly costly services such as hospitalization. Utilization Review (“UR”) also known as Utilization Management is the process by which the health plan, payor or UR firm determine which services are medically appropriate and cost effective. Many insurance plans and all HMOs require that UR procedures are followed prior to all inpatient and some outpatient and emergency care or they will not pay for services rendered. See UM and UR in class 2.
URAC
Utilization Review Accreditation Commission. A not-for-profit organization that performs reviews of external utilization review agencies (freestanding companies, utilization management departments of insurance companies, or utilization management departments of managed care plans). Its sole focus is managed indemnity plans and PPOs, not HMOs or similar type of plans. States often require certification by URAC for utilization management organizations to operate.
AFFORDABLE CARE ACT
BENCHMARK
The term “benchmark” is used the Affordable Care Act about 64 times.
OUTCOMES
The term “Outcomes” is used under the Affordable Care Act about 118 times in different ways including: HEALTH OUTCOMES, CLINICAL OUTCOMES, QUALITY OUTCOMES, PATIENT LEVEL OUTCOMES, CLINICAL LEVEL OUTCOMES.
QUALITY
The term “Quality” is used under the Affordable Care Act about 562 times. The term “Quality Improvement” is used about 49 times.
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