Comparative Clinical Effectiveness Research
Posted on July 1, 2010 |
Comment (1)
By Nancy Lopez and Jane Thorpe
Background
The Institute of Medicine (IOM) defines comparative effectiveness research (CER) as the study of methods, including alternative approaches, to “prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care” and to inform decision-making by “consumers, clinicians, purchasers, and policy makers.”[1] CER is an important tool for generating evidence necessary to improve the quality of health care and to assure the greatest value from the nation’s investment in the health care system. Although U.S. health expenditures as a percent of gross domestic product vastly exceed those of other wealthy nations, researchers have documented that U.S. adults and children receive only half of all recommended health care.[2] Leading health system reform analysts have thus advocated that the U.S. follow the example found in other nations and adopt a national CER policy.[3]
In the American Recovery and Reinvestment Act of 2009 (ARRA), Congress began to move toward the establishment of such a national policy.[4] ARRA appropriated funding totaling $1.1 billion for CER and created a Federal Coordinating Council (FCC) to make recommendations related to federal CER initiatives. The FCC, in its 2009 Report to the President and Congress, described the purpose of CER as being “to provide information that helps clinicians and patients choose which option best fits an individual patient’s needs and preferences.”[5] In its report, the FCC defined CER, set forth a prioritization strategy, and made initial recommendations regarding expenditure of CER funding, including research synthesis and development of the tools essential for CER (such as clinical registries and clinical data networks).
ARRA also directed the U.S. Department of Health and Human Services (HHS) to contract with IOM to recommend national CER priorities.[6] In its June 2009 priorities report, the IOM expanded traditional CER to include not only comparison of clinical interventions (drugs or other forms of clinical treatment), but also alternative strategies that reflect population and community interventions.[7] The IOM also identified 100 “initial priority topics” for comparative effectiveness research.[8] The IOM list included both clinical treatment “head to head” comparisons (for example, different types of treatments for atrial fibrillation) as well as research into the effectiveness of population health interventions (for example, regulating foods sold in schools) associated with such chronic conditions as obesity.
During the debate over ARRA, the use of evidence generated by CER was a critical issue. The Conference Committee stated that funds could be used to “conduct or support research to evaluate . . . medical treatments and services . . .” but clarified that CER could not be used to “mandate coverage or reimbursement” policy.[9]
Changes Made by the Health Reform Law
P.L. 111- 148, §§ 6301 and 10602
The law:
- Renames CER “comparative clinical effectiveness research (CCER)”
- Defines CCER as “research evaluating and comparing health outcomes and the clinical effectiveness, risk, and benefits of two or more medical treatments, services, and items.” Further defines “medical treatments, services, and items”[10] to include “health care interventions, protocols for treatment, care management, procedures, medical devices, diagnostic tools, pharmaceuticals (including drugs and biologicals), integrative health practices, and any other strategies or items being used in the treatment, management, and diagnosis of, or prevention of illness or injury in individuals.”[11]
- Replaces the FCC as of enactment[12] with a Patient-Centered Outcomes Research Institute (Institute), which operates as a nonprofit corporation rather than as a governmental agency.[13] Specifies governance by a Board of Governors consisting of the Director of the Agency for Healthcare Research and Quality (AHRQ), the Director of the National Institutes of Health (NIH), and 17 members appointed by the Comptroller General and representing patients, providers, drug and device manufacturers, health services researchers, experts in quality improvement, and federal and state government officials.[14]
- Specifies that the Institute’s primary purpose is to advance the quality and relevance of evidence that can be used by patients, clinicians, purchasers, and policymakers to make informed health care decisions.[15]
- Requires the Institute to consider variations in patient subpopulations and disseminate research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of medical treatments, services and items.[16]
- Specifies the Institute’s duties as:
- Identifying national priorities for research, taking into consideration factors such as disease incidence, prevalence and burden, gaps in evidence, potential for new evidence to improve care, potential impact on health expenditures, and relevance to patients and providers;
- Establishing, by majority vote of the Board of Governors, and implementing, a research project agenda in accordance with approved methodological standards that include systematic reviews and assessments of existing and future research, primary research, and other methods identified by the Board;
- Assuring that research takes into account differences in the effectiveness of health care treatments, services, and items for various subpopulations, such as racial and ethnic minorities, women, age, and groups of individuals with different co-morbidities, genetic and molecular sub-types, or quality of life preferences;
- Assuring that the research addresses different treatment modalities; and
- Making research findings available to clinicians, patients, and the general public within 90 days after the conduct or receipt of research findings. Findings must: convey the research in a manner that is useful to patients and providers; address considerations specific to certain subpopulations, risk factors, and co-morbidities; and identify limitations of the research and what further research may be needed.
- Eliminates the bar against use of research findings to guide coverage and payment, while setting forth restrictions on the use of CER in Medicare administration, as follows:
- Specifies that CER findings should not be construed as allowing the Institute to “mandate coverage, reimbursement or other policies for any public or private payer”[17];
- Specifies that CER data must not include any data which would violate the privacy of research participants[18];
- Clarifies that nothing in the law “shall be construed as superceding or modifying the coverage of items or services under [Medicare] that the Secretary determines are reasonable and necessary or as authorizing the Secretary to deny coverage of items or services under Medicare solely on the basis of comparative clinical effectiveness research”[19];
- Bars the use of CER evidence in a manner that treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill[20]; and
- Prohibits the Secretary from using evidence or findings from CCER in determining Medicare coverage “in a manner that precludes or with the intent to discourage, an individual from choosing a health care treatment based on how the individual values the tradeoff between extending the length of their life and the risk of disability,” while specifying that this prohibition does not “limit the application of differential copayments based on factors such as cost or type of service or prevent the Secretary from using evidence or findings in determining coverage, reimbursement or incentive programs based on a comparison of the difference in the effectiveness of alternative health care treatments in extending an individual’s life due to that individual’s age, disability, or terminal illness.”[21]
- Requires the HHS Secretary to make Medicare, Medicaid, CHIP and other data available to the Institute and authorizes the Institute to seek other public and private entities such as clinical databases and registries subject to applicable laws and standards.[22]
- Authorizes the Institute to enter into contracts for the management of funds and the conduct of research with “appropriate” agencies and instrumentalities of the federal government and “appropriate academic research, private sector research, or study-conducting entities”[23] that meet conditions for contracts, including the right of peer-review publication as long as a data use agreement exists with the Institute.[24]
- Prohibits “subsequent” use of data from original research in “work-for-hire contracts with individuals, entities, or instrumentalities that have a financial interest in the results, unless approved under a data use agreement with the Institute.”[25]
- Establishes financial and governmental oversight procedures.[26]
- Directs the Institute to ensure “transparency, credibility, and access” through the use of public comment periods, public forums, and public availability of research findings, the process and methods used to conduct research, and the identity of the entity and the investigators conducting such research along with any conflicts of interest.[27]
- Directs AHRQ, in consultation with NIH, to create tools for dissemination of research as well as a research data base. Further directs AHRQ to build CCER capacity by establishing a program of CCER research methods training.[28]
- Establishes a Patient-Centered Outcomes Research Trust Fund (PCORTF) providing for directed spending to support CCER between FY 2010 and 2019.[29] Funding is derived from general revenues, fees, and Medicare Parts A and B. Amends the Internal Revenue Code to establish the standards and procedures used to assess, collect, and transfer fees collected to the PCORTF.[30]
Implementation
Agencies
The law does not specify which agency of the federal government has direct responsibility for establishing and incorporating the Institute.
Key Dates
None as of this writing.
Process
The health reform law does not provide specific direction regarding the administrative process used to implement the law suggesting broad authority in the Executive Branch to devise an implementation process while also assigning a role to the Comptroller General in appointing members of the Board of Governors. A wide range of tools can be used to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period, or using other types of approaches such as posted policy instructions, funding availability announcements, official letters to affected entities, and posted rulings and notices. Agency websites can be checked regularly for updates.
Key Issues
- The Institute: What will be the process, timetable, and allocation of responsibilities in the development of the Institute?
- CER Standards: What process will be used to develop the standards governing permissible and impermissible uses of CER findings and evidence?
- CER and Medicare: What standards will the HHS Secretary develop for incorporating CER findings and evidence (to the extent permissible) into Medicare program operations, including national coverage determinations, cost sharing policies, and payment for treatments and therapies?
- Dissemination Standards: What standards will the Institute and AHRQ develop for the dissemination of research results, including findings, methods, and information regarding the process by which research is conducted?
- CER and Private Research: What standards will be established for private entities that seek to conduct CER?
Recent Agency Action
No action as of the time of this posting.
Authorized Funding Levels
The PCORTF[31] specifies funding levels by fiscal year (FY) through September 30, 2019, with a specified amount of funds made available to HHS, AHRQ, and NIH to support the dissemination of the research findings of the Institute.[32] Funding levels are specified as follows.
- Appropriated funds in the amount of $10,000,000 for FY 2010; $50,000,000 for FY 2011; $150,000,000 for FY 2012;[33]
- For FY 2013, appropriated funds including net revenues received from fees on health insurance and self-insured plans, an amount equal to $1 multiplied by the average number of individuals entitled to benefits under Medicare Part A or enrolled under Part B, and $150,000,000 for each FY;[34] and
- For FYs 2014 – 2019, appropriated funds including net revenues from fees on health insurance and self-insured plans, an amount equal to $2 multiplied by the average number of individuals entitled to benefits under Medicare Part A or enrolled under Part B (with adjustments for increases in health care spending) and $150,000.000.[35]
[1] Institute of Medicine, “Initial National Priorities for Comparative Effectiveness Research,” Report Brief (Washington, DC: IOM, 2009).
[2] Elizabeth A.McGlynn, Steven Asch, John Adams, Joan Keesey, Jennifer Hicks, Alison DeCristofaro, Eve A.Kerr, “The Quality of Healt Care Delivered to Adults in the United States,” New England Journal of Medicine 348, (26):2635-45, June 26, 2003.
[3] Gail R. Wilensky, “The Policies and Politics of Creating a Comparative Clinical Effectiveness Research Center,” Health Affairs (28(4): w719-w729, July/August 2009).
[4] The American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, 111th Congress, 1st sess. (2009).
[5] Federal Coordinating Council for Comparative Effectiveness Research Report to the President and Congress, available at http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf, June 30, 2009 (Accessed May 21, 2010).
[6] ARRA, Title VIII.
[7] Institute of Medicine, “Initial National Priorities for Comparative Effectiveness Research,” Report Brief (Washington, DC: IOM, 2009), available at http://www.iom.edu/~/media/Files/Report%20Files/2009/ComparativeEffectivenessResearchPriorities/Stand%20Alone%20List%20of%20100%20CER%20Priorities%20-%20for%20web.ashx (Accessed May 21, 2010).
[8] Institute of Medicine, “Initial National Priorities for Comparative Effectiveness Research,” Report Brief (Washington, DC: IOM, 2009), available at http://www.iom.edu/~/media/Files/Report%20Files/2009/ComparativeEffectivenessResearchPriorities/Stand%20Alone%20List%20of%20100%20CER%20Priorities%20-%20for%20web.ashx (Accessed May 21, 2010).
[9] U.S. House of Representatives, “Joint Explanatory Statement of the Committee of the Conference,” www.house.gov/billtext/hr1_cr_jes.pdf (accessed April 30, 2010).
[10] Id. at § 6301(a), adding new § 1181(a)(2)(A) to the Social Security Act.
[11] Id. at § 6301(a), adding new § 1181(a)(2)(B) to the Social Security Act.
[12] Id. at §6302.
[13] Id. at § 6301(a), adding new § 1181(b)(1) to the Social Security Act.
[14] Id. at § 6301(a), adding new § 1181(f) to the Social Security Act.
[15] Id. at § 6301(a), adding new § 1181(c) to the Social Security Act.
[16] Id. at § 6301(a), adding new § 1181(c) to the Social Security Act.
[17] Id. at § 6301(a), adding new § 1181(j)(1)(A) to the Social Security Act.
[18] Id. at § 6301(a), adding new § 1181(d)(8)(A)(v) to the Social Security Act.
[19] Id. at § 6301(c), adding new § 1182(b) to the Social Security Act.
[20] Id. at § 6301(c), adding new § 1182(c)(1) to the Social Security Act.
[21] Id. at § 6301(c), adding new § 1182(d)(1) to the Social Security Act.
[22] Id. at § 6301(a), adding new § 1181(d)(3) to the Social Security Act.
[23] §6301 (a) adding new § 1181(d)(2)(B)(i) of the Social Security Act.
[24] §6301(a), adding § 1181(d)(2)(B)(ii) to the Social Security Act.
[25] §10602(1)(B), amending § 1181(d)(2)(B)(iv) of the Social Security Act.
[26] Id. at § 6301(a), adding new § 1181(g) to the Social Security Act.
[27] Id. at § 6301(a), adding new § 1181(h)) to the Social Security Act.
[28] Id. at § 6301(b), adding new § 937(a) to the Public Health Service Act.
[29] Id. at § 6301(a), adding new § 1181(c) to the Social Security Act; § 6301(e), adding new § 9511(a) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[30] Id. at § 6301(e), adding new § 9511(b-f) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[31] Id. at § 6301(e), adding new § 9511(a) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[32] Id. at § 6301(e), adding new § 9511(d)(2) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[33] Id. at § 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[34] Id. at § 6301(d), adding new § 1183 to the Social Security Act; § 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
[35] Id. at § 6301(d), adding new § 1183 to the Social Security Act; § 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Institute of Medicine, “Initial National Priorities for Comparative Effectiveness Research,” Report Brief (Washington, DC: IOM, 2009).
Elizabeth A.McGlynn, Steven Asch, John Adams, Joan Keesey, Jennifer Hicks, Alison DeCristofaro, Eve A.Kerr, “The Quality of Healt Care Delivered to Adults in the United States,” New England Journal of Medicine 348, (26):2635-45, June 26, 2003.
Gail R. Wilensky, “The Policies and Politics of Creating a Comparative Clinical Effectiveness Research Center,” Health Affairs (28(4): w719-w729, July/August 2009).
The American Recovery and Reinvestment Act of 2009 (ARRA), Pub. L. No. 111-5, 111th Congress, 1st sess. (2009).
ARRA, Title VIII.
Id. at
§ 6301(a), adding new § 1181(a)(2)(A) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(a)(2)(B) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(b)(1) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(f) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(c) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(c) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(j)(1)(A) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(d)(8)(A)(v) to the Social Security Act.
Id. at
§ 6301(c), adding new § 1182(b) to the Social Security Act.
Id. at
§ 6301(c), adding new § 1182(c)(1) to the Social Security Act.
Id. at
§ 6301(c), adding new § 1182(d)(1) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(d)(3) to the Social Security Act.
§6301 (a) adding new § 1181(d)(2)(B)(i) of the Social Security Act.
§6301(a), adding § 1181(d)(2)(B)(ii) to the Social Security Act.
§10602(1)(B), amending § 1181(d)(2)(B)(iv) of the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(g) to the Social Security Act.
Id. at
§ 6301(a), adding new § 1181(h)) to the Social Security Act.
Id. at
§ 6301(b), adding new § 937(a) to the Public Health Service Act.
Id. at
§ 6301(a), adding new § 1181(c) to the Social Security Act;
§ 6301(e), adding new § 9511(a) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(e), adding new § 9511(b-f) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(e), adding new § 9511(a) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(e), adding new § 9511(d)(2) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(d), adding new § 1183 to the Social Security Act;
§ 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Id. at
§ 6301(d), adding new § 1183 to the Social Security Act;
§ 6301(e), adding new § 9511(b)(1) to Subchapter A of chapter 98 of the Internal Revenue Code of 1986.
Office of the National Coordinator for Health Information Technology –
Health Information Technology for Economic and Clinical Health Act – Part of American Recovery and Reinvestment Act, the act imposes more stringent regulatory requirements under the security and privacy rules of HIPAA, increases civil penalties for a violation of HIPAA, provides funding for hospitals and physicians for the adoption of health information technology, and requires notification to patients of a security breach.
Culturally and linguistically appropriate and competent services – A federal standard designed to assure better access and quality of care in order to eliminate ethnic and racial disparities in health care.
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Health Insurance Portability and Accountability Act – A federal law that regulates health information privacy, health insurance portability and non-discrimination and health insurance simplification and whose provisions have been broadly expanded by the Patient Protection and Affordable Care Act.
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National Strategy to Improve Health Care Quality – A national strategy spanning federal and state health programs, health care providers, and public and private health insurers whose aim is to prioritize areas for national health care quality improvement and coordinate across payers and programs to make more rapid change possible. The National Strategy is required under the Patient Protection and Affordable Care Act.
Interagency working group on health care quality – A working group established as part of a national strategy to improve health care quality. The group will identify national priorities for quality improvement as determined by certain criteria and coordinate efforts across federal and state agencies and programs as well as the private sector to achieve quality improvement.
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Agency for Health Care Research and Quality – The federal agency within the United States Department of Health and Human Services that has lead responsibility for efforts to improve the quality of health care and the promotion of health services research.
Exchange-participating health benefit plans – Health insurance plans offered to individuals and small employers through health insurance exchanges. Companies offering plans in the exchange must meet federal and applicable state requirements.
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Comptroller General of the United States – See Government Accountability Office.
Subrogation of health insurance benefits – The practice by which an insurer pays an individual health insurance claim then seeks to recoup losses from a responsible third party, such as another health insurer or a recovery in a medical liability or personal injury action. Individuals who sue for medical malpractice and recover may be required to repay their insurers for the cost of covered medical care.
Employee Retirement Income Security Act – A law passed by Congress in 1974, which establishes federal standards governing both pension plans and employer-sponsored “health and welfare benefit plans,” offered by private employers. Church plans are exempt, as are public employee health benefit plans. The health reform law establishes additional federal standards for ERISA-governed health benefit plans.
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Health information privacy and security – Standards and procedures to ensure that personal health information is not compromised or disclosed in processing health care transactions.
Multiple Employer Welfare Arrangements– An employee health or welfare benefit plan that is marketed to two or more employers and is subject to ERISA regulation as well as applicable state law.
Federal Employee Health Benefits Plan – The health benefit plan that covers federal civilian employees and their dependents.
Children’s Health Insurance Program– A program established in 1997 and reauthorized in 2009, which is administered by states and funded through a combination of federal and state payments. CHIP allows states to provide health insurance (known as child health assistance) to uninsured “targeted” low-income children. States also may provide coverage to targeted low-income pregnant women. State CHIP programs can establish state CHIP plans as separately administered programs, Medicaid expansions, or a combination of the two. Unlike Medicaid, the CHIP program caps federal funds available to states and must periodically be reauthorized.
Discrimination based on health status – Insurer practices that deny coverage either prior to or following enrollment. Discrimination at the point of enrollment can encompass the total denial of enrollment or the imposition of waiting periods or pre-existing condition exclusions following enrollment. Post enrollment discrimination can involve the use of flat limits on treatment (expressed either on a dollar or quantitative basis) that are aimed at limiting coverage for costlier conditions. For example, a child born with cerebral palsy might be denied coverage entirely; alternatively an insurer might impose waiting periods, exclusions on coverage, or limits on the amount of coverage available for certain treatments (e.g., only $10,000 annually for physical therapy or only 20 physical therapy sessions annually, or a total exclusion of physical therapy for conditions related to birth injuries). .
Interstate health insurance compacts – An agreement among multiple states to permit the sale of multiple-state licensed insurance products across state lines.
National Health Workforce Commission – A special commission to advise Congress, the President, the states, and localities on health workforce needs and measure the unmet need for care.
Medicare Payment Advisory Commission – An independent Congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program. The Commission's statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare's traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.
Graduate medical education payments – Payments made under Medicare or other health care financing authorities to support the cost of medical residency training.
Small business employer health plan – A plan offered by an employer with fewer than 100 full-time employees.
Comparative effectiveness research– A specific type of health services research that compares different approaches to treating medical conditions in order to determine which methods are most likely to produce the best outcomes.
Indian Health Care Improvement Act – A federal law that provides for the establishment and support of health care services to American Indians, Native Hawaiians, and Alaska Natives. The Indian Health Care Improvement Act is overseen by the Indian Health Service.
Government Performance Results Act– A federal law enacted in 1993 designed to prevent waste and fraud in federal programs, which, as a result of amendments in the Patient Protection and Affordable Care Act, is strengthened in terms of federal enforcement and violations for penalties.
Federally Qualified Health Center – A federally funded community health center, as well as a health center that meets all federal requirements applicable to the federal community health centers program (location, scope of services, use of a sliding fee scale, and community board governance) but that does not actually receive a federal grant. Because of their location and high level of treatment of the uninsured, FQHCs receive special payment rates from Medicare, Medicaid. and CHIP and are eligible for special supplemental payments from exchange-participating health insurance plans. See also Community health centers.
Home and community-based services – Health care services offered in the home and community to individuals with serious and chronic physical, mental, or developmental conditions that require ongoing care. Home and community based services are designed to promote community residence and to avoid unnecessary institutional care.
Essential health benefits package – See Essential health benefits.
State health insurance exchanges – State-based marketplaces for the sale and purchase of health insurance established in federal law and operated in accordance with federal requirements. Health insurers that sell products in the exchanges to small employers and individuals will be required to meet federal standards of coverage, fair practices, and plan administration.
Government Accountability Office– A special arm of Congress that oversees the integrity and accountability of federal programs and expenditures and that is headed by the Comptroller General of the United States.
Disproportionate share hospital – A hospital whose patients are disproportionately low-income as measured by federal standards under the Medicare and Medicaid programs. DSH hospitals receive additional payments to offset the greater severity of illness present among low-income patients.
Health insurance market reforms – Reforms contained in the Patient Protection and Affordable Care Act that are designed to stop certain types of exclusionary or discriminatory activities by insurers. Conduct specifically targeted by market reforms encompasses the use of preexisting condition exclusions, discrimination based on health status, fair health insurance premiums whose rates vary by family size, rating area, age and tobacco use, guaranteed availability and renewability of coverage, non-discrimination against health care provider participation, and the use of excessive waiting periods.
Modified adjusted gross income–The calculation of income and assets used to determine eligibility for federal programs including Medicaid, and premium and cost sharing assistance for tax credits provided to low and moderate income individuals under the health reform law. In determining income, states must disregard or reduce countable income by 5 percent for the income pathway.
Discrimination in health care – Differences in patient treatment by health care providers based on race, gender, age, ability to pay for care, disability, language, or severity of illness. Under federal civil rights laws, discrimination may be intentional or de facto.
Public health investment fund – A trust fund established in health reform legislation designed to ensure a consistent funding stream for federal public health, prevention, and wellness activities.
National Health Service Corps – A program authorized under the Public Health Service Act that provides grants and loan repayment assistance to medical and health professionals in exchange for a specified term of service in an urban or rural location identified as having a shortage of health professionals.
National Institutes of Health – A federal agency within the Department of Health and Human Services that has lead responsibility for biomedical, clinical, and translational research.
Accountable care organization – A group of health care providers that have entered into a formal arrangement to assume collective responsibility for the care of a specific group of patients and that receive financial incentives to improve the quality and efficiency of health care. .
Health coverage participation – The requirement under the Patient Protection and Affordable Care Act that most individuals not eligible for public insurance programs purchase private health insurance coverage.
Health information technology – Technology that allows the comprehensive management of health information and enables its exchange among health professionals, consumers, health care providers, health care payers, and public health agencies.
Employer sponsored insurance– A health benefit plan offered by an employer to employees and dependents. Health insurance coverage is optional for employers. Employers may opt to purchase an insurance policy for their employees, offer coverage on a self-insured basis, or a combination of the two.
Nurse-managed health centers – Clinics managed by nurses supported by federal grants authorized under the Patient Protection and Affordable Care Act.
Exchange-eligible individual – An individual who is permitted to obtain coverage through a state health insurance exchange.
Food and Drug Administration – The federal agency within the United States Department of Health and Human Services responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), veterinary products, and cosmetics.
Supplemental Security Income– A Federal income supplement program funded by general tax revenues to help aged, blind, and disabled people, who have little or no income.
Guaranteed issue and renewal – A rule that bars insurers from denying enrollment or dropping coverage for reasons other than fraud or non-payment of health insurance premiums. Guaranteed issue and renewal are commonly associated with the Patient Protection and Affordable Care Act’s broad prohibition against discrimination on the basis of health status.
Administrative transactions – The exchange of health care information between health plans and providers to determine eligibility, coverage, and payment for health services.
Flexible Spending Accounts – See Cafeteria plans.
Primary care professionals – Health care professionals who specialize in a primary care practice field such as family medicine, pediatrics, obstetrics and gynecology, adult medicine, nurse practice, and other types of practice designated as primary health care. State Medicaid programs will be required to pay for primary health care at 100 percent of the Medicare payment rate (which typically is significantly higher) beginning in 2014. For two years, the federal government will contribute 100 percent of the cost of primary care payments.
Graduate medical education – See Graduate medical education payments.
Minimum essential coverage – The minimum insurance package that fulfills the requirement of the mandate that all individuals carry insurance.
School-based health clinic – A clinic that is located in or in connection with a school and that receives funding under a new grant program authorized in the Patient Protection and Affordable Care Act.
Exchange-eligible employer – An employer that is permitted to obtain coverage for its employees through a state health insurance exchange.
Health insurance ombudsman – A grant program authorized under health reform legislation to assist in health insurance enrollment, eligibility for premium assistance eligibility determinations, consumer education on rights and responsibilities, and assistance in dispute resolution between plan beneficiaries and health insurers.
Individual responsibility – The requirement that all individuals obtain health insurance or pay a penalty. This is also referred to as the “individual mandate.”
Small business tax credit – A tax credit for small employers to help offset the cost of health insurance coverage provided to their employees. Eligible small businesses consist of those with 25 or fewer employees whose employees’ average annual wages do not exceed specified limits.
Office of Minority Health – OMH was established in 1986 by the U.S. Department of Health and Human Services (HHS). It advises the Secretary and the Office of Public Health and Science (OPHS) on public health program activities affecting American Indians and Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians, and other Pacific Islanders.
Excessive waiting periods – The period of time before coverage begins for a new enrollee. The Patient Protection and Affordable Care Act limits waiting periods to no more than 90 days.
Hawaii Prepaid Health Act – Hawaii’s state law, enacted in 1974 (and later exempted from ERISA’s bar against state laws that regulate employee benefit plans) that requires employers to provide health insurance coverage to employees who work more than twenty hours per week.
Grandfathered health plan– See Grandfathered plan.
Health care related taxes – Taxes imposed on the health care industry under the Patient Protection and Affordable Care Act on health insurance plans, prescription drugs, and medical devices.
Essential health benefits – The minimum level of coverage that must be offered by qualified health plans operating in state health insurance exchanges. Essential benefits are defined in relation to the classes of services and benefits covered, the level of financial protection against deductibles, and cost-sharing protection they provide.
State innovation waivers – Special waivers given by the Secretary of the United States Department of Health and Human Services that would allow a state to replace the exchange system with an alternative approach to coverage. The Secretary is authorized to waive provisions of the Patient Protection and Affordable Care Act related to qualified health plans, consumer choices cost-sharing protections, and individual and small employer tax credits. Waivers of the law’s provisions related to exchanges can be combined with Medicare and Medicaid waivers so as to permit states to create entirely alternative forms of health insurance coverage, such as a single payer plan.
Insurance premium rating – The process by which health insurers determine what rates will be charged for health insurance premiums, taking into consideration age, health status, gender, industry, certain personal health care practices (such as use of tobacco), geography, and other factors.
Federal Trade Commission – An independent federal agency charged with protecting consumers from anticompetitive practices in the health care industry and other types of conduct that violates federal laws related to competition.
Information transparency – Provisions of the Patient Protection and Affordable Care Act that promote clearness and fairness in health insurance information including coverage, rights and responsibilities, and patient and consumer protections. The law mandates that information on health plan terms and conditions and payment policies be spelled out in plain language consumers can understand.
Community health centers – Non-profit clinics established under the Public Health Service Act and that provide or arrange for a broad range of primary health care services. Health centers must meet a series of federal criteria related to the scope of care they furnish, the prospective adjustment of charges in accordance with the ability to pay, location in or service to medically underserved communities and populations, and governance by a community board, 51% of whom must be patients of the clinic. See also, Federally Qualified Health Centers.
Coordination of benefits – The process of reconciling health care that is covered by more than one form of health insurance. For example, if a child is insured through both parents, one insurer is generally considered the primary policy, and the secondary policy reimburses for services not covered under the primary policy.
Health insurance issuers – Entities that sell health insurance products to employer-sponsored health plans, individuals in exchanges, and the open market.
Electronic Health Record - An evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems.
Diagnosis related group – A system of patient care classification based on diagnosis, which is used to establish payment rates to hospitals. Certain further adjustments are made to the payment based on patient age, geographic location and severity of illness.
Retiree health benefits – Health benefits provided by an employer to its retirees.
Therapeutic foster care – Services provided to special-needs children in foster care by families and group care providers that have received special training as well as ongoing support and supervision including regular contact with case managers or care coordinators.
Public health workforce – A term used to define a range of health professionals in public and private practice who provide public health services such as disease diagnosis, primary care, and public education.
Performance measurement – A set of recommendations, requirements, or data used to determine whether plans, providers, or programs meet or exceed a specified standard of care.
Presumptive eligibility – A state option under Medicaid which permits certain health care providers to presume that a patient is eligible for Medicaid and allow Medicaid reimbursement for services for a limited time until an official eligibility determination is made by the state.
Employer responsibility– A requirement that certain employers assist in the cost of coverage for workers and their dependents, either through the provision of a health plan or through contribution toward coverage via a payment on the individual’s behalf to a state health insurance exchange. This is also referred to as an “employer mandate.”
Pre-existing condition – A health condition that exists for a set time prior to enrollment into a health plan, regardless of whether the condition has been formally diagnosed. The Patient Protection and Affordable Care Act prohibits insurers and employer-sponsored health plans from denying or limiting coverage to individuals with pre-existing health conditions.
Value-based purchasing – An approach to health care purchasing employed by consumers and health care payers that considers and rewards health care value as part of paying for care. Health care value is typically associated with quality (as measured by objective benchmarks), provision of useful comparative information about performance, and efficiency as measured by objective standards.
Participating provider - An entity comprised of providers of services and suppliers, including a hospital, a physician group, a skilled nursing facility, and a home health agency, who are otherwise participating in Medicare.
Advanced care planning – A process in which a patient and physician discuss treatment options and develop a treatment or care plan. This is helpful for patients who choose to make their preferences known to family members and providers in case they are incapacitated, as well as for those with a terminal illness.
Acute episodes of care – A period of time related to a major health event that requires medical intervention. An episode of care may include tests performed prior to surgery, a surgical procedure, and post-operative treatment or follow-up care.
Bundled payment system - Under a bundled-payment system, providers are not reimbursed for each discrete service, interaction, or procedure. Instead, a single payment is made for each episode of care for a single patient, which is divided appropriately amongst the providers involved in his or her care.
Department of Defense– The federal cabinet-level agency that administers health care programs for active military and their dependents. Coverage is furnished through a publicly funded and privately administered health program called TriCare. The DOD also administers federal military health care facilities.
Basic health programs – An option under the Patient Protection and Affordable Care Act that permits a state to establish and oversee a health insurance program for low-income persons who are ineligible for Medicaid and whose family incomes do not exceed twice the federal poverty level. States electing this option would cover the low-income population directly, rather than through a health insurance exchange. States would receive direct federal assistance for the cost of establishing and administering such programs equal to the premium support available were low-income individuals to enroll into an exchange-qualified health plan.
Qualified health plan – Health insurance plans that meet minimum federal insurance-market rules including offering a standard set of services, benefits, and other requirements as determined by health exchanges.
Indian Health Service – The federal agency within the United States Department of Health and Human Services that oversees health care programs and services for American Indians, Native Hawaiians, and Alaska Natives.
Federal Poverty Level – Income criteria that are adjusted by family size and are published by HHS that are used to determine eligibility for income-related programs, such as Medicaid and the CHIP. Although guidelines are usually updated and published in March of each year, Congress has prohibited HHS from updating the 2009 guidelines until after March 1, 2010. As of date of posting, HHS has not updated the guidelines. Current guidelines are available online at:
http://aspe.hhs.gov/POVERTY/09extensionfedreg.shtml.
Medical underwriting – The practice of assessing the medical condition of individuals prior to insurance enrollment in order to identify existing physical or mental health conditions that may affect eligibility for enrollment or the level of coverage following enrollment. The Patient Protection and Affordable Care Act limits medical underwriting both prior to and following enrollment in order to eliminate discrimination based on health status. Medical underwriting may result in the total exclusion from a plan (i.e., the denial of availability) or restrictions on coverage for individuals once they are enrolled.
Nursing Home Compare – A website sponsored by the Department of Health and Human Services designed to provide nursing home quality information to consumers.
Rights of conscience – Federal or state laws that prohibit discrimination against health care professionals, entities, or health insurers that refuse to furnish or cover certain types of treatments because of religious or personal beliefs.
Cadillac health plan – A term used to describe health coverage available through employee health benefit plans where the value of the coverage exceeds a stated annual dollar threshold. See also Excise tax.
Preventive services – Procedures and treatments whose purpose is to avoid disease or to identify disease or conditions before they become acute and symptomatic. Immunization, screening programs for breast, cervical, or prostate cancer, and “well-child” or “well-adult” checkups are examples of preventive services.
Department of Labor – The federal cabinet-level agency responsible for administration and enforcement of the Employee Retirement Income Security Act (ERISA), a federal law that sets requirements for private employer-sponsored health benefit plans, both those that are self-insured as well as plans that are fully insured.
Creditable coverage– A term that encompasses public and private health insurance as well as coverage under certain other arrangements such as the Indian Health Service. The term is defined in §2701(c) of the Public Health Service Act.
Patient protections – Certain laws establishing protections for patients, such as the right to health information, choice of provider, access to care, the right to file a grievance, or the right to appeal a denied health benefit claim.
Ready Reserve Corps – A special group of health care professionals within the Commissioned Corps of the United States Public Health Service, whose establishment is authorized by the Patient Protection and Affordable Care Act in order to carry out specific duties in the event of a public health emergency.
Premium tax credits – Refundable tax credits, paid in advance, that are used for the purchase of health insurance through a state health insurance exchange. Individuals with family incomes greater than 133 percent of the federal poverty level but below 400 percent of the federal poverty level will be eligible for premium credits beginning in 2014.
Affordable coverage – A term used in the health reform law to designate both the types of coverage arrangements available to individuals and the level of family income that is considered available to pay health insurance premiums. The term is used to describe an individual who lacks access to coverage below 8 percent of household income for the purposes of being eligible for a free choice voucher and below 9.8 percent of income for purposes of allowing the purchase of a catastrophic health insurance plan. Medicaid, employer-sponsored coverage, coverage secured through state health insurance exchanges, and the Children’s Health Insurance Program (CHIP),all are considered forms of coverage. The health reform law also directs the HHS Secretary to conduct a study of affordable coverage.
Eligible individual – A term used in the health reform law to describe an individual who meets the eligibility criteria for a program or service authorized under federal law. Program or benefit criteria vary based on the program.
Medicare donut hole– The uncovered portion of a Medicare beneficiaries’ Part D prescription drug benefit plan that leaves them financially obligated for the cost of covered prescription drugs once a certain level of expenditures is reached during an enrollment year. The Patient Protection and Affordable Care Act gradually eliminates the donut hole.
Patent exclusivity– The period of time during which a prescription drug or biological product can be marketed and sold only by the manufacturer holding the patent and cannot be generically copied.
Benchmark coverage –Benefit plans defined under Section 1937 of the Social Security Act that states may use in lieu of Medicaid mandatory and optional benefits, for newly eligible Medicaid beneficiaries, who gain eligibility as a result of the provisions of the health reform law.
Medicare Advantage – Private health insurance plans and HMOs that participate in Medicare and into which Medicare beneficiaries may elect to enroll.
Price transparency – The ability on the part of consumers and patients to see the actual price of health care charges, as well as accurate information about health insurance charges, in order to promote knowledgeable health care purchasing decisions.
Grandfathered plan – A health benefit plan or health insurance policy in effect as of the date of enactment of the Patient Protection and Affordable Care Act. The term is not defined in the law; the Departments of Health and Human Services, Labor, and Treasury are expected to provide additional clarification regarding the conditions under which grandfathering protections are available as well as what constitutes a “plan” that may be subject to grandfathering limitations.
Dependent coverage – Health insurance coverage of a spouse, child, or domestic partner of an insured individual.
Health disparities – Measurable differences in health and health care that are associated with race, ethnicity, income, language, place of residence, and other factor unrelated to the need for or ability to benefit from health care.
Inspector General – The office within the Department of Health and Human Services (HHS) that is charged with protecting the financial integrity of programs administered by the Department, protecting the health and welfare of program beneficiaries and reporting problems to the secretary of HHS and Congress along with recommendations for correcting identified problems.
Wellness programs – Special services and benefits offered by employers to employees in addition to coverage under health benefit plans. First authorized in HIPAA, wellness programs offer participation “incentives,” such as premium or cost-sharing discounts, as a means of encouraging employees to lose weight, quit smoking, follow health-maintenance regimens, and generally adopt more healthy lifestyles.
Individual market – The health insurance market for individuals who purchase health insurance directly rather than through an employer-sponsored or other group health plan. This is also known as the “non-group market.”
Program Integrity – A special program of the federal government to detect and stop health care fraud and abuse.
Health care homes – Primary health care providers that furnish or arrange for comprehensive primary health care, use health information technology, and meet federal and state standards of quality and efficiency. Health care home demonstrations are authorized under the Patient Protection and Affordable Care Act.
Employer mandate – See Employer responsibility.
Non-group market– Also known as the individual market, the health insurance market for individuals who purchase coverage directly rather than through an employer-sponsored or group health plan.
Current coverage – A health insurance policy in effect before the effective date of the Patient Protection and Affordable Health Care Act. Current coverage is “grandfathered” under the law. Certain new requirements, such as a prohibition on excessive waiting periods, limits on lifetime coverage, prohibitions against rescissions, and extension of dependent coverage, would apply to grandfathered plans.
Fraud and abuse – Practices by health insurers or health care providers that violate a range of federal and state civil and criminal laws such as the filing of false claims, payment or receipt of bribes and kickbacks, racketeering, self-referrals and other forms of prohibited self-dealing, and violation of laws requiring good faith and fair dealing.
Actuarial value– A mathematical calculation used to determine the monetary value of benefits.
Episode of care– A concept that focuses on a health condition from its inception through treatment as a means of measuring both the quality of care received and the efficiency of the care provided. For example, an episode of care in the context of a stroke would include a specified period of time preceding the stroke, the acute hospitalization episode, and aftercare aimed at helping an individual recover from the stroke and its effects. Episodes of care are the unit by which bundled payment arrangements will be designed and the quality of care measured.
Risk adjustment – A tool for evaluating the relative risk of enrollees within each insurance plan and providing for a financial transfer from plans with low-risk to plans with higher-risk enrollees.
Plan disclosure – A requirement in the Patient Protection and Affordable Care Act to provide consumers with information on the terms and conditions of health insurance policies and the relationships between insurers, providers, pharmacy benefit managers, and other third-party benefit providers.
Bundled payment - A single payment for all health care services related to a specific course of treatment or condition over a period of time.
High-risk pools – A method provided under the Patient Protection and Affordable Care Act for insuring individuals with pre-existing conditions who have been uninsured for six months. High-risk pools will be operated by states during the period prior to the implementation of health insurance exchanges as a means of providing coverage availability to individuals who otherwise cannot secure coverage in the individual market. The subsidies that are available to exchange participants in 2014 will not begin earlier for high-risk pool participants.
Small employers – Employers that on an average business day employ 100 employees or fewer.
Large employers – Employer groups that, on average, of a certain number of full-time employees. The definition of large employer varies based on the provision of law. For determining participation in insurance markets, a large employer has 101 or more employees. For determining whether a large employer may be subject to a fine if the employer fails to provide coverage, a large employer has 50 or more employees.
Lifetime limits – An aggregate upper limit on the amount of benefits that an insurer will pay over the lifetime of a policy.
Newly eligible – Effective January 1, 2014, states will be required to provide Medicaid coverage to individuals ages 19-65 with incomes under 133 percent of FPL, who were not eligible for Medicaid based on the state’s eligibility criteria as of December 1, 2009.
SHOP exchanges – Exchange programs run for small businesses.
Fair marketing – A term that encompasses a range of reforms aimed at assuring accuracy and completeness in the information provided by an insurer or health benefit plan, fairness in the premium charged, and reasonable and fair practices in coverage.
Cafeteria plan – A benefit plan sponsored by an employer under which employees may set aside pre-tax wages to be used for various expenses, including medical expenses not otherwise covered by their health insurance, such as copayments and deductibles, or uncovered medical costs, such as dental care. The special accounts that hold these pre-tax wages to be spent on health care are known as Flexible Spending Accounts (FSAs). Health reform legislation limits employee contributions to FSAs to $2,500 annually (indexed for inflation) and reverses previous policy by prohibiting their use for over-the-counter medications.
Affordability – See Affordable coverage.
CO-OP Program – A special program established under the Patient Protection and Affordable Care Act that allows for the development of qualified non-profit health plans selling essential health benefit plans through state exchanges.
Early retiree – Early retirees are defined under the Patient Protection and Affordable Care Act as individuals aged 55 and over who are not yet eligible for Medicare.
Elder Justice Act – Provisions included the health reform law to authorize services and supports aimed at protecting elderly persons from the knowing infliction of physical or psychological harm.
Whistleblower – An individual (typically a current or former employee) who discloses information not readily obtainable and in connection with potential fraud and abuse.
Antitrust law – A body of federal laws whose purpose is to promote market competition and to prevent anticompetitive, monopolistic, and collusive conduct. Health insurers are exempt from certain aspects of antitrust law, but not others. Antitrust laws also cover health care providers.
Annual limits – Limits imposed by insurers or employer sponsored health benefit plans on the amount of covered treatment or services that will be considered covered during a single plan year. Limits may be expressed in dollar or quantitative terms (e.g., no more than $1000 annually; no more than 30 treatments annually). The health reform law addresses dollar limits but not quantitative treatment limits.
Medical home – Health care entities that offer and arrange for comprehensive health care, meet performance, quality, and efficiency standards, use health information technology, and meet other requirements that may be established by public and private health insurers.
Urban Indian – Special programs administered by the Indian Health Service (IHS) and by tribal governments that serve American Indians, Native Hawaiians, and Alaska Natives who reside in urban areas.
Cost-sharing – A requirement that insured patients pay a portion of their medical costs, either as a deductible, or a flat dollar copayment, or as coinsurance (i.e., a percentage of the total paid claim for a covered benefit or service).
Gainsharing– Allowing health care providers that meet standards of quality and efficiency to share in savings realized by insurers for reduced use of unnecessary care.
Reinsurance – Risk protection offered to insurers or self-insured employer-sponsored health benefit plans in order to protect them from unpredictably high cost exposure. Reinsurance begins at an “attachment” point and is designed to cover losses after the losses incurred by an insurer or self-insured plan reach this threshold.
Territories – Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.
Coinsurance – Cost-sharing for covered health insurance benefits and services, expressed as a percentage of the approved payment amount for the benefit or service (e.g., 20 percent of the payable amount).
Young adult – Individuals ages 22-26 who, under the Patient Protection and Affordable Care Act, can remain covered under their parents’ employer-sponsored or individually purchased health benefit plans.
Grievances – A complaint against an insurer or health plan other than one involving the denial of covered benefits. An example of a grievance would be inappropriate behavior by a network provider or too few pharmacies that are members of a network.
Deductible– The amount patients must pay out of pocket before coverage begins.
Telehealth – Electronic information and telecommunications technologies that support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.
Preemption – A legal concept, grounded in the United States Constitution’s Supremacy Clause, which specifies the displacement of state laws by federal laws with which state laws are found to conflict.
Rescission – The cancellation or refusal to renew a health insurance policy following issuance, typically after the filing of medical claims. A policy may be rescinded in cases in which an individual made material misrepresentations of health status at the time of enrollment. Insurers have been found liable for rescinding policies simply because medical claims were filed and in the absence of any fraud on the part of the enrollee.
Excise tax – A tax on health insurance and health benefit plans whose annual dollar value exceeds a specified limit, as well as on the sale of certain health care items and services such as medical devices and equipment. See also Cadillac health plan.
Copayments– Cost-sharing for covered health insurance benefits, expressed as a flat dollar payment (e.g., $5.00 for a prescription drug).
CLASS Act – A federal program of voluntary long-term care insurance.
Exclusion – The denial of coverage on the basis that the requested item or service is not covered under the terms of the plan. An exclusion differs from a medical necessity denial because treatment is not covered regardless of the medical facts of a particular case. An example would be a request for a prescription drug not on a plan’s drug formulary or exclusion of particular types of surgery (e.g., bariatric surgery).
Medicare – The federal health insurance program for individuals ages 65 and older, as well as persons with end-stage renal disease and certain persons with disabilities. Medicare covers beneficiaries for hospital, post-hospital extended care, and home health care, as well as a range of medical care services and benefits. Medicare enrollment is compulsory for all individuals covered by the Social Security Act. At their option, Medicare beneficiaries can buy “Part D” outpatient prescription drug coverage. Beneficiaries can elect to enroll either in “traditional” Medicare (which allows patients to receive care from any participating physician, hospital or health care supplier) or through Medicare Advantage plans, most of which restrict patients to specific network providers while typically offering additional benefits and coverage. The Patient Protection and Affordable Care Act expands Medicare coverage for preventive services and additional levels of prescription drug coverage while also introducing reforms to improve health care quality and efficiency.
Medicaid – A federal program enacted in 1965 that is funded by the federal and state governments and administered by the states that provides health insurance coverage to certain low-income populations. The Patient Protection and Affordable Care Act expands Medicaid to cover all low-income individuals with family incomes below 133 percent of the federal poverty level. Medicaid is a major source of health insurance coverage for “dual enrollees” who are elderly and disabled Medicare beneficiaries who are low-income or medically impoverished and who qualify for both Medicare and Medicaid.
Bundling – A health insurance payment arrangement under which which providers are paid a set amount for the treatment they furnish for a particular condition or for an “episode of care.” In contrast to fee-for-service payments, which can encourage a high volume of treatment, “bundling” is thought to incentivize more cost-effective care.
Premium – The recurring charge paid by individuals or employer-sponsored groups for the purchase of health insurance.
Appeals – The process by which health insurance beneficiaries can dispute a denial, reduction, or delay in covered treatments and services.
Rating – The practice by insurers of charging different premium amounts to different individuals or groups based on the characteristics of the individual or group as well as other considerations such as location.
SAMHSA – See Substance Abuse and Mental Health Services Administration.
MACPAC – See Medicaid and CHIP Payment and Access Commission.
EMTALA – See Emergency Medical Treatment and Labor Act.
MedPAC – See Medicare Payment Advisory Commission.
HITECH – See Health Information Technology for Economic and Clinical Health Act.
Parity – See Mental health and substance abuse disorder parity.
ERISA – See the Employee Retirement Income Security Act.
FEHBP – See Federal Employee Health Benefits Plan.
HIPAA – See Health Insurance Portability and Accountability Act.
COBRA – The nickname for a law, enacted as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), that allows individuals to continue to purchase employee health benefits for a period of 18 to 36 months following a “qualifying event” such as unemployment, death of a wage earner, divorce, or termination of minor dependent coverage.
MEWAs – See Multiple Employer Welfare Arrangements.
FQHC – See Federally Qualified Health Center.
AHRQ – See Agency for Health Care Research and Quality.
HRSA – See Health Resources and Services Administration.
GPRA – See Government Performance Results Act.
Pool – A group of individuals whose premiums are used to pay the covered medical costs of its members. Insurance companies may charge higher premiums to a pool whose members are older or less healthy in order to cover the risk that its members will submit more medical claims.
CHIP – See Children’s Health Insurance Program.
SSI– See Supplemental Security Income.
VBP – See Value-based purchasing.
ACO – See Accountable care organization.
CMS – See Center for Medicare and Medicaid Services.
EHR - See Electronic Health Record.
DSH – See Disproportionate share hospital.
GAO – See Government Accountability Office.
FTC – See Federal Trade Commission.
ESI – See Employer sponsored insurance.
FDA – See Food and Drug Administration.
DRG – See Diagnosis related group.
DOL – See Department of Labor.
NIH – See National Institutes of Health.
OIG – See Inspector general.
CDC – See Centers for Disease Control and Prevention.
CER – See Comparative Effectiveness Research.
DOD– See Department of Defense.
HIT – See Health information technology.
OMH – See Office of Minority Health.
[...] This article explains Comparative Clinical Effectiveness Research and its roles in health reform: http://www.healthreformgps.org/resources/comparative-clinical-effectiveness-research/ [...]