The act of an employee’s physical absence from the workplace, often in a frequent or chronic pattern (and may be the due to an underlying health condition).
Americans with Disabilities Act of 1990 (ADA)
A national civil rights law that prohibits, under certain circumstances, discrimination based on disability -- defined by the Act as “a physical or mental impairment that substantially limits a major life activity.”
Used to describe measurable biological changes in human anatomy or physiology. A biometric screening is a short health examination that determines the risk level of a person for certain diseases and medical conditions. Many employers encourage employees to complete this type of health screening as a baseline for engaging them in healthy behaviors. In the value-based approach to healthcare, often times rewards or incentives given to employees may be based upon positive changes made in an individual's biometrics that demonstrate weight loss, lower cholesterol levels or better management of blood sugar levels.
Payment mechanism in which provider(s) receive a set payment covering the average cost of a group/bundle of services (instead of billing separately for each service). There is an inherent incentive to reduce the number of services that have no or minimal benefit. It also encourages coordination of care by holding multiple providers in multiple settings jointly accountable, through shared payment, for the total cost of care for a given treatment or condition.
Payment mechanism in which a provider is paid a fixed rate per person per month, usually prospectively, to cover all care within a specified set of services and administrative costs without regard to the actual number of services provided.
A chronic condition is a disease that has one or more of the following characteristics: (1) Is permanent; (2) Is progressive if unmanaged; (3) Is caused by nonreversible pathological alteration; (4) Requires special training of the patient for rehabilitation, self-monitoring, and self-management; or (5) May require a long period of supervision, observation, or care.
Chronic disease management
A system of coordinated health care interventions and communications for populations with long-term conditions in which patient self-care plays a significant role.
Co-insurance is a health insurance policy provision under which the individual and the insurance company share the total cost of covered medical services after the deductible has been met set as fixed percentages. This is in contrast to a co-payment, which is a fixed dollar amount paid by the individual policyholder.
A co-payment is a specific charge health insurance plan may require that a policy holder to pay for a specific medical service or supply. The insurance company often pays the remainder of the charges. This is in contrast to coinsurance, a fixed percentage of the total cost of a covered medical service for which the policy holder is financially responsible.
Consumer Directed Health Plans (CDHP)
Also known as high-deductible health plans. These health plans have higher annual deductibles than typical plans and out of pocket maximums for covered expenses. The thresholds are set by the Internal Revenue Service. In 2010, the minimum allowable annual deductible was $1,200 for self coverage and $2,400 for family coverage. The maximum annual deductible was $5,950 for self coverage and $11,900 for family coverage. Health savings accounts (HSAs) are allowable by the IRS to be offered alongside high-deductible plans. CDHPs were built with the intention of making consumers savvy users of health care. This strategy is predicated upon the belief that the increasing health care costs are based largely because people's overuse the health care system with unnecessary test, procedures and treatment. If they become more knowledgeable about the health care costs associated with their care, they will consume less health care services and products.
Cost control or cost containment refers to the control of the rate of growth of health care expenditures through managing unit prices and/or service utilization.
In the context of employer-based health benefits, cost sharing refers to the benefit design arrangement between an employer and his or her employees that may result in higher premium contributions or an employee's premium share of contribution, variations in deductibles, and copays or coinsurance.
De-identified patient data
In compliance with privacy laws, de-identified patient data is gleaned from patient-specific information that has all personal identity removed. It is used in data management and warehousing to help employers and coalitions better understand their population.
The amount of money a patient or family must pay before costs (or percentages of costs) are covered by the health plan or insurance company, usually per year.
A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Physicians must be consistent with clinical guidelines and patients must monitor their own health and follow directions from clinicians.
Recommendations for appropriate clinical care based on peer-reviewed research. For example, ""Diabetic patients should receive a retinal exam once a year."" One goal of value-based purchasing is to increase providers' adherence to evidence-based guidelines.
Fee for service
A payment mechanism in which a provider is paid for each individual service rendered to a patient.
Genetic Information Nondiscrimination Act of 2008 (GINA)
A national law designed to prohibit discrimination on the basis of genetic information with respect to health insurance and employment. Health insurance coverage cannot be denied to a healthy individual nor can higher premiums be charged based solely on their genetic predisposition to developing a disease in the future. Also, employers are prohibited from using individuals’ genetic information when considering employment (hiring or firing), job placement, or promotion of an employee.
A comprehensive payment to a group of health providers that is intended to account for most or all of the expected cost of care for a group of patients for a defined time period. While generally synonymous with the term “capitation”, advocates of the concept use the term “global payment” to distinguish its design and application from early capitation models under which some providers suffered financial losses.
Health reimbursement arrangement (HRA)
A tax-free account established by an employer and there are no limits on the amount nor are they considered employee income. HRAs may be offered in conjunction with other employer-provided health benefits. Employers have complete flexibility to offer various combinations of benefits in designing their plan. It is not necessary to be covered under any other health care plan to participate. Employees are reimbursed tax-free for qualified medical expenses up to a maximum dollar amount for the coverage period. An HRA may be offered with other health plans, including flexible savings accounts. Because the HRA is only funded by the employer, the unspent funds stay with the employer. All funds put into an HRA account must be used for medical expenses.
Health Risk Assessment
A tool (questionnaire) or method that is used to catalog, assess, and estimate the probability of an adverse health effect for an individual and the likely magnitude of the health effect and/or cost of that adverse effect. HRAs integrate science with patient-reported information to estimate measurable odds of something happening to any one individual or group over a future time frame. A benefit of the HRA is the ability to identify high-risk individuals whose health status can be closely monitored.
Health Savings Account (HSA)
A tax-free mechanism by which consumers can pay for their health care, enabling one to pay for current or future health-related expense. An individual must be covered in a high deductible plan to be able to open such an account, but the amount one can contribute is dependent upon one's age and the type of high deductible plan under which he or she is covered. Consumers can sign up for HSAs with banks, insurance companies or credit unions. Employers can also set up such plans for employees. If an employee has an HSA at one job and moves to another, his or her account goes with them. Under 65 years of age, the HSA is tax-free and so are the withdrawals made to pay for medical expenses. Upon reaching 65, the holder can withdraw funds for any reason. If the funds are used for health-related expenses, the monies are not taxed. However, if the monies are withdrawn for purposes other than health-related expenses, it is subject to tax.
High deductible plan
High deductible health care plans are usually considered to be plan that require the policy holder to pay at least $5,000 out of pocket annually before the plan begins paying out for medical services, drugs or supplies. These plans are often combined with health reimbursement arrangements (HRA) or spending/savings accounts with the intention of making consumers savvy users of health care. This strategy is predicated upon the belief that the increasing health care costs are based largely because people's overuse the health care system with unnecessary tests, procedures and treatment.
An advanced primary care model in which physicians actively work with patients to help them manage and improve their health status. Also referred to as ""patient-centered medical home."" Definitions of medical home vary, but typically include features such as care coordination, use of healthcare information technology, convenient communication (e.g. email), tracking and acting on gaps in care, and open scheduling.
Medication adherence refers to a patient complying with directives for taking a prescribed medication. The patient complies with the dosage, the timing, circumstances and duration in accordance with his health care provider.
According to the International Society of Pharmacoeconomics and Outcomes Research, medication persistence is the duration of time from initiation to discontinuation of therapy.
Medication therapy management (MTM)
A collaboration among a pharmacist, a patient (and/or caregiver) and the patient's team of health care professionals. The goal is to help the patient achieve the targeted outcomes from their prescribed medication therapy. The Asheville Project in North Carolina fully developed this model, proving that better health outcomes and cost-savings can be achieved through such arrangements.
Payment models that reward providers for performance in quality and efficiency based on predetermined benchmarks, such as meeting pre-established performance targets, demonstrating improved performance, or performing better than peers in the delivery of health care services. Often abbreviated as ""P4P"". P4P payments are typically made in addition to fee-for-service payments.
The science of health economics and outcomes research which evaluates the costs and effects of pharmaceutical products.
The extent to which care delivered by a physician conforms to evidence-based guidelines, based on their adherence to evidence-based guidelines and/or the health of the patient population they manage.
A sophisticated tool which helps payers anticipate future costs rather than relying solely on cost history. Predictive modeling takes into account clinical factors and population demographics such as age, gender, and income level.
Financial cost, usually shared between an employer and an insured person, of obtaining health insurance coverage, paid as a lump sum or in monthly installments.
Describes when an employee is physically at work but not working at his/her optimal performance due to be hindered by health problems.
Health care services that are aimed at preventing complications of existing diseases, or preventing the occurrence of a disease. Recommended services may vary by age and gender. Examples of preventive services include physical exams, immunizations and certain cancer screenings.
Provider Performance Measurement
The utilization of statistical indicators representing provider performance that can be systematically tracked to assess quality, access, efficiency, and/or patient experience at a point in time or over time.
The ability of employers and health plans to influence health care delivery through the design of health care payment models, measured by the quantity and quality of goods and services that are purchased.
The methodology used to account for patient-related attributes, such as age, gender, or pre-existing conditions, so that comparison of health care measures among providers seeing different mixes of patients is as fair and meaningful as possible.
A payment mechanism in which an employer and/or insurer shares with a healthcare provider(s) a percentage of savings accrued as a a result of more efficient, coordinated care being delivered.
A payment mechanism in which a healthcare provider is paid an additional fee, usually on a prospective per person per month fee basis, to recognize structural investments made to a practice (e.g. electronic medical records), and/or manage and/or perform additional services not usually reimbursable under a fee-for service payment mechanism.
Value-Based Benefit Design
Value Based Benefit Design is the explicit use of plan incentives to encourage enrollee adoption of one or more of the following: 1) appropriate use of high value services, including certain prescription drugs and preventive services; 2) adoption of healthy lifestyles, such as smoking cessation or increased physical activity; 3) use of high performance providers who adhere to evidence-based treatment guidelines. Value-Based Benefit Design is distinguished from Value-Based Insurance Design in that it extends beyond the realm of insurance to include incentive-based programming such as wellness services.
Value-Based Insurance Design
Value-based insurance design bases an individual's out-of-pocket
costs according to the value of a medical service or product for a specific
patient population. Although cost-sharing still occurs in this design, it is
used to encourage use of the clinical intervention, mitigating adverse health
consequences that may lead to even higher cost interventions. The value of the
clinical intervention will vary across patient groups and their demographic
differences and therefore be subject to different cost-sharing levels.
Wellness programs are designed to: (1) Help individuals maintain and improve their level of health and well-being by identifying health risks and educating them about ways to mitigate these risks; (2) Increase awareness of factors that can affect health and longevity; (3) Enable individuals to take greater responsibility for their health behaviors; (4) Prevent or delay the onset of disease; and (5) Promote healthful lifestyles and general well-being.