PAHM key terms

A group of doctors, hospitals, and other providers that voluntarily coordinate care for a defined patient population and share in savings when they meet quality and cost targets.

The deliberate organization of patient care activities and information sharing among participants so that needs are met and handoffs do not cause gaps, duplication, or error.

A primary care model in which a personal physician leads a team that provides continuous, coordinated, accessible, and whole-person care, often supported by enhanced per-member payments.

An organization that owns or contracts with hospitals, physicians, and other providers across a continuum of care and accepts joint accountability for clinical and financial outcomes.

A strategy in which one organization owns or controls successive stages of the care continuum, such as a health plan owning clinics or a hospital owning physician practices and post-acute services.

Combining organizations that perform similar functions, such as two hospitals merging or a system acquiring competing physician groups, to gain scale, market share, and bargaining leverage.

A hospital, clinic, or health center that by mission or legal obligation serves a large share of uninsured, Medicaid, and other low-income patients regardless of ability to pay.

The amount an individual or employer pays, usually monthly, to a health plan to maintain coverage, independent of how much care is actually used.

The portion of covered medical costs a member pays directly, including deductibles, coinsurance, and copayments, which limits plan liability and gives members financial stake in utilization.

A fixed amount a member must pay out of pocket for covered services each plan period before the health plan begins paying its share of costs.

The percentage of covered service costs a member pays after meeting the deductible, with the plan paying the remaining percentage until an out-of-pocket maximum is reached.

A flat dollar amount a member pays at the time of service for a covered benefit, such as a fixed charge per office visit or prescription fill.

The cap on a member's cost sharing for covered in-network services in a plan year; once reached, the plan generally pays 100 percent of covered benefits.

The process a health plan uses to evaluate and classify the risk of applicants or groups and to set premiums and enrollment conditions accordingly, subject to regulatory limits.

A tendency for people with higher expected health costs to enroll or stay enrolled more than lower-risk people, which can raise average costs and destabilize premiums if not managed.

A payment methodology that shifts funds toward plans or providers caring for sicker populations, using diagnosed conditions and demographics to reduce incentives to avoid high-cost enrollees.

A payment model that pays a provider or plan a fixed amount per enrolled person per period, regardless of how many services that person uses.

A payment method that reimburses providers for each service, test, or procedure delivered, typically based on a fee schedule, which rewards volume rather than outcomes.

A reimbursement approach that sets a predetermined payment rate before services are delivered, such as inpatient DRG rates, shifting financial risk for cost overruns to the provider.

A patient classification system that groups inpatient stays by diagnosis, procedures, and severity so hospitals can be paid a fixed amount per discharge under prospective payment.

A unit that reflects the resources, skill, and time required to deliver a physician service, used with a conversion factor to set Medicare fee schedule payments.

The payment methodology that assigns relative value units to physician services based on work, practice expense, and malpractice cost, then converts them to dollars.

A single payment covering a defined episode of care, such as a joint replacement plus related recovery services, which encourages providers to coordinate and avoid unnecessary spending.

A payment strategy that ties part of a provider's reimbursement to performance on quality, cost, and patient experience measures rather than to volume alone.

A measure of the average severity and resource intensity of a hospital's patient population, used to adjust payment and compare performance across facilities.

The set of processes a payer uses to review whether services are medically necessary, appropriate, and delivered in the right setting before or after care is provided.

A requirement that a provider obtain plan approval before delivering certain services or drugs, so the payer can confirm medical necessity and coverage in advance.

A collaborative process in which a clinician or nurse assesses, plans, and coordinates services for high-need patients to improve outcomes and control avoidable costs.

An ongoing, data-driven management approach in which teams repeatedly measure processes, identify root causes of variation, and test changes to improve performance.

A structured rapid-improvement method in which a change is planned, tested on a small scale, studied for results, and then adopted, adapted, or abandoned.

Comparing an organization's performance measures against internal targets, external standards, or peer organizations to identify gaps and prioritize improvement efforts.

A federal law requiring hospitals with emergency departments to provide a medical screening exam and stabilizing treatment to anyone who presents, regardless of insurance or ability to pay.

A federal law that protects health coverage portability and sets national standards for safeguarding protected health information and for its permitted uses and disclosures.

Individually identifiable health information created or held by a covered entity or business associate, in any form, that relates to a person's health, care, or payment.

The HIPAA principle that a covered entity should use, disclose, or request only the least amount of protected health information needed to accomplish the intended purpose.

A federal law that makes it a crime to knowingly offer, pay, solicit, or receive anything of value to induce referrals for items or services paid by federal health programs.

A federal statute that prohibits physicians from referring Medicare patients for designated health services to entities with which the physician or an immediate family member has a financial relationship, absent an exception.

A federal law that imposes civil liability on parties who knowingly submit or cause false claims for government payment, and that allows whistleblowers to sue on the government's behalf.

An organization's structured set of policies, training, auditing, monitoring, and reporting channels designed to prevent, detect, and correct violations of law and payer requirements.

A digital, longitudinal record of a patient's health information that is shared across care settings and supports clinical documentation, orders, results, and decision support.

The electronic movement of health information among organizations according to recognized standards, enabling clinicians to access patient data across separate systems and settings.

The ability of different information systems to exchange data and use the exchanged information without special effort, using shared standards for format, terminology, and transport.

A federal incentive framework that tied EHR payments to demonstrable use of certified technology for defined objectives such as e-prescribing, data exchange, and quality reporting.

A quantifiable measure selected to track progress toward a specific operational, financial, or clinical goal and to inform management decisions.

A performance management framework that tracks measures across financial, customer, internal process, and learning perspectives so leaders balance short-term results with long-term capability.

Any person or group with an interest in or affected by an organization's decisions, such as patients, employees, physicians, payers, regulators, and the community.

A situation in which a person's private interests or relationships could improperly influence their professional judgment or duties, requiring disclosure and management.

A concise declaration of an organization's core purpose and the population it serves, which guides strategy, priorities, and ethical decision making.