Healthcare Reform: Terms You Should Know – Part 1

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May 15th, 2012
Categories: Healthcare Reform

In the following weeks, PayerFusion will be posting healthcare reform terms that you should know in a three part series.  These terms are useful in establishing a basic understanding of what Healthcare Reform offers you.  Without further ado, below we kick off our quick-glance glossary of terms. Stay tuned for parts two and three!

Part 1 - Healthcare Reform Glossary Terms A through D


Access to Health Services – A person’s or population’s ability to engage in healthcare services and coverage, which are a) geographically proximate, b) physically accessible (for people with limited mobility), c) temporally (timing) appropriate d) socioculturally consistent, and e) without financial barriers.


Bending the Curve – Healthcare cost trends in the United States are two to three times greater than inflation and are therefore unsustainable. This popular phrase describes current efforts to promote health and wellbeing as well as a more effective and efficient healthcare delivery system that will thereby slow the growth in healthcare spending.

Bundled Payments/Episodic Payments – A bundled payment is a single, standardized comprehensive payment that covers all services provided to a patient during an episode of care for a procedure or an acute or chronic condition.


Cadillac Tax – The Cadillac Tax is a 40 percent excise tax on healthcare premiums (employer + employee) that is placed on employers for premiums that exceed $10,200 for individual coverage and $27,500 for family coverage. The Cadillac Tax is part of the Patient Protection and Affordable Care Act and is slated to go into effect on January 1 in 2018.

Care Continuum – The care continuum describes the full range of services that a patient may encounter from prenatal care prior to birth to palliative services at end of life. This term also recognizes that care is provided across the full spectrum of healthcare delivery including outpatient, inpatient, home care, rehabilitation, nursing, virtual, and pre- and post-acute care settings.

Center for Medicare and Medicaid Innovation (CMMI) – The CMMI was established to test new healthcare delivery and payment models. The threefold focus of the CMMI is to help find better ways to care for individuals, better overall health and reduced costs. The initial focus will be on patient-centered medical homes, advanced primary care practice within community health centers, and comprehensive treatment practices for dual (Medicare and Medicaid) eligibles.

Clinical Decision Support – These are computerized tools that incorporate information-gathering, as well as monitoring and delivery systems, to ensure optimal decision-making on the part of the treating clinician. They assist physicians and other providers at the point of care to follow evidence-based guidelines and improve healthcare outcomes.

Comparative Effectiveness Research – Presently most research compares a treatment or intervention to a placebo or doing nothing. There are few studies that compare multiple approaches to medical concerns. Comparative Effectiveness Research addresses this problem. According to the Department of Health and Human Services, “Comparative effectiveness research is the conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions. The purpose of comparative effectiveness research is to inform patients, providers, and decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.” Source: Accessed 7/28/2010.

Computerized Physician Order Entry – Computerized Physician Order Entry (CPOE) is the electronic entry of medical practitioner instructions for services, tests, and treatments of patients into a computerized system that relays the orders to the appropriate party such as a hospital pharmacists or blood-draw lab. These systems can be used for care orders, prescriptions, lab tests, and radiological orders.

Coverage Limits – A health insurance plan has been able dictate the maximum number of dollars spent on benefits per individual/family/policy, and these restrictions come in two forms — annual and lifetime.

Culture of Health – This is an ideological transformation of an organization’s culture that passively accepts rising, unsustainable healthcare costs to a proactive entity that encourages the holistic wellbeing of each of its employees. Such organizations integrate the health status of their workforce into their mission and vision statements and require all of their employees to be accountable for their health.


Demonstration Projects – These are federally funded efforts to test and evaluate care delivery, cost reduction, health improvement, and payment reform models. The goal of these projects is to develop new, effective methodologies for care and payment, which can be expanded to a broader, perhaps national, scope. The Affordable Care Act has several funded pilots dealing with innovations such as the bundled payment model and programs for chronically ill Medicare beneficiaries using home-based teams. Note that demonstration project opportunities have been ongoing for years and are not solely tied to recent legislation.

Disease Management – Disease management programs address the needs of population cohorts affected by chronic illnesses to reduce their medical costs and the deleterious effects of these conditions. A successful effort involves an effective way to identify worthy patients and engage them to fully participate in evidence-based interventions that produce measurable improvements in care, reduced costs, and perceived value.