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Population Health Management (PHM) is a term that describes the application of various interventions and strategies aimed at improving the health outcomes and managing the costs of a targeted group of individuals. PHM models vary based on the degree of risk, degree to which payment is tied to quality, reliance on data analytics, and level of care coordination.
Historically, population health models have been led by hospitals, health systems, physician groups and large insurance organizations. More recently long-term care (LTC) and post-acute care (PAC) providers have been assuming a leadership role in developing and employing some PHM models.
Accountable Care Organizations (ACOs) are one of the largest alternative payment models in Medicare, and they also exist in Medicaid and commercial payors.
ACOs are networks of physicians, hospitals, and other healthcare providers that voluntarily come together to coordinate care and manage the total costs of a defined population, sharing in the financial risks and rewards of performance against benchmarks and on patient outcomes.
Bundled payments are a type of alternative payment model designed to incentivize high quality, cost-effective care. Bundled payments, also known as episode-based payments, are single payments for all care and services provided, which could include multiple settings, for a single condition over a defined period of time (episode of care).
Direct Contracting (DC) is part of The Center for Medicare and Medicaid Innovation’s (CMMI) Primary Cares Initiative and was released in April 2019. It is one of the newest Medicare fee-for-service (FFS) risk sharing models built on lessons learned from the Medicare Shared Savings Program (MSSP) and Next Generation ACOs (NGACOs) and leverages innovative approaches from Medicare Advantage (MA) and private sector risk-sharing arrangements. The design is intended to broaden participation beyond current participants in Medicare FFS risk models by attracting traditional providers new to risk as well as other innovative partnerships/organizations looking to take risk for Medicare FFS beneficiaries.
Managed care involves a healthcare delivery system that encompasses care, services, and payment and seeks to control costs and enhance quality through the establishment of provider networks and employment of utilization management strategies.
Provider networks are a joint venture of independent providers that come together to focus on the benefits for the residents, enhance quality outcomes, and work on value-based reimbursement.
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