Ratings Examiner Report on New York Health Plan Methodologies

Glossary of terms used in this site

Attribution Methods – How the organization assigns particular patient services to specific physicians, practices or medical groups.
AQA – Ambulatory Care Quality Alliance
Case-Mix – Risk adjustment that takes into account variations in the composition of physicians' populations, often defined by age, gender, or marital status.
Clinical Quality Measures – A measure of an aspect of patient care based on administrative or medical record data.
Complaint – An oral or written expression of dissatisfaction related to the organization's program of measurement and action.
Confidence Interval – A range of values centered on the sample estimate that is known to contain the true value with a given degree of confidence.
Confidence Level – The degree of certainty that a statistical prediction is accurate.
Consumers – Individuals who can use the information resulting from measurement to aid in their choice of a health plan, physician or hospital. The organization being certified may also refer to consumers as patients or members.
Cost – A financial amount determined using actual unit prices per service or using unit prices from a standardized fee schedule. Examples of cost of care measurement include: dollars per episode, overall or by type of service; dollars per member per month (PMPM), overall or by type of service or dollars per procedure.
Criteria – Systematically developed, objective and quantifiable statements used to assess the appropriateness of specific health care decisions, services and outcomes.
Decision Support Tools – Tools that support informed decision-making by presenting information in an integrated, interactive manner.
Documented Process – Policies and procedures, process flow charts, protocols and other mechanisms that describe the methodology used by the organization to complete a task.
Episodes of Care – A period of care provided by a health care facility or other health care provider
Episode Treatment Group – A patient case-mix based classification system that adjusts for patient severity, intensity, and complexity
HMO – Health management organization. An organized health care system that is accountable for both financing and delivering a broad range of comprehensive health services to an enrolled population. An HMO is responsible for assessing access and ensuring quality and appropriate care. Services are rendered by practitioners affiliated with the health care system. To receive reimbursement in an HMO, members must obtain all services by an affiliated provider and must comply with a predefined authorization system.
The Joint Commission – Joint Commission on the Accreditation of Healthcare Organizations. Previously known as "JCAHO"
Medical Groups – A group of physicians comprised of more than one practice site. The term also refers to a physician organization.
Member – A person insured or otherwise provided coverage by a health plan.
Minimum Observations – The number of observations necessary for evaluating physician performance.
NCQA – National Committee for Quality Assurance
NQF – National Quality Forum
Outliers – Extreme and usually rare data values that are likely to be inaccurate or unrepresentative of general patterns.
Patient Case Mix – Distribution of patients within a health care or medical provider facility
Patient-Centered – The inclusion of a patient's perspective about the overall treatment or care
Performance Measure – A quantifiable measure to assess how well the organization carries out specific functions or processes.
POS – Point of service. Coverage options that combine HMO features and out-of-network coverage with economic incentives for using network practitioners. POS options may be offered by health plans or indemnity insurers. In this type of health plan, members may choose to receive services either within the health plan's health care system (from an in-network practitioner) or outside the health plan's health care delivery system (from an out-of-network practitioner).
PPO – Preferred provider organization (PPO) plans take responsibility for providing health benefits-related services to covered individuals and for managing a practitioner network. They may administer health benefits programs for employers, either by assuming insurance risk or by providing only administrative services.
Practice – One physician or a group of physicians who practice together at a single geographic location.
Practice Site – An office or facility where one or more practitioners provide care or services.
Primary Care – The level of care that encompasses routine care of individuals with common health problems and chronic illnesses that can be managed on an outpatient basis.
Provider – An institution or entity that provides services for health plan members. Examples of providers include hospitals and home health agencies. NCQA uses the term practitioner to refer to the professionals who provide health care services, but recognizes that a "provider directory" generally includes both providers and practitioners and the inclusive definition is the more common usage of the word.
Purchasers – Entities, including employers and states, that contract with health plans to provide health care benefits and services
Resource Use – The amount of health care services used; these measures may consider the relative intensity or cost of services in addition to the count of services, such as the difference in intensity between a major surgery and a 15-minute office visit.
Severity – Patient's degree of illness for specific conditions (e.g., cancer stages, comorbid conditions).
Specifications – The criteria for inclusion and exclusion for a particular measure, including numerators and denominators, requirements for diagnostic and procedure codes, pharmacy or laboratory data, medical record data, registry data, age, sex and the time period the measure covers, as applicable.