Vital Signs

Underuse means patients do not receive care that would have benefited them. This post explains how underuse fits with overuse and misuse as categories of quality problems, what research shows about missed recommended care, causes and equity implications, and how quality measures, health IT, and nurses help close gaps.

Capitation is a payment method in which a provider receives a fixed amount per person for a defined period to cover specified services, regardless of how many services each person uses. This post explains how capitation works, types of capitation, risk adjustment, the incentives it creates, the data and health IT it requires, and what it means for nurses.

Value-based insurance design (VBID) aligns patients’ out-of-pocket costs with the clinical value of services, lowering cost sharing for high-value care and sometimes raising it for low-value care. This post explains how VBID works, examples such as reduced copays for chronic disease medications, what CMS learned from its Medicare Advantage VBID model, the data VBID requires, and nursing roles.

Managed care is an approach to health insurance that combines financing with the organization of care, using provider networks, utilization management, quality programs, and financial incentives to control cost and support appropriate care. This post explains common managed care models, Medicare Advantage and Medicaid managed care, the data and health IT they depend on, criticisms, and nursing roles.

The Merit-based Incentive Payment System (MIPS) is the Medicare program, created by MACRA, that adjusts payments to eligible clinicians based on performance in quality, cost, improvement activities, and Promoting Interoperability. This post explains how MIPS works, MIPS Value Pathways, how scores affect payment, the role of certified EHR technology and electronic measures, and what MIPS means for nurses.

Fee-for-service (FFS) is a payment model in which providers are paid separately for each service they deliver, regardless of outcome. This post explains how FFS works, including fee schedules and claims, why it encourages volume, how Medicare and other payers are layering quality and value incentives on top of it, the role of health IT, and what FFS means for nursing work.

A patient-centered medical home (PCMH) is a model of primary care that is comprehensive, patient-centered, coordinated, accessible, and focused on quality and safety. This post explains the five core functions, how practices achieve recognition, how payers support medical homes, what the evidence shows, and how health IT and nurses make team-based primary care work.

HEDIS (Healthcare Effectiveness Data and Information Set) is the set of performance measures the National Committee for Quality Assurance (NCQA) maintains to assess health plan quality. This post explains what HEDIS measures, how results are used for ratings and accreditation, how clinical data from providers affects scores, the shift toward digital measurement, and what it means for nurses.

Alternative payment models (APMs) pay healthcare providers in ways that reward quality and cost efficiency rather than the volume of services alone. This post explains common types of APMs, how they fit into MACRA’s Quality Payment Program, the HCP-LAN framework for classifying payment, and why APMs depend on data, analytics, and care coordination.

Care coordination is the deliberate organization of patient care activities and information sharing among everyone involved in a patient’s care. This post explains why fragmented care causes harm, the health IT tools that support coordination, Medicare care management services, and the central role nurses play as coordinators and care managers.

Utilization management (UM) evaluates whether healthcare services are necessary, appropriate, and efficiently delivered. This post explains prior authorization, concurrent and retrospective review, hospital utilization review requirements, the federal push toward electronic prior authorization, and the central role nurses play in UM work.

A diagnosis related group (DRG) is a category that groups hospital stays with similar diagnoses, treatments, and resource use so that a hospital receives a set payment for each case. This post explains how Medicare’s MS-DRGs work, what drives a case into a group, how case mix and relative weights affect payment, and why accurate clinical documentation matters.

Social determinants of health (SDoH) are the conditions where people are born, live, learn, work, and age that shape their health. This post explains how SDoH differs from individual social needs, how SDoH data is screened, coded, and exchanged, how it supports value-based care, and how nurses gather and act on it.

Value-based care pays providers for health outcomes rather than for the number of services they deliver. This post explains how VBC differs from fee-for-service, the spectrum of value-based payment models, the federal programs that drive it, and why it depends on good data and good nursing.

The ACO model is one of the most consequential operational structures in modern U.S. healthcare — and one of the most demanding for health IT. This post breaks down what an ACO is, why it depends entirely on informatics, and how it shows up at the bedside and on the CAHIMS exam.