Reference

Glossary

Plain-language definitions of the terms used across the curriculum, written the way the lessons use them.

4

42 CFR Part 2: The federal rule governing substance use disorder record confidentiality since the 1970s, historically stricter than HIPAA and requiring record segregation. Rewritten in 2024 to permit a single consent and drop segregation, with compliance due February 16, 2026.

A

Accountable Care Organization ACO: A group of providers collectively accountable for the total cost and quality of care for an attributed population, judged against a spending benchmark with quality gates.
Actuarial soundness: The federal requirement, in place since 1981, that Medicaid managed care rates be set by qualified actuaries at levels appropriate for the population and services covered.
Administrative services only ASO: An arrangement in which a self-funded employer pays a carrier or third-party administrator to process claims and provide network access without transferring any insurance risk.
ADT feed: Near-real-time admission, discharge, and transfer notifications that tell a care team a patient has hit a hospital while there is still time to act.
Adverse selection: Avoiding the patients most likely to be expensive. The quiet failure mode of any model that pays for a population without adjusting properly for how sick it is.
Alternative Payment Model APM: Any payment arrangement that moves provider revenue away from pure fee-for-service toward accountability for quality and cost.
Ambulatory Specialty Model ASM: Medicare's mandatory model beginning 2027 that applies performance-based payment adjustments to selected heart failure and low back pain specialists, the first to hold individual specialists accountable for longitudinal condition management.
APM Performance Pathway APP: The reporting track through which Medicare ACOs submit their quality measures to meet the performance standard that gates shared savings.
Attachment point: The dollar threshold in a stop-loss arrangement above which coverage begins to pay. A lower point transfers more risk at a higher premium.
Attribution: The rule set that decides which patients a provider is accountable for, built from claims patterns, patient designation, or enrollment.
Average commercial rate ACR: The average price a service commands from private insurers in a state. Since 2024 it is the ceiling on Medicaid state directed payments.

B

BATNA: Best alternative to a negotiated agreement: what you would do if this deal fell through. The quality of your alternative sets how much leverage you actually hold.
Behavioral health carve-out: Splitting mental health and substance use benefits off to a separate managed vendor, so the organization accountable for total cost of care neither manages nor sees them.
Behavioral health carve-out: Contracting behavioral services to a specialized organization separate from the medical benefit. Brings expertise and a dedicated network, and separates the party that would invest in integration from the party whose medical spending falls.
Benchmark: An estimate of what an attributed population would have cost without the provider's efforts; the yardstick savings and losses are measured against.
Benefit period: The window Part A cost sharing is measured against, beginning with admission and ending after 60 consecutive days without inpatient or skilled nursing care. A beneficiary admitted twice in a year with enough time between stays owes the deductible twice.
Bid: What a Medicare Advantage plan says it costs to provide the standard Medicare benefit to an average beneficiary in an area, compared against the benchmark to set payment.
Budget neutrality: The condition on Section 1115 waivers that federal spending under the demonstration not exceed what it would have been without it. Set by CMS policy, not statute, so its meaning shifts over time.
Bundled payment: One target price covering all services in a defined episode of care, such as a joint replacement plus 90 days of follow-up.
Buy-and-bill: The arrangement in which a provider purchases an administered drug, gives it to the patient, and bills the payer, so the provider's margin is the spread between acquisition cost and reimbursement.

C

Capitation: A fixed, risk-adjusted payment per member per month that makes the provider responsible for delivering all covered care within it.
Care gap: The difference between the care a patient should have received, by guideline or measure, and the care they actually got. Each gap is a specific, closable opportunity to improve quality and often cost.
Care management: Structured, proactive support for patients whose conditions put them at risk: outreach, coordination, medication reconciliation, and follow-up between visits.
Care transition: The handoff when a patient moves between settings, especially hospital discharge. A high-risk moment where prompt follow-up is among the most reliable ways to prevent readmissions.
Center of excellence COE: A facility designated for specific procedures based on procedure-specific outcomes, usually paid a bundled price and paired with travel benefits and waived cost sharing to steer volume.
Churn: Patients cycling on and off an attributed list, which erodes the return on longitudinal investment in their care.
Claims reserve: Money a risk-bearing organization holds against claims it owes but has not yet paid, including IBNR, plus a margin for the chance costs run higher than expected.
CMMI (Innovation Center): The CMS center that tests payment models; models that improve quality without raising spending can expand nationally without new legislation.
CMS-0057-F: The CMS Interoperability and Prior Authorization Final Rule: it sets faster prior-authorization turnaround times (from 2026) and requires payers to implement several FHIR APIs, including Prior Authorization and Payer-to-Payer APIs (by 2027).
Co-management agreement: An arrangement paying specialists for defined service-line management responsibilities such as pathway development and governance rather than for volume. It funds the unbillable work that determines results.
Coding intensity: The tendency for recorded diagnoses, and therefore risk scores, to rise where payment depends on them, independent of how sick patients actually are.
Collaborative Care Model CoCM: Behavioral health integration pairing the primary care clinician with a behavioral health care manager and a psychiatric consultant who reviews the caseload. Medicare has paid for it since 2017 through dedicated codes.
Community health worker CHW: A frontline worker hired for lived experience and community trust who connects patients to care and social support.
Comparative analysis: The documented demonstration, required since the Consolidated Appropriations Act, 2021, that a plan's nonquantitative limits on behavioral benefits are no more restrictive than those on medical benefits. Plans must produce it on request.
Comparison group: A similar population that did not receive the program, watched over the same period so shared trends can be separated from the program's effect.
Completion factor: The estimated share of a period's claims already paid by a given point, used to project total incurred cost and set IBNR.
Composite quality score CQS: The quality adjustment applied to an episode reconciliation amount after spending performance is calculated and before payment caps bind, which is why it moves a result within the band rather than beyond it.
Confidence interval: The range within which the true effect probably falls. If it includes zero, the result is not statistically significant.
Confounding: A third factor that influences both who is in a program and how they turn out, creating a correlation that is not causal. The core reason voluntary-program results mislead.
Convener: An organization that assumes financial accountability for episodes on behalf of participating providers, bearing the risk and coordinating the parties in bundled payment arrangements.
Conversion factor: The dollar figure that turns relative value units into a payment. From 2026 Medicare uses two, a higher one for qualifying participants in Advanced Alternative Payment Models and a lower one for everyone else.
Counterfactual: What would have happened to the same population without the program. Unobservable, so it must be estimated, and every claimed effect is a comparison against it.
Cut point: The performance threshold between Star Rating levels. Set relative to how the whole market performs, so a plan can improve and still lose a star if competitors improve faster.

D

Data governance: The rules and responsibilities for how data is owned, defined, protected, and used, so that metrics are consistent, reproducible, and trusted enough to act on.
Difference-in-differences: An evaluation method that subtracts the comparison group's change over time from the program group's, netting out trends that hit both.
Disproportionate share hospital payment DSH: Extra Medicaid payments to hospitals serving a large share of low-income patients, one of the older tools for offsetting low base rates.
DSRIP: Delivery System Reform Incentive Payment: 1115-funded programs that paid provider systems for hitting delivery-reform milestones rather than for volume. Most have wound down.
Dual eligibility: Qualifying for both Medicare and Medicaid, commonly used in risk models as a marker of social and clinical complexity.

E

E-consult: A documented specialist answer to a specific clinical question, delivered without a visit. Resolves questions that are genuinely questions rather than requests to transfer care.
Electronic clinical quality measure eCQM: A quality measure computed directly from electronic clinical (and claims) data rather than manual chart review, the direction quality reporting is moving.
Empanelment: Assigning each patient to a specific primary care clinician and care team, creating the defined panel a practice is accountable for. The clinical counterpart to payer attribution.
Episode of care: A defined bundle of clinically related services over a set window, the unit of accountability in bundled payment.
Episode trigger: The event that starts an episode of care and puts the accountable party on the hook, usually an admission, a procedure, or a diagnosis. Triggers defined by care setting go stale when procedures migrate between settings.
Episode window: How long accountability lasts after the trigger. A 30-day window asks an organization to manage a discharge; a 90-day window asks it to manage a recovery, and the two require different capabilities.
ERISA: The Employee Retirement Income Security Act of 1974, which sets minimum standards for private employer benefit plans, creates fiduciary duties for those managing plan assets, and preempts most state insurance law as applied to self-insured plans.

F

Federal Medical Assistance Percentage FMAP: The share of Medicaid costs the federal government pays, set by a per-capita-income formula with a 50 percent floor and 83 percent ceiling, and 90 percent for the expansion population.
Federal Register: The official daily journal where federal agencies publish proposed and final rules, notices, and other regulatory documents.
Federally Qualified Health Center FQHC: A community-based primary care provider serving a high share of Medicaid and uninsured patients, central to the Medicaid safety net.
Fee-for-service FFS: Payment per visit, test, and procedure. Rewards volume and is indifferent to outcomes.
FHIR: The prevailing modern exchange standard, which lets one system request discrete pieces of a record rather than shipping a whole document and hoping the receiver can parse it.
Fully insured plan: An employer health plan in which the employer pays a set premium and the insurer bears the risk that claims exceed it. Unlike self-funded plans, these are regulated by the state.

G

Gag clause: A contract term restricting a health plan from sharing provider-specific cost or quality information or from accessing its own de-identified claims data. Prohibited since 2020, with annual attestation of compliance required.
Gainsharing: Distributing a share of savings to the clinicians whose decisions produced them, subject to quality thresholds. The mechanism that sustains behavior change, and the reason many episode programs succeed in year one and drift afterward.
Generalizability: Whether a result found in one population, condition, and era transfers to another. Also called external validity; early-adopter pilots often do not generalize to scale.
Global budget: A fixed annual revenue amount for an institution, making an empty hospital bed an avoided cost rather than lost income.
Global risk: A delegated arrangement in which a Medicare Advantage plan passes the bulk of its capitation to a physician group, which then bears responsibility for the total cost of care for its attributed members.
Gold-carding: Exempting clinicians whose ordering has proven reliably appropriate from prior authorization, on the logic that reviewing a decision you keep approving is wasted motion.
Gross versus net drug cost: Gross is the price before rebates; net is what the payer actually bears. Nearly all published drug spending is gross, and one manufacturer reported rebates and fees at roughly 40 percent of its products' cost.

H

Health Information Exchange HIE: The electronic movement of clinical data across organizational boundaries, and also the name for the regional organizations that broker it.
Health-related social needs HRSN: An individual's unmet adverse social conditions, such as housing instability or food insecurity, that drive poor health. Medicaid can cover some through in-lieu-of services or 1115 waivers.
HEDIS: The standardized measure set most health plans report, maintained by NCQA; much of the quality language in provider contracts is HEDIS borrowed downstream.
Hierarchical Condition Category HCC: The dominant family of risk adjustment models: recorded diagnoses map to weighted condition categories that sum into a payment-scaling risk score.
Hospital Insurance trust fund: The account funding Medicare Part A, financed by a payroll tax fixed in statute. Because the revenue is capped while spending grows, it faces projected depletion, unlike the general-revenue financing behind Parts B and D.
Huddle: A brief team meeting before or during a session to review who is coming in, what each patient needs, and who will do what. The coordinating ritual of team-based primary care.

I

IBNR: Incurred but not reported: the estimated cost of care already delivered whose claims have not yet arrived. Added to paid claims, it gives the true incurred cost of a period.
In lieu of services ILOS: A medically appropriate, cost-effective substitute a Medicaid managed care plan may offer in place of a covered service, one of the two routes to funding social-needs support.
Information blocking: Practices that knowingly interfere with the access, exchange, or use of electronic health information. Now prohibited by federal rule for providers, developers, and exchanges alike.
Intent-to-treat: Analyzing everyone who started a program, including dropouts, so that attrition cannot inflate the measured result.
Interoperability: The ability of one organization's systems to find, send, receive, and actually use another's patient data. The fourth is where most efforts stall: records that arrive but cannot be integrated are closer to noise than information.

L

Leakage: Attributed patients receiving care outside an ACO's coordinated network, where the ACO has little influence over cost and quality but remains accountable for the spending.
Loss cap: A contractual limit on the total amount a risk-bearing organization can lose under an agreement, expressed as a dollar amount or a percentage of the benchmark. The term that bounds an otherwise open-ended downside.

M

Machine-readable file MRF: The public file in which plans and issuers must publish in-network negotiated rates and out-of-network allowed amounts. The raw material for benchmarking commercial prices.
MACPAC: The Medicaid and CHIP Payment and Access Commission, the parallel advisory body for Medicaid and CHIP, which consults with MedPAC on people dually eligible for both programs.
MACRA: The 2015 law that pushed Medicare clinicians toward value through MIPS or advanced alternative payment models.
Managed care organization MCO: A private health plan a state pays a fixed amount per member to cover Medicaid enrollees; the delivery vehicle for most of the program.
Management services organization MSO: A partner that supplies value-based infrastructure (data, analytics, care management) to providers, letting smaller organizations take risk without building it all in-house.
Market basket: The index measuring what the goods and services a provider buys actually cost. It sets the starting point for each year's Medicare payment update before other adjustments are applied.
Maximum Fair Price MFP: The price resulting from Medicare's direct negotiation for selected high expenditure, single source drugs without generic or biosimilar competition. The first ten Part D drugs took effect January 1, 2026.
Measurement-based care: Administering a validated symptom instrument at defined intervals, recording the score as structured data, and changing treatment when the target is not met. A score that changes nothing is documentation rather than measurement.
Medicaid Core Set: Standardized child and adult quality measures. Reporting of the Child Core Set and adult behavioral-health measures became mandatory for states in 2024.
Medical benefit drug: A drug administered by a clinician and billed on a medical claim, such as an office or hospital infusion. Corresponds to Medicare Part B, and is managed through prior authorization and site-of-care policy rather than a formulary.
Medical loss ratio MLR: The share of capitation a plan spends on care and quality rather than administration and profit. Medicaid requires rates to support at least 85 percent.
Medical trend: The year-over-year growth in per-capita cost for the same population, driven by unit price and utilization. The assumption baked into every rate and benchmark.
Medicare Severity Diagnosis-Related Group MS-DRG: The classification assigned to an inpatient stay, carrying a relative weight based on the average resources used to treat Medicare patients in that group. Multiplying the weight by a wage-adjusted base rate produces the hospital's payment.
Medicare Shared Savings Program MSSP: The permanent Medicare ACO program, written into statute. Offers the BASIC track (a one-sided to two-sided glide path) and the higher-risk ENHANCED track.
Medication for opioid use disorder MOUD: Buprenorphine, methadone, or naltrexone treatment. Mortality falls substantially during time in treatment and rises on discontinuation, which makes retention rather than initiation the outcome that matters.
Medigap: Private supplemental insurance that covers cost sharing traditional Medicare leaves to the beneficiary. Policies are standardized as plans A through N, and outside a one-time six-month window most states permit insurers to underwrite on health status.
MedPAC: The Medicare Payment Advisory Commission, which advises Congress on Medicare payment and policy through recommendations issued twice a year. Nonpartisan and influential but does not make rules.
Member month: One member enrolled for one month. The denominator of population finance, because it counts enrolled time rather than headcount and so handles mid-year churn correctly.
Mental Health Parity and Addiction Equity Act MHPAEA: The 2008 law barring plans that cover behavioral health from limiting it more restrictively than medical care. It is a comparison rule, not a coverage mandate, so a plan covering nothing is not in violation.
MIPS: The Merit-based Incentive Payment System: scores clinicians in traditional Medicare on quality, cost, improvement, and interoperability, adjusting fees up or down.

N

Net savings: Gross reduction in medical spending minus shared-savings payouts and program operating costs. The figure that tells a payer whether a program was worth funding.
Nonquantitative treatment limitation NQTL: A restriction that does not appear as a number in a benefit summary, such as prior authorization, network composition standards, or out-of-network rate methodology. Where unequal behavioral access actually lives.
Notice-and-comment rulemaking: The Administrative Procedure Act process for making binding regulations: a proposed rule, a public comment period, and a final rule that must respond to significant comments.

O

Outcome measure: A measure of what happened to the patient: mortality, readmission, function, symptom relief. The truest quality signal and the hardest to compare fairly.
Outlier payment: An additional amount paid when a case is unusually expensive, protecting a provider from large losses under a fixed prospective rate. Stop-loss protection built directly into an administered price system.

P

Panel: The defined group of patients a primary care clinician and team are responsible for, whether or not those patients book a visit. The denominator for all proactive management.
Part 2 (42 CFR): The federal rule on confidentiality of substance use disorder records, historically stricter than HIPAA because such records have been used to prosecute and stigmatize patients. Rewritten in 2024 to align with HIPAA; compliance came due in February 2026.
Patient matching: Linking records that belong to the same person across systems that use inconsistent identifiers. Foundational and imperfect: matching too loosely merges people, too tightly splits them, and either error corrupts analysis.
Patient-reported outcome PROM: An outcome the patient reports directly, such as pain or function before and after treatment.
Pay-for-performance P4P: Bonus payments layered on fee-for-service for hitting quality targets; the gentlest step on the risk spectrum.
Percent of Medicare: The ratio of a commercial negotiated rate to what Medicare would pay for the same service. The most portable benchmark in commercial purchasing, since it is comparable across hospitals, markets, and years.
Pharmacy benefit manager PBM: The intermediary that builds formularies, negotiates manufacturer rebates, and administers pharmacy claims. Six firms manage nearly 95 percent of US prescriptions, vertically integrated with the largest insurers and pharmacies.
PMPM: Per member per month: the standard unit for capitated payments and population-level cost reporting.
Post-acute care PAC: Care after a hospital stay: skilled nursing, home health, inpatient rehabilitation, long-term care hospitals. Among the most discretionary spending in Medicare, and where episode budgets are usually won or lost.
Pre-visit planning: Reviewing what a patient needs before they arrive, so overdue screenings, labs, and follow-up can be addressed during the visit instead of missed.
Primary nonadherence: A prescription written and never filled. Invisible to the prescriber, visible only in pharmacy claims, and one of the clearest reasons an organization at risk needs pharmacy data.
Prior authorization: Payer approval required before a service is delivered. The sharpest edge of utilization management, and the one most likely to delay care it goes on to approve anyway.
Process measure: A measure of whether the right thing was done, such as a screening or timely medication. Actionable and fair, but invites teaching to the test.
Productivity adjustment: A subtraction from the market basket that assumes providers become more efficient each year. It applies whether or not efficiency actually improved, which is why Medicare updates routinely fall below input cost growth.
Proposed rule: An agency's published draft regulation (a Notice of Proposed Rulemaking) that lays out what it plans to do and invites public comment before anything becomes binding.
Psychiatric collaborative care management CoCM: The billing pathway, live in Medicare since 2017, through which a treating clinician bills for a team including a behavioral care manager and a caseload-reviewing psychiatric consultant who do not bill separately.

Q

QHIN: A Qualified Health Information Network: one of the designated hubs through which TEFCA moves data between exchange networks that would otherwise not talk to each other.
Quality bonus payment QBP: The Medicare Advantage bonus that raises a plan's benchmark by five percentage points, or ten in designated counties, based on its Star Rating. MedPAC estimates it adds roughly $16 billion in 2026.

R

RADV: Risk Adjustment Data Validation: the audit in which CMS samples enrollees and checks whether submitted diagnoses are supported by the medical record. Expanded to all eligible MA contracts, with extrapolated penalties currently paused by court ruling.
Ratchet effect: When benchmarks built on historical performance tighten after success, making this year's savings next year's harder target.
Rebasing: Resetting a benchmark for a future period, often based partly on the organization's own recent spending. The mechanism behind the ratchet, where past success raises the future bar.
Rebate: The share of the gap between an MA plan's bid and its benchmark that returns to the plan, which must be spent on enrollees as supplemental benefits, lower cost sharing, or lower premiums. The source of MA's extra benefits.
Rebate: A confidential payment from a manufacturer to a plan or PBM, typically larger for drugs facing therapeutic competition. Because rebates are not reflected in published figures, gross and net drug costs can point to opposite decisions.
Reconciliation: The after-the-fact settlement of a value-based contract: once claims run out, actual spending is compared to the benchmark and savings or losses are paid.
Reference-based pricing: Setting the plan's payment at a defined multiple of a benchmark, usually Medicare, rather than accepting a negotiated discount off charges. Shifts the balance-billing risk toward the member unless paired with provider agreements.
Registry: A continuously updated list of patients grouped by condition or need, with care gaps attached; useful only when worked as a daily queue.
Regression to the mean: The tendency of a group selected for being extreme to drift back toward average on its own. The most common way programs targeting high-cost patients fake a success.
Reinsurance: Coverage a risk-bearing organization buys to cap its own losses; in this context largely synonymous with stop-loss.
Relative value unit RVU: The measure of resources a physician service requires, split into work, practice expense, and malpractice components. Because total RVUs are held to a fixed budget, raising the value of one service lowers payment for all others.
Risk adjustment: Statistical correction for how sick a population is, so payment and performance comparisons reflect care rather than patient mix.
Risk corridor: A limit on gains and losses in a risk contract, protecting both sides from extreme results.
Risk score: A number summarizing a patient's expected cost, normalized so the average is 1.0; payments and benchmarks scale with it.
Risk stratification: Sorting a panel into tiers of expected need so care management effort concentrates where it can still change the trajectory.
Risk-based capital RBC: The capital a risk-bearing entity must hold to stay solvent, scaled to how much risk it has taken on; the regulated backstop behind claims reserves.
Runout window: The period a contract allows for claims to finish arriving before spending is tallied for reconciliation, so late claims are captured in the settlement.

S

Section 1115 waiver: Demonstration authority that lets the HHS Secretary waive most Medicaid rules and fund otherwise-unallowed services to test projects promoting the program's objectives, subject to budget neutrality.
Section 1115A: The provision of the Social Security Act (added by the ACA) that created the Innovation Center and gives it authority to test payment models and expand successful ones nationally without new legislation.
Selection bias: Distortion of results by who joins, stays, or leaves a program. Includes self-selection at entry and attrition as strugglers drop out.
Self-funded plan: An employer health plan in which the employer pays covered claims directly and bears the financial risk, usually retaining a carrier for administration and buying stop-loss for catastrophic claims. Two-thirds of covered workers are in one.
Shared savings: An arrangement in which providers keep a share of spending below the benchmark, one-sided (upside only) or two-sided (losses owed too).
Site of service: Where a procedure or test is performed, which in commercial markets can change the price more than any negotiation. Hospital outpatient departments carry a far larger premium over Medicare than ambulatory surgery centers.
Social drivers of health: Non-clinical conditions that shape health: housing, food security, transportation, isolation. Largely invisible in claims and clinical data.
Standing order: A pre-authorized protocol letting team members take defined clinical actions, such as ordering a due screening, without individual physician direction each time. What makes panel-wide gap closure feasible.
Star Ratings: The one-to-five composite quality score for Medicare Advantage plans; four stars and above unlocks bonus payments large enough to shape the whole industry's behavior.
State directed payment SDP: A payment a state requires its managed care plans to make to providers, used to raise rates or, less often, to require value-based arrangements. Capped at the average commercial rate.
Stop-gain: The cap on how much an organization can earn from a value arrangement, the mirror of stop-loss. Together they define the band inside which every other adjustment operates.
Stop-loss: Protection that caps a provider's exposure to catastrophic individual cases or aggregate losses under risk contracts.
Sub-regulatory guidance: An agency's interpretation and operational detail (bulletins, manuals, model announcements, participation agreements) that can be issued quickly, does not require notice-and-comment, and does not carry the full force of regulation.

T

Target price: The prospectively set amount an episode is expected to cost, covering all included spending regardless of who is paid. Performance is measured against this figure rather than against actual efficiency, so how it is built determines who wins.
TEFCA: The Trusted Exchange Framework and Common Agreement: the federal attempt to set one nationwide floor for data exchange in place of a patchwork of regional deals.
Third-party administrator TPA: An organization that processes claims and administers benefits for a self-funded employer. It handles the money without owning the risk, and often without having negotiated the prices.
Tiered network: A network design that retains all providers but assigns them to tiers with different member cost sharing, creating a financial nudge toward preferred providers without removing access.
Total cost of care: Everything spent on a patient across all settings over a defined period; the honest denominator for any value calculation.
Transforming Episode Accountability Model TEAM: Medicare's mandatory surgical episode model running 2026 through 2030 in selected geographic areas, covering five procedure categories through 30 days after hospitalization, and the first to require referral to primary care.
Two-sided risk: A contract in which providers share savings and owe a share of overruns; where evaluations show value-based models start producing reliable results.

U

Utilization management UM: Deciding whether a service is necessary and delivered in the right setting, before, during, or after the fact. Its reputation is denial; its purpose is appropriateness.

V

v28: The current CMS-HCC risk adjustment model used in Medicare Advantage, which restructured condition categories and removed diagnoses prone to coding variation. Fully phased in by 2026.
Value-based care VBC: Care and payment arrangements judged on outcomes achieved relative to total cost, rather than volume of services delivered.
Value-based insurance design VBID: Setting member cost sharing by a service's clinical value rather than uniformly, lowering or removing copays for high-value medications on the reasoning that a copay is a barrier the patient's clinical need does not account for.
Voluntary alignment: A patient formally designating their primary clinician, which can add them to an ACO's attributed panel beyond what claims-based rules capture.

W

Wage index: The geographic adjuster applied to the labor-related share of a Medicare base payment rate, so that hospitals in high-wage areas receive more for the same service. A recurring source of dispute because it redistributes billions.
Walk-away point: The terms under which a deal is not worth doing, decided before negotiating. A credible willingness to walk is the strongest source of negotiating leverage.