Da Vinci Value-Based Performance Reporting Implementation Guide
1.1.0 - STU 1.1 United States of America flag

Da Vinci Value-Based Performance Reporting Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-vbpr/ and changes regularly. See the Directory of published versions

ValueSet: Performance Metric

Official URL: http://hl7.org/fhir/us/davinci-vbpr/ValueSet/vbp-performance-metric Version: 1.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: VbpPerformanceMetricsVS
Other Identifiers: OID:2.16.840.1.113883.4.642.40.30.48.10

Type of value-based performance reporting performance metric.

References

Logical Definition (CLD)

 

Expansion

Expansion performed internally based on codesystem Performance Metric Codes v1.1.0 (CodeSystem)

This value set contains 93 concepts

CodeSystemDisplay (en-US)Definition
  avg-risk-scorehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAverage risk scoreAverage risk score is a numeric score where a higher score indicates a riskier population on average. Example scores: 0.70, 1.00, 1.30.
  avg-risk-score-markethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMarket average risk scoreThe market average risk score.
  capitationhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricCapitationTotal capitation amount.
  capitation-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricCapitation per member per monthCapitation per member per month (PMPM). Capitation is a fixed amount of money per patient per month paid in advance to the physician [or health care provider] for the delivery of health care services.
  dental-capitationhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricDental capitationTotal dental capitation.
  dental-capitation-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricDental capitation PMPMTotal dental capitation per member per month (PMPM).
  reinsurance-capitationhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricReinsurance capitationTotal reinsurance capitation.
  reinsurance-capitation-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricReinsurance capitation PMPMReinsurance captitation per member per month (PMPM).
  ccfhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricCare coordination feeCare coordination fee (CCF) is per member per payments based on the number of patients that are assigned to primary care physicians.
  goal-hcc-rafhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricGoal HCC RAFGoal or target hierarchical condition category (HCC) Risk Adjustment Factor (RAF).
  actual-hcc-rafhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricActual HCC RAFAcutal hierarchical condition category (HCC) Risk Adjustment Factor (RAF).
  earnings-ccfhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEarnings CCFEarnings from care coordination fees.
  performance-ccfhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPerformance CCFPerformance for care coordination fees.
  potential-upside-ccfhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential upside CCFPotential upside earnings for care coordination fees.
  potential-downside-ccfhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential downside CCFPotential downside earnings for care coordination fees.
  earned-incentivehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEarned incentiveEarned incentive payment.
  earnings-qiphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEarnings QIPEarnings from quality incentive payments.
  performance-qiphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPerformance QIPPerformance for quality incentive payments.
  potential-upside-qiphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential upside QIPPotential upside earnings for quality incentive payments.
  potential-downside-qiphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential downside QIPPotential downside earnings for quality incentive payments.
  earnings-sslhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEarnings SSLEarnings from shared savings surplus/loss.
  performance-sslhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricperformance SSLPerformance for shared savings surplus/loss.
  potential-upside-sslhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential upside SSLPotential upside earnings for shared savings surplus/loss.
  potential-downside-sslhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricpotential downside SSLPotential downside earnings for shared savings surplus/loss.
  earnings-caphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEarnings capitatedEarnings from capitated payments.
  performance-caphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPerformance capitatedPerformance for capitated payments.
  potential-upside-caphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential upside capitatedPotential upside earnings from capitated payments.
  potential-downside-caphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPotential downside capitatedPotential downside earnings for capitated payments.
  quality-gate-percentagehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricQuality gate percentage% of payment tied to quality.
  quality-gate-performance-percentagehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricQuality gate performance percentage% of shared savings can earn based on quality metric performance.
  interim-pmt-ratehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricInterim payment rateInterim payment rate.
  ibnr-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricIBNR PMPMIncurred but not yet reported (IBNR) per member per month (PMPM).
  med-ibnrhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical IBNREstimated medical expenses incurred but not yet reported (IBNR).
  rx-ibnrhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy IBNREstimated pharmacy expenses incurred but not yet reported (IBNR).
  med-rx-ibnrhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical pharmacy IBNREstimated medical and pharmacy expenses incurred but not yet reported (IBNR).
  revenuehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricRevenueTotal revenues earned, which includes premiums and other resources that a payer receives.
  revenue-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricRevenue PMPMRevenue earned per member per month (PMPM).
  avg-revenue-pmpm-markethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMarket average revenue PMPMAverage revenue per member per month (PMPM) for a market.
  cost-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricCost targetCost target.
  admin-costhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAdministrative costA general term that refers to Medicare and Medicaid administrative costs, as well as CMS administrative costs. Medicare administrative costs are comprised of the Medicare related outlays and non-CMS administrative outlays. Medicaid administrative costs refer to the Federal share of the States' expenditures for administration of the Medicaid program. CMS administrative costs are the costs of operating CMS (e.g., salaries and expenses, facilities, equipment, rent and utilities, etc.). These costs are reflected in the Program Management account.
  rx-costhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy costTotal amount of the pharmacy cost.
  rx-cost-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy cost targetThe goal or target pharmacy spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
  rx-cost-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy cost PMPMPharmacy cost per member per month (PMPM).
  rx-cost-pmpm-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy cost PMPM targetThe goal or target pharmacy spend level per member per month (PMPM) as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
  med-costhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical costTotal amount of the medical cost.
  med-cost-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical cost targetThe goal or target medical spend level as specified by a value-based contract below which savings are generated, often represented as a percent of total revenue.
  med-cost-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical cost PMPMMedical cost per member per month (PMPM).
  med-cost-pmpm-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical cost PMPM targetThe goal or target medical cost per member per month (PMPM).
  med-cost-fundhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical cost fundTotal dollars available for medical spend calculated using the medical cost target relative to estimated revenue.
  avg-med-cost-fund-markethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMarket average medical cost fundThe market average medical cost per member per month (PMPM) over revenue PMPM.
  med-rx-costhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical pharmacy costTotal spend on medical and pharmacy cost for a specified population.
  med-rx-cost-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical pharmacy cost targetTarget spend on medical and pharmacy cost for a specified population.
  med-rx-cost-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical pharmacy cost PMPMTotal spend on pharmacy cost for a specified population represented on a per member per month (PMPM) basis.
  avg-med-rx-cost-pmpm-markethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMarket average medical pharmacy cost PMPMThe market average medical pharmacy cost per member per month (PMPM).
  variance-costhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricVariance costHow much actual costs vary from projected (target) costs.
  med-loss-ratiohttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical loss ratioThe Medical Loss Ratio (MLR) is the proportion of premium revenues spent on clinical services and quality improvement.
  med-loss-ratio-targethttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical loss ratio targetThe goal or target medical spend level relative to revenue as specified in a value-based care contract, often represented as a percent of revenue.
  med-expense-ratiohttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical expense ratioMedical expense ratio.
  med-expense-ratio-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical expense ratio PMPMMedical expense ratio per member per month (PMPM).
  member-monthshttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMember monthsTotal member months in a given period.
  med-member-monthshttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricMedical member monthsTotal medical member months in a given period.
  rx-member-monthshttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPharmacy member monthsTotal pharmacy member months in a given period.
  adjusted-paid-claimhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAdjusted paid claimAdjusted paid claim, excludes catastrophic claims.
  annual-care-visit-bonushttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAnnual care visit bonusBonus to qualified annual care visit (ACV). A type of quality incentive payment.
  avg-star-rating-bonushttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAverage star rating bonusBonus earned when achieve a certain Average Star Rating. A type of quality incentive payment.
  avg-star-rating-improvement-bonushttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAverage star rating improvement bonusBonus earned when achieve improvement performance year over year based on average star rating. A type of quality incentive payment
  quality-metric-performance-incentivehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricQuality metric performance incentiveQuality metric performance incentive payment is a type of quality incentive payment.
  quality-pmt-chronichttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricQuality payment chronic disease managementQuality payment chronic disease management.
  quality-pmt-office-visithttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricQuality payment annual office visitQuality payment annual office visit.
  shared-saving-deficithttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricShared saving deficitThe amount of shared saving deficit.
  weighted-avg-starhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricWeighted average starThe average quality score across a specified set of measures, weighted by importance of the individual measures for a specific population. Often used in relation to CMS Medicare Star rating reports, e.g., where medication adherence measures are 3x weighted relative to other quality measures in the set.
  condition-counthttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricCondition countThe number of conditions.
  1-gap-closedhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric1 gap closedNumber of members with 1 closed gap.
  2-gap-closedhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metric2 gaps closedNumber of members with 2 closed gaps.
  paid-claimhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPaid claimTotal paid claim amount.
  paid-claim-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricPaid claim PMPMPaid claim per member per month (PMPM).
  drg-expensehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricDRG expenseTotal diagnosis related group (DRG) expense.
  drg-expense-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricDRG expense PMPMDiagnosis related group (DRG) expense per member per month (PMPM).
  provider-quality-expense-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricProvider quality expense PMPMProvider quality expense per member per month (PMPM).
  subrogation-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricSubrogation PMPMSubrogation per member per month (PMPM).
  avg-member-office-visithttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAverage members with office visitAverage number of members with office visit.
  ed-visithttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricED visitTotal number of Emergency Department (ED) visits.
  eligible-memberhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricEligible membersTotal number of eligible members.
  inpatient-acutehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricInpatient acuteTotal number of inpatient acute stays.
  inpatient-admissionhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricInpatient admissionTotal number of inpatient admissions.
  nurse-hotlinehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricNurse hotlineTotal number calls of the nurse hotline.
  nurse-hotline-pmpmhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricNurse hotline PMPMTotal nurse hotline per member per month (PMPM).
  snf-avg-loshttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricSkilled Nursing Facility average length of stayThe number of skilled nursing facility average length of stay.
  readmissionhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricReadmissionTotal number of readmissions
  snf-admissionhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricSkilled Nursing Facility admissionTotal number of skilled nursing facility admissions.
  provider-quality-expensehttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricProvider quality expenseTotal provider quality expense.
  subrogationhttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricSubrogationTotal subrogation amount.
  avg-membershiphttp://hl7.org/fhir/us/davinci-vbpr/CodeSystem/vbp-performance-metricAverage membershipAverage membership.

Explanation of the columns that may appear on this page:

Level A few code lists that FHIR defines are hierarchical - each code is assigned a level. In this scheme, some codes are under other codes, and imply that the code they are under also applies
System The source of the definition of the code (when the value set draws in codes defined elsewhere)
Code The code (used as the code in the resource instance)
Display The display (used in the display element of a Coding). If there is no display, implementers should not simply display the code, but map the concept into their application
Definition An explanation of the meaning of the concept
Comments Additional notes about how to use the code