Download Handout - Definitions (PDF: 103KB/4 pages)

Definitions 
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Clinically Effective Clinical effectiveness most simply is a measure of the extent to which a particular intervention works to improve health outcomes. It often is used more generically as an umbrella term to refer to activities which have as their focus the measuring, monitoring and improving of clinical care quality as part of clinical governance. For example, clinical audit, R&D, education and training, continuous quality improvement, care pathways, and evidence‐based clinical guidelines could all be included. In this broader definition, clinical practice is continuously refined in light of emerging evidence of effectiveness, and considers aspects of efficiency and safety from the perspective of the individual patient or community. With respect to the EBS, the legislation specifically mentions scientifically based practice standards established by the Institute for Clinical Systems Improvement (ICSI). In additional to ICSI, many other accredited and widely accepted organizations supply evidence based research such as protocols or guidelines including the Agency for Healthcare Research and Quality (AHRQ), the Minnesota Evidence‐based Practice Center, and many Physician Specialty Societies. Some of these focus on particular practice areas such as prevention or technology. Clinical Services Services, procedures, tests, drugs and technologies directed primarily to the diagnosis and or treatment of patients to treat, cure, assess, or prevent illness, injury or disease or related symptoms. Examples include (but are not limited to) inpatient hospital care, professional/physician services including care coordination done by the physician, drugs, and mental health and substance abuse services. Comprehensive Per Minnesota Statute 62U.08, Subdivisions 1 and 2, the term refers to a broad range of necessary health care services, procedures, diagnostic tests, and technologies that are scientifically proven to be both clinically effective and cost‐effective. The term specifically does not relate to the level of patient cost sharing on services included within the EBS. Cost‐effective Society confronts many difficult choices in the provision of health care services through an insurance or public health programs. Options exist for resolving these choices, though none without compromise. To make informed choices, we need information about the therapeutic or diagnostic impact of a given service or program, the cost of the service or program, and the consequences of choosing one option over another. The term "cost‐effective" combines this information to describe a conclusive opinion. For example, for a given cost, program A is cost‐effective if its impact is greater than that of program B, all other factors being equal. Or for a given therapeutic and diagnostic results, program A is cost‐effective if its cost is less than program B. "Cost‐effective" options may vary among groups in society because they assess costs or value life, improved health outcomes, or other consequences differently. A state legislative body, business leaders, managed care organizations, health care providers, the pharmaceutical industry, and the public may all view an analysis differently because they seek different objectives and may consider impacts over different time horizons. The common undercurrent is “value for money" or return on investment (ROI). Differences in how various groups view a particular program reflect how different alternatives are valued. For example, ROI evaluated by societal objectives would favor a longer time horizon and, in some cases, chose to consider broader population health benefits including the intrinsic value of a healthy population. 
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EBM The conscientious, explicit and judicious use of current best‐available evidence gained from scientific study to make decisions about the care of individual patients. Scientific evidence includes both clinical research (for example, epidemiological studies and clinical studies about the impact of particular interventions on health care quality and cost) and health services research (for example, studies of various benefits designs and their impact on health care access, quality and affordability). EBM seeks to assess the quality of evidence of the risks and benefits of treatments, including lack of treatment. EBM seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best possible prediction of outcomes in current medical treatment. In some circumstances, the development of guidelines or protocols is based on clinical consensus where rigorous scientific studies are not available or sufficient. It is should also be noted that many aspects of medical care depend on individual factors such as quality‐of‐life and value judgments, which may not be subject to scientific methods. EBM guidelines are largely silent on these areas. Health Plan Activities Affecting Individual or Population Health Activities by the health plan to promote access to and/or effective use of targeted clinical services. Examples include (but are not limited to) consumer education, care coordination done by the health plan, health promotion, and prevention reminders. Insurance Benefits Payments or services provided under stated circumstances under the terms of an insurance policy. In the case of health insurance, the policy is the certificate of coverage and includes coverage information for both in and out of network providers, the schedule of benefits and coverage terms, exclusions, coordination of benefits, and other sections. Examples under and EBS plan could include access to disease management programs, medical homes, or other programs or services that seek to apply scientific evidence to increase the clinical effectiveness and cost‐effectiveness of care. 
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Investigative Services ‐ New services, procedures, tests, drugs or technologies that lack sufficient evidence to make sound judgments concerning their safety, clinical or cost‐effectiveness. Additionally, existing services, procedures, tests, drugs or technologies that are being applied in new ways or to new areas may also fit into this category. Lifestyle Services Services of limited or no medical necessity provided primarily to enhance the quality of life. Examples include lifestyle drugs that allow users to perform an activity 'on demand' or without consequences, ameliorate an imprudent binge, or modify the effects of aging. Other examples include elective surgical treatments such as hair transplants, cosmetic surgery or complications from cosmetic surgery. Exceptions are possible. Maintenance Services Services, procedures, tests and technologies directed primarily to maintain a given level of health, capacity or function over a long‐term period, often combining clinical and non‐clinical elements. Examples include (but are not limited to) assisted living, adult foster care, targeted supports, waivered services, long term nursing home care, personal care attendants, and respite care. Medically Necessary Services, supplies, procedures, tests and technologies which meet the following tests: o They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; o They are provided for the diagnosis or direct care and treatment of the medical condition; o They meet the standards of good medical practice within the medical community in the service area; o They are not primarily for the convenience of the plan member or a plan provider; and o They are the most appropriate level or supply of service which can safely be provided. Population Health Factors General characteristics of society and/or the environment that have a significant effect on population health. Examples include (but are not limited to) education, employment, the environment (clean water and air), and public safety. Supportive/Non‐Clinical Care Services, procedures, tests and technologies that are not clinical but are indirectly related to care and are supportive of overall health and/or enabling access to clinical 
care. Examples include (but are not limited to) transportation, housing assistance, and income assistance. Self‐Care Activities Activities done by individuals that promote or maintain personal health and wellness. Examples include (but are not limited to) personal diet and nutrition choices, exercise, and personal safety.