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| the ability to obtain health care when needed |
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| billing of the leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed |
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| a reimbursement mechanism under which the provider is paid a set monthly fee per enrollee (sometimes referred to as per member per month or PMPM rate) regardless of whether or not an enrollee sees the provider and regardless of how often an enrollee sees the provider. Used primarily by Health Maintenance Organizations. |
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| excessive medical tests and procedures performed as a protection against malpractice lawsuits, otherwise regarded an unnecessary |
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| a person enrolled in a health plan, especially in a managed care plan |
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| a plan of total expenditures in a health care system established in advanced |
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| a system that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services |
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| a joint federal-state program of health insurance for the poor |
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| a federal program of health insurance for the elderly, certain disabled individuals, and people with end-stage renal disease |
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| consumer behavior that leads to a higher utilization of health care services because people are covered by insurance |
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| bundled of fees for an entire package of related services |
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| basic and routine health care provided in an office or clinic by a provider (physician, nurse, or other health care professional) who takes responsibility for coordinating all aspects of a patient’s health care needs. An approach to health care delivery that is the patient’s first contract with the health care delivery system and the first element of a continuing health care process |
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| any entity that delivers health care services and can either independently bill for those services or is tax supported. Common examples include physicians, dentists, optometrists, and therapists in private practices; hospitals, diagnostic and imaging clinics; and suppliers of medical equipment (e.g., wheelchairs, walkers, ostomy supplies, oxygen) |
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| artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes. |
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| the four key functions necessary for health care delivery—financing, insurance, delivery, and payment |
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| the amount insurers pay to a provider. The payment may only be a portion of the actual charge |
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| a health care reform proposal in which the financing of health care is in the government’s hands |
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| in a multipayer system, the payers for covered services, for example, insurance companies, managed care organizations, and the government. They are called third parties because they are neither the providers nor the recipients of medical services. |
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| health insurance coverage for all citizens; managed by the government |
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| The quantity of health care consumed |
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| Characteristics that differntiate U.S. health care system |
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Definition
1. No central agency
2. Partial access
3. Imperfect market
4. Third-party insurers and payers
5. Multiple payers
6. Power Balancing
7. Legal Risks
8. High technology
9. Continuum of Services
10. Quest for quality |
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| health care is available to all citizens |
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Health care is partially managed by free market.
This system is also known as an imperfect market. |
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Surgery is a good example to illustrate______. Patients can generally obtain the fees the surgeon would charge for a particular operation. But the final bill, after the surgery has been performed, is likely to include charges for supplies, use of the hospital's facilities, and services performed by providers, such as anesthesiologists, nurse anesthetics, and pathoologists. |
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| Bundled fee for a group of related services |
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| All health care services included under one set fee per covered individual |
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| Bill for their services separately. E.g. anesthesiologist, pathologist, supplies, hospital facility use |
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- Curative
- Restorative
- Preventative
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| Broad categories of medical services |
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| Government's roles in U.S. health service system |
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Definition
- Major financier of health care delivery
- Determine reimbursement rates to providers who render Medicare/Medicaid services
- Regulates through licensing
- Health policy
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Term
| Functional components of health care delivery |
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Definition
- Financing
- Insurance
- Delivery
- Payment
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Definition
| Employers require their employees to pay a portion of the health insurance |
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| Why are people uninsured? |
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Definition
- Unemployed
- Employers not required to offer health insurance
- Employers not required to buy health insurance
- Don't fit eligibility of government programs
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Term
| Four factors that affect access |
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Definition
- Ability to pay(got insurance?)
- availability of services (delivery)
- Payment(many providers don't accept Medicaid)
- Enablement barriers (e.g. transportation)
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