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Orientation to Healthcare
Exam 2 Spring 2011
76
Health Care
Undergraduate 1
03/01/2011
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Term
Merger
 Definition
A mutual agreement to unify two or more organizations into a single entity. The new organizations typically form a new name. Both former entities cease to exist.
Term
Deductible
 Definition
Amount the insured pays first before benefits are paid by the insurance plan.
Term
Ambulatory Payment Classification
 Definition
APC- The reimbursement based on CPT codes for outpatient services.
Term
Medicare/Medicaid
 Definition
Categorical programs that were created under the Social Security Amendments of 1965.
Term
Macro Quality Indicators
 Definition
Cost, access, population health
Term
Medicare Part A
 Definition
Covers inpatient services, short term convalescence, rehabilitation, SNF, hospice and home health, all qualify for services. The deductible must be paid for each benefit period. After 3 consecutive days a patient is eligible for SNF though they must go to SNF within 30 days of discharge.
Term
Medicare
 Definition
Covers those 65 years or older, disabled people who get SS benefits, end stage renal.
Term
Consumer Price Index
 Definition
CPI- Measures the general economic inflation.
Term
Current Procedural Terminology
 Definition
CPT- Code numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services based on a diagnosis.
Term
Diagnosis Related Groups
 Definition
DRG's- The coding system developed for acute hospital settings that is based on admitting diagnosis and other factors for which reimbursement is based upon as an effort to reduce costs.
Term
Access Disparities
 Definition
Factors such as race, income and occupation that can determine health care access.
Term
State Children's Health Insurance
 Definition
For children under 19 who aren't covered under any plan but who's families don't meet Medicaid income levels up to 200% of the federal poverty level.
Term
Gross Domestic Product
 Definition
GDP- Measures the total value of goods and services produced and consumed which are frequently compared with health care expenditures to determine overall economic status.
Term
Cost containment measures
 Definition
Health planning, price controls, peer review, competitive approaches, electronic medical records, and health care delivery.
Term
Health Maintenance Organization
 Definition
HMO: This type of insurance is where all your care is centrally coordinated by your primary care physician (gatekeeper). This plan offers low copayments and deductibles and offers tighter controls regarding health service utilization than other plans. HMO's are responsible for delivering health care services. This offers tighter utilization controls than other plans.
Term
HHRG
 Definition
Home Health Resource Groups- A fixed per diem rate for each 60 day episode of care regardless of services given for home health.
Term
Fee-For-Service
 Definition
Individual charges(prices) set by providers, the physician reimbursement process that is based on the specific services which are billed independently.
Term
Alliance
 Definition
Is an agreement between two organizations to share resources without joint ownership. They are often a testing, with little financial commitment and can be easily dissolved.
Term
Critical Health Planning
 Definition
It is a time line that identifies planned medical interventions along with expected patient outcomes for specific diagnosis or class of cases often defined by a DRG.
Term
Self-Insurance
 Definition
Large employers who's workforces are large and diversified enough can assume the risk, budget and control their claims through this type of insurance.
Term
Medicare Part C
 Definition
Mandated by the Balanced Budget Act of 1997 that allows private managed care health plans such as HMO and PPO's to provide additional coverage. Medicare pays a set amount of money each month to the
Term
State and Federal Government
 Definition
Medicaid is funded by this source.
Term
Payroll deductions
 Definition
Medicare Part A primarily funded by this source.
Term
Taxes and Premiums
 Definition
Medicare Part B primarily funded by this source.
Term
Medicare Part D
 Definition
Medicare prescription drug coverage, you must opt for this and pay the premium.
Term
Copayment
 Definition
Money paid out-of-pocket each time health services are received by insured.
Term
Price/Cost
 Definition
Patients and Physicians are desensitized by health insurance against these.
Term
Reimbursement
 Definition
Payment made by third party payers to the providers of health care services.
Term
Preferred Provider Plan
 Definition
PPO: This is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Physicians reimbursement is based on discounted fee for service (25-35%) for in-network providers and patients pay high deductibles for out-of-network providers.
Term
Reinsurance
 Definition
Private insurance used to cover self-insured companies against the risk of high losses.
Term
Resource Based Relative Value Scale
 Definition
RBRVS- Physician services are reimbursed based on the time, skill and intensity it takes to provide the service.
Term
Resource Utilization Groups
 Definition
RUG- The reimbursement for SNF based on the case mix of the facility.
Term
Micro Quality Indicators
 Definition
Small area variations, medical errors, patients satisfaction, quality of life, health incomes.
Term
Medicare Part B
 Definition
Supplemental Medical Insurance that covers physician services, outpatient services, diagnostic tests, radiology, you must opt for this and pay a premium. This par has an annual deductible.
Term
Gatekeeping
 Definition
Term for the physician who is the primary care physician who determines whether or not to refer a patient out to a specialist within an HMO.
Term
Premium
 Definition
The amount charged by insurer(shared with employee and employer) to provide coverage(usually monthly).
Term
Horizontal Integration
 Definition
The growth strategy in which a health organization expands its core product or service to achieve geographic expansion.
Term
Vertical Integration
 Definition
The growth strategy in which a health organization links to services at different stages in the provision of health care continuum to increase the comprehensiveness and continuity of care.
Term
Structure
 Definition
The health care quality that is defined by the characteristics of providers of care, of the tools and resources they have at their disposal and of the physical and organizational setting in which they work.
Term
Outcomes
 Definition
The health care quality that is defined by the effects or final results obtained from utilizing the structure and processes of health care delivery.
Term
Process
 Definition
The health care quality that is defined by the specific way in which care is provided.
Term
Beneficiary
 Definition
The insures person who is covered under a health insurance plan.
Term
Capitation
 Definition
The physician, hospital, or other health care provider is paid a contracted monthly rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided. The contractual rates are usually adjusted for age, gender, illness, and regional differences.
Term
Risk
 Definition
The possibility of substantial financial loss from some event.
Term
Utilization Review
 Definition
The process of evaluating the appropriateness of services provided.
Term
Supply Side Rationing
 Definition
The process of restricting expensive procedures by the insurance companies.
Term
Stop Loss
 Definition
The regulation that limits the total out-of-pocket costs that are paid out by the insured.
Term
Managed care
 Definition
The single most dominant force in the fundamental transformation of health care. It controls the quantity of health care and the amount of reimbursement to providers. They collect premiums and assumes all the risk.
Term
Financing
 Definition
The term for any mechanism that gives people the ability to pay for health care services.
Term
Moral Hazard
 Definition
The term for when, based on insurance coverage, consumer behavior leads to higher utilization of health care services.
Term
Demand side rationing
 Definition
The term used for when patients don't seek or utilize a treatment because without insurance people can't afford it.
Term
Benefit Period
 Definition
The timing of benefits as determined by the day the insured is hospitalized and ends when the beneficiary has not been in a hospital for 60 consecutive days. Medicare part A has unlimited benefit periods.
Term
Health Network
 Definition
They are formed by large hospitals that have acquired other health care delivery organizations. These were developed to reduce costs and provide services over a large geographic area.
Term
Underwriters
 Definition
They evaluate, select/reject, classify and rate risk insurance companies.
Term
Reasons for High Cost
 Definition
Third party payment, imperfect market, growth of technology, increase in elderly population, medical model of health care delivery, practice variations, defensive medicine, waste and abuse, and multipayer system.
Term
Group Model HMO
 Definition
This HMO model contracts with a specialty group practice, where the physicians are employed by the practice. This HMO pays an all inclusive capitation fee to the group practice.
Term
Independent Practice Association Model HMO
 Definition
This HMO model contracts with solo practitioners and group practices, the HMO pays a general capitation fee to the IPA who pays the physician.
Term
Staff Model HMO
 Definition
This HMO model has the ability to exert control and manage physician practices. Physicians are paid a salary and are employed by the HMO.
Term
Central Health Planning
 Definition
This is a characteristic of a socialized national health care system.
Term
Medicaid
 Definition
This is a means-tested program, run by each state, based on income. It provides medical coverage for those deemed by the state as "medically needy".
Term
Risk Management
 Definition
This process improvement area consists of proactive efforts to prevent adverse events related to clinical care and facilities operations and is especially focused on avoiding medical malpractice. It causes review of occurrences, identification of unusual ones and developing ways reduce the recurrences.
Term
Insurance
 Definition
This provides the individual a means of protection against risk.
Term
Rand Health Insurance Experiment
 Definition
This study found that cost sharing had a material impact on lowering the utilization without significant negative health consequences.
Term
Individual Private Health Insurance
 Definition
This type of insurance is for those who don't have a group coverage where risk is individually determined based on the persons health and often quite expensive.
Term
Cost Sharing
 Definition
This was originally created so the insured assume some risk and hopefully it would reduce misuse of insurance benefits.
Term
UCR
 Definition
Usual, customary, and reasonable- The rate of reimbursement set by the insurance companies.
Term
Noncovered medicaid expenses
 Definition
Vision, dentures, eye glasses, hearing aids, preventative services, routine physical exams.
Term
Group Insurance
 Definition
Was developed to spread the risk across a large number of enrollee's.
Term
Third-Party Payers
 Definition
What is the broad category for insurance companies, managed care organizations, BCBS, private health insurance companies, government insurance. They are seen as hiding the real price of health care.
Term
Joint Venture
 Definition
When 2 or more institutions share resources to create a new organization to pursue a common purpose, where each participant continues to conduct business independently.
Term
Bundled Pricing
 Definition
When a number of related services are covered under one price.
Term
Retrospective reimbursement
 Definition
When historical rates are used to determined reimbursement amounts.
Term
Preverse Incentives
 Definition
When hospitals increase the costs so that they can raise their profits during retrospective reimbursement periods.
Term
Defensive Medicine
 Definition
When physicians order tests or treatment which aren't medically necessary out of fear of malpractice.
Term
Prospective Reimbursement
 Definition
When we use certain pre-established criteria to determine in advance the amount of reimbursement.
Term
Employer Sponsored Plans
 Definition
Which group of beneficiaries makes up the largest group of managed care plans.
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