U.S. Health Care Systems

The ability of persons needing health services to obtain appropriate care in a timely manner.

Can ou get medical care when yyou need it? if yes, you have access to meical care. Access is not the same as health isurance coverage, although insurance coverage is a stron predicator of access for primary care services.

Cost that are incidental to the delivery of health services.

These costs are not only associated with the billing and collection of claims for services deliverded but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, cost incurred by isurance and managed care organizations to market their products and time and effort involved in the negotiation of rates

Billin the leftover sum by the provider to the patien after insuarce has only partiallly paid the charge initially billed

A reimbursement mechanism under which the provider is paid a set monthly fee per enrolle (sometimes refered to as "per member per month [PMPM] rate, regardless of whether or not an enrollee sees the provider and regardless of how often an enrollee sees the provider.

Excessive medical test and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnessesary

(Need) driven by the prices prevailing in the free market

A person enrolled in a health plan, especially in a manged care plan

mutiple patients (buyers) and providers (sellers) act independently. (buyers can choose whatever seller they like)

Setting the total volume of expenitures in a health care system in advance

The contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to

institutional health services (predominitaly associated with acute care hospitals)

A systerm that combines the functions of health insurance and the actual delivery of care, where costs and utilisation of services are controlled by such mathods as gatekeeping, case management, and utilization review.

A joint federal-state program of health insurance for the poor

A federal program of health insurance for the elderly and some disabled persons

Consumer behavior that leads to higher utilization of healthcare servcises because people are covered by insurance

the goverment finances healthcare through general taxes, but the actual care is delivered by private providers

in addition to financing a tax-supportted NHI program, the government also manages the infastructure for the delivery of medical care (sidenote: the goverment owns must of the medical institutions

generally defined as the amount of medical care that medical experts believe a person should have to remain or become healthy. Can also be based on self-evaluation of one's own health status

Most health care services are delivered in noninstituional settings mainly associated with processes reffed to as outpatient care

Bundling of fees for and entire package of related services

• examples: anesthetist, nurse anesthetist and pathologist
• They function in an adjunct capacity and bill for their services seprately.

Employers rarely pay 100 percent of insurance permium; most require their employees to pay a portrion of the cost

Basic and routine health care that is provided in an office or clinic by a provider (physician, nurse, or other health care professional) who takes responsibility for coordinating all of a patien's health care needs. An approach to health care delivery that is the patien'ts first contact with health care delivery system and the first element of a continuing health care process.

Any individual or organization that provides services generally covered under health insurance (including Medicaid and medicare) ex physicians, hospitals, dentists, laboratories, pharmacies, and providers of durable medical equipment

the four key function necessary for health care delivery; financing, insurance, delivery, and payment

the amount insurers pay to the provider ( the payment may only be a portion of the actual charge)

A health care reform proposal ot create a single organization, ususally a govenment agency, to pay all medical claims. (the united states currently has a mutiple-payer system)

government-manddated contributions, by employers and employees, finance health care. Private providers deliver health care. Sickness funds (private not-for-profit insurance companies) are responsible for collecting the contributions and paying physicians and hospitals

• formulated by the government through health policy and regulation; providers must comply with the stardards established by the government to be certified to provide services to Medicaid, SCHIP, and Medicare beneficiaries
• Certification standars are regarded as minimum standards of quality in most sectors of the health care industry

when providers increase demand by prescribing medical care beyond what is clinically necessary. such as follow up appts, excessive medical test, and unnessary surgery

network of interrelated components designed to work together coherently

payment and insurance fuctions intoruce a third party into the transaction. ( patient is 1st, provider is 2nd)

without private or public health insurance coverage

Extent to which health care services are actually used. For example, the number of physicians visits per person per year is a measure of utilization for primary care services