U.S. Health Care Systems

  1. Access
    The ability of persons needing health services to obtain appropriate care in a timely manner.
  2. Access (Explanation)
    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.
  3. Administrative Costs
    Cost that are incidental to the delivery of health services.
  4. Administrative Cost (explanation)
    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
  5. Balance Bill
    Billin the leftover sum by the provider to the patien after insuarce has only partiallly paid the charge initially billed
  6. Capitation
    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.
  7. Defensive Medicine
    Excessive medical test and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnessesary
  8. Demand
    (Need) driven by the prices prevailing in the free market
  9. Enrollee
    A person enrolled in a health plan, especially in a manged care plan
  10. Free Market
    mutiple patients (buyers) and providers (sellers) act independently. (buyers can choose whatever seller they like)
  11. Global Budget
    Setting the total volume of expenitures in a health care system in advance
  12. Health Plan
    The contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to
  13. Inpatient Care
    institutional health services (predominitaly associated with acute care hospitals)
  14. Managed Care
    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.
  15. Medicaid
    A joint federal-state program of health insurance for the poor
  16. Medicare
    A federal program of health insurance for the elderly and some disabled persons
  17. Moral Hazard
    Consumer behavior that leads to higher utilization of healthcare servcises because people are covered by insurance
  18. National Health Insurance
    the goverment finances healthcare through general taxes, but the actual care is delivered by private providers
  19. National Health System
    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
  20. Need
    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
  21. Outpatient Care
    Most health care services are delivered in noninstituional settings mainly associated with processes reffed to as outpatient care
  22. Package Pricing
    Bundling of fees for and entire package of related services
  23. Phantom Providers
    • examples: anesthetist, nurse anesthetist and pathologist
    • They function in an adjunct capacity and bill for their services seprately.
  24. Premium Cost Sharing
    Employers rarely pay 100 percent of insurance permium; most require their employees to pay a portrion of the cost
  25. Primary Care
    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.
  26. Provider
    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
  27. Quad-function Model
    the four key function necessary for health care delivery; financing, insurance, delivery, and payment
  28. Reimbursement
    the amount insurers pay to the provider ( the payment may only be a portion of the actual charge)
  29. Single-payer System
    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)
  30. Socialized Health Insurance
    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
  31. Standards of Paricipation
    • 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
  32. Supplier-induced demand
    when providers increase demand by prescribing medical care beyond what is clinically necessary. such as follow up appts, excessive medical test, and unnessary surgery
  33. System
    network of interrelated components designed to work together coherently
  34. Third-Party
    payment and insurance fuctions intoruce a third party into the transaction. ( patient is 1st, provider is 2nd)
  35. Uninsured
    without private or public health insurance coverage
  36. Utilization
    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
Card Set
U.S. Health Care Systems
Ch 1 Vocab