Prepaid Health Plans
Contracts between an insurer and a subscriber or a group of subscribers whereby a specified set of health benefits is provided in return for a periodic premium.
Managed Care Programs
Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as HEALTH MAINTENANCE ORGANIZATIONS and PREFERRED PROVIDER ORGANIZATIONS.
Health Benefit Plans, Employee
Health Status
The level of health of the individual, group, or population as subjectively assessed by the individual or by more objective measures.
Insurance, Health
Public Health
Branch of medicine concerned with the prevention and control of disease and disability, and the promotion of physical and mental health of the population on the international, national, state, or municipal level.
State Health Plans
State plans prepared by the State Health Planning and Development Agencies which are made up from plans submitted by the Health Systems Agencies and subject to review and revision by the Statewide Health Coordinating Council.
Delivery of Health Care
The concept concerned with all aspects of providing and distributing health services to a patient population.
Health Maintenance Organizations
Organized systems for providing comprehensive prepaid health care that have five basic attributes: (1) provide care in a defined geographic area; (2) provide or ensure delivery of an agreed-upon set of basic and supplemental health maintenance and treatment services; (3) provide care to a voluntarily enrolled group of persons; (4) require their enrollees to use the services of designated providers; and (5) receive reimbursement through a predetermined, fixed, periodic prepayment made by the enrollee without regard to the degree of services provided. (From Facts on File Dictionary of Health Care Management, 1988)
Health Care Reform
Innovation and improvement of the health care system by reappraisal, amendment of services, and removal of faults and abuses in providing and distributing health services to patients. It includes a re-alignment of health services and health insurance to maximum demographic elements (the unemployed, indigent, uninsured, elderly, inner cities, rural areas) with reference to coverage, hospitalization, pricing and cost containment, insurers' and employers' costs, pre-existing medical conditions, prescribed drugs, equipment, and services.
Deductibles and Coinsurance
Cost-sharing mechanisms that provide for payment by the insured of some portion of covered expenses. Deductibles are the amounts paid by the insured under a health insurance contract before benefits become payable; coinsurance is the provision under which the insured pays part of the medical bill, usually according to a fixed percentage, when benefits become payable.
Health Care Surveys
Statistical measures of utilization and other aspects of the provision of health care services including hospitalization and ambulatory care.
Health Policy
Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.
Health Planning
Planning for needed health and/or welfare services and facilities.
Quality of Health Care
Insurance Selection Bias
Competitive Medical Plans
Alternative health care delivery mechanisms, such as PREFERRED PROVIDER ORGANIZATIONS or other health insurance services or prepaid plans (other than HEALTH MAINTENANCE ORGANIZATIONS), that meet Medicare qualifications for a risk-sharing contract. (From Facts on File Dictionary of Health Care Management, 1988)
Preferred Provider Organizations
Arrangements negotiated between a third-party payer (often a self-insured company or union trust fund) and a group of health-care providers (hospitals and physicians) who furnish services at lower than usual fees, and, in return, receive prompt payment and an expectation of an increased volume of patients.
Health Promotion
Health Surveys
A systematic collection of factual data pertaining to health and disease in a human population within a given geographic area.
Health Services Accessibility
The degree to which individuals are inhibited or facilitated in their ability to gain entry to and to receive care and services from the health care system. Factors influencing this ability include geographic, architectural, transportational, and financial considerations, among others.
Health Services Research
The integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. Health services research is usually concerned with relationships between need, demand, supply, use, and outcome of health services. The aim of the research is evaluation, particularly in terms of structure, process, output, and outcome. (From Last, Dictionary of Epidemiology, 2d ed)
Health Care Sector
Economic sector concerned with the provision, distribution, and consumption of health care services and related products.
Managed Competition
A strategy for purchasing health care in a manner which will obtain maximum value for the price for the purchasers of the health care and the recipients. The concept was developed primarily by Alain Enthoven of Stanford University and promulgated by the Jackson Hole Group. The strategy depends on sponsors for groups of the population to be insured. The sponsor, in some cases a health alliance, acts as an intermediary between the group and competing provider groups (accountable health plans). The competition is price-based among annual premiums for a defined, standardized benefit package. (From Slee and Slee, Health Care Reform Terms, 1993)
Cost Sharing
Provisions of an insurance policy that require the insured to pay some portion of covered expenses. Several forms of sharing are in use, e.g., deductibles, coinsurance, and copayments. Cost sharing does not refer to or include amounts paid in premiums for the coverage. (From Dictionary of Health Services Management, 2d ed)
United States
The term "United States" in a medical context often refers to the country where a patient or study participant resides, and is not a medical term per se, but relevant for epidemiological studies, healthcare policies, and understanding differences in disease prevalence, treatment patterns, and health outcomes across various geographic locations.
Health Expenditures
The amounts spent by individuals, groups, nations, or private or public organizations for total health care and/or its various components. These amounts may or may not be equivalent to the actual costs (HEALTH CARE COSTS) and may or may not be shared among the patient, insurers, and/or employers.
Medical Savings Accounts
Primary Health Care
Insurance Coverage
Generally refers to the amount of protection available and the kind of loss which would be paid for under an insurance contract with an insurer. (Slee & Slee, Health Care Terms, 2d ed)
Health Services
Services for the diagnosis and treatment of disease and the maintenance of health.
Insurance Carriers
Attitude to Health
Public attitudes toward health, disease, and the medical care system.
Insurance Claim Review
Review of claims by insurance companies to determine liability and amount of payment for various services. The review may also include determination of eligibility of the claimant or beneficiary or of the provider of the benefit; determination that the benefit is covered or not payable under another policy; or determination that the service was necessary and of reasonable cost and quality.
Health Services Needs and Demand
Health services required by a population or community as well as the health services that the population or community is able and willing to pay for.
Health Behavior
Behaviors expressed by individuals to protect, maintain or promote their health status. For example, proper diet, and appropriate exercise are activities perceived to influence health status. Life style is closely associated with health behavior and factors influencing life style are socioeconomic, educational, and cultural.
Insurance Benefits
Cost Control
The containment, regulation, or restraint of costs. Costs are said to be contained when the value of resources committed to an activity is not considered excessive. This determination is frequently subjective and dependent upon the specific geographic area of the activity being measured. (From Dictionary of Health Services Management, 2d ed)
Economic Competition
Delivery of Health Care, Integrated
A health care system which combines physicians, hospitals, and other medical services with a health plan to provide the complete spectrum of medical care for its customers. In a fully integrated system, the three key elements - physicians, hospital, and health plan membership - are in balance in terms of matching medical resources with the needs of purchasers and patients. (Coddington et al., Integrated Health Care: Reorganizing the Physician, Hospital and Health Plan Relationship, 1994, p7)
Quality Assurance, Health Care
Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps.
Capitation Fee
A method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount without regard to the actual number or nature of services provided to each patient.
World Health
The concept pertaining to the health status of inhabitants of the world.
Group Purchasing
A shared service which combines the purchasing power of individual organizations or facilities in order to obtain lower prices for equipment and supplies. (From Health Care Terms, 2nd ed)
Health Education
Education that increases the awareness and favorably influences the attitudes and knowledge relating to the improvement of health on a personal or community basis.
Health Personnel
Men and women working in the provision of health services, whether as individual practitioners or employees of health institutions and programs, whether or not professionally trained, and whether or not subject to public regulation. (From A Discursive Dictionary of Health Care, 1976)
Quality Indicators, Health Care
Norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.
Health Care Rationing
Planning for the equitable allocation, apportionment, or distribution of available health resources.
Health Knowledge, Attitudes, Practice
Knowledge, attitudes, and associated behaviors which pertain to health-related topics such as PATHOLOGIC PROCESSES or diseases, their prevention, and treatment. This term refers to non-health workers and health workers (HEALTH PERSONNEL).
National Health Programs
Oral Health
Mental Health Services
Organized services to provide mental health care.
Employer Health Costs
That portion of total HEALTH CARE COSTS borne by an individual's or group's employing organization.
Patient Protection and Affordable Care Act
An Act prohibiting a health plan from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary after January 1, 2014. It permits a restricted annual limit for plan years beginning prior to January 1, 2014. It provides that a health plan shall not be prevented from placing annual or lifetime per-beneficiary limits on covered benefits. The Act sets up a competitive health insurance market.
Medicaid
Federal program, created by Public Law 89-97, Title XIX, a 1965 amendment to the Social Security Act, administered by the states, that provides health care benefits to indigent and medically indigent persons.
Patient Acceptance of Health Care
The seeking and acceptance by patients of health service.
Public Health Administration
Management of public health organizations or agencies.
Insurance, Pharmaceutical Services
Oregon
I'm sorry for any confusion, but the term "Oregon" is a geographical location and not a medical concept or condition. It is a state in the Pacific Northwest region of the United States. If you have any questions related to medical topics, I would be happy to help answer those!
Preventive Health Services
Services designed for HEALTH PROMOTION and prevention of disease.
Blue Cross Blue Shield Insurance Plans
Prepaid health and hospital insurance plan.
Risk Sharing, Financial
Any system which allows payors to share some of the financial risk associated with a particular patient population with providers. Providers agree to adhere to fixed fee schedules in exchange for an increase in their payor base and a chance to benefit from cost containment measures. Common risk-sharing methods are prospective payment schedules (PROSPECTIVE PAYMENT SYSTEM), capitation (CAPITATION FEES), diagnosis-related fees (DIAGNOSIS-RELATED GROUPS), and pre-negotiated fees.
Fee-for-Service Plans
Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. In addition to physicians, other health care professionals are reimbursed via this mechanism. Fee-for-service plans contrast with salary, per capita, and prepayment systems, where the payment does not change with the number of services actually used or if none are used. (From Discursive Dictionary of Health Care, 1976)
Outcome Assessment (Health Care)
Formularies as Topic
Works about lists of drugs or collections of recipes, formulas, and prescriptions for the compounding of medicinal preparations. Formularies differ from PHARMACOPOEIAS in that they are less complete, lacking full descriptions of the drugs, their formulations, analytic composition, chemical properties, etc. In hospitals, formularies list all drugs commonly stocked in the hospital pharmacy.
Medicare Part C
The Balanced Budget Act (BBA) of 1997 establishes a Medicare+Choice program under part C of Title XVIII, Section 4001, of the Social Security Act. Under this program, an eligible individual may elect to receive Medicare benefits through enrollment in a Medicare+Choice plan. Beneficiaries may choose to use private pay options, establish medical savings accounts, use managed care plans, or join provider-sponsored plans.
Environmental Health
The science of controlling or modifying those conditions, influences, or forces surrounding man which relate to promoting, establishing, and maintaining health.
Child Health Services
Organized services to provide health care for children.
Attitude of Health Personnel
Gatekeeping
The controlling of access to health services, usually by primary care providers; often used in managed care settings to reduce utilization of expensive services and reduce referrals. (From BIOETHICS Thesaurus, 1999)
Health Status Disparities
Occupational Health
The promotion and maintenance of physical and mental health in the work environment.
Community Health Services
Health Plan Implementation
Those actions designed to carry out recommendations pertaining to health plans or programs.
Health Priorities
Preferentially rated health-related activities or functions to be used in establishing health planning goals. This may refer specifically to PL93-641.
Public Health Practice
The activities and endeavors of the public health services in a community on any level.
Marketing of Health Services
Application of marketing principles and techniques to maximize the use of health care resources.
Socioeconomic Factors
Cross-Sectional Studies
Drug Costs
The amount that a health care institution or organization pays for its drugs. It is one component of the final price that is charged to the consumer (FEES, PHARMACEUTICAL or PRESCRIPTION FEES).
Private Sector
Organizations, Nonprofit
Rural Health
The status of health in rural populations.
Physician Incentive Plans
Compensatory plans designed to motivate physicians in relation to patient referral, physician recruitment, and efficient use of the health facility.
Health Literacy
Reimbursement, Incentive
A scheme which provides reimbursement for the health services rendered, generally by an institution, and which provides added financial rewards if certain conditions are met. Such a scheme is intended to promote and reward increased efficiency and cost containment, with better care, or at least without adverse effect on the quality of the care rendered.
Urban Health
The status of health in urban populations.
World Health Organization
State Government
Community Health Planning
Planning that has the goals of improving health, improving accessibility to health services, and promoting efficiency in the provision of services and resources on a comprehensive basis for a whole community. (From Facts on File Dictionary of Health Care Management, 1988, p299)
Health Care Coalitions
Voluntary groups of people representing diverse interests in the community such as hospitals, businesses, physicians, and insurers, with the principal objective to improve health care cost effectiveness.
Health Resources
Available manpower, facilities, revenue, equipment, and supplies to produce requisite health care and services.
Group Practice, Prepaid
An organized group of three or more full-time physicians rendering services for a fixed prepayment.
Medicare
Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976)
Insurance, Health, Reimbursement
Payment by a third-party payer in a sum equal to the amount expended by a health care provider or facility for health services rendered to an insured or program beneficiary. (From Facts on File Dictionary of Health Care Management, 1988)
Management Audit
Fees and Charges
Amounts charged to the patient as payer for health care services.
Health Insurance Exchanges
State-provided health insurance marketplaces established under the PATIENT PROTECTION AND AFFORDABLE CARE ACT.
Rural Health Services
Health services, public or private, in rural areas. The services include the promotion of health and the delivery of health care.
Independent Practice Associations
A partnership, corporation, association, or other legal entity that enters into an arrangement for the provision of services with persons who are licensed to practice medicine, osteopathy, and dentistry, and with other care personnel. Under an IPA arrangement, licensed professional persons provide services through the entity in accordance with a mutually accepted compensation arrangement, while retaining their private practices. Services under the IPA are marketed through a prepaid health plan. (From Facts on File Dictionary of Health Care Management, 1988)
Decision Making, Organizational
California
I'm sorry for any confusion, but "California" is a place, specifically a state on the western coast of the United States, and not a medical term or concept. Therefore, it doesn't have a medical definition.
Regional Health Planning
Planning for health resources at a regional or multi-state level.
Cost Savings
Massachusetts
I'm sorry for any confusion, but "Massachusetts" is a geographical location and not a medical term or concept. It is a state located in the northeastern region of the United States. If you have any medical questions or terms you would like me to define, please let me know!
Health Insurance Portability and Accountability Act
Public Law 104-91 enacted in 1996, was designed to improve the efficiency and effectiveness of the healthcare system, protect health insurance coverage for workers and their families, and to protect individual personal health information.
Electronic Health Records
Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online consumer health information that is relevant to the health conditions and treatments related to a specific patient.
Health Manpower
The availability of HEALTH PERSONNEL. It includes the demand and recruitment of both professional and allied health personnel, their present and future supply and distribution, and their assignment and utilization.
National Health Insurance, United States
National Health Insurance in the United States refers to a proposed system of healthcare financing that would provide comprehensive coverage for all residents, funded through a combination of government funding and mandatory contributions, and administered by a public agency.
Washington
#### My apologies, but the term 'Washington' is not a medical concept or condition that has a defined meaning within the medical field. It refers to various concepts, primarily related to the U.S. state of Washington or the District of Columbia, where the nation's capital is located. If you have any questions about medical topics or conditions, please feel free to ask!
Models, Econometric
Pharmaceutical Services
Total pharmaceutical services provided by qualified PHARMACISTS. In addition to the preparation and distribution of medical products, they may include consultative services provided to agencies and institutions which do not have a qualified pharmacist.
Costs and Cost Analysis
Drug Utilization Review
Formal programs for assessing drug prescription against some standard. Drug utilization review may consider clinical appropriateness, cost effectiveness, and, in some cases, outcomes. Review is usually retrospective, but some analysis may be done before drugs are dispensed (as in computer systems which advise physicians when prescriptions are entered). Drug utilization review is mandated for Medicaid programs beginning in 1993.
Federal Government
Technology, High-Cost
Logistic Models
Statistical models which describe the relationship between a qualitative dependent variable (that is, one which can take only certain discrete values, such as the presence or absence of a disease) and an independent variable. A common application is in epidemiology for estimating an individual's risk (probability of a disease) as a function of a given risk factor.
Outcome and Process Assessment (Health Care)
Interviews as Topic
Ownership
Employee Retirement Income Security Act
A 1974 Federal act which preempts states' rights with regard to workers' pension benefits and employee benefits. It does not affect the benefits and rights of employees whose employer is self-insured. (From Slee & Slee, Health Care Reform Terms, 1993)
Drugs, Generic
Program Evaluation
Choice Behavior
Community Health Centers
Facilities which administer the delivery of health care services to people living in a community or neighborhood.
Questionnaires
Utilization Review
Catchment Area (Health)
A geographic area defined and served by a health program or institution.
Information Services
Organizational Case Studies
Descriptions and evaluations of specific health care organizations.
Women's Health Services
Social Responsibility
Patient Satisfaction
The degree to which the individual regards the health care service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial.
Health Care Costs
The actual costs of providing services related to the delivery of health care, including the costs of procedures, therapies, and medications. It is differentiated from HEALTH EXPENDITURES, which refers to the amount of money paid for the services, and from fees, which refers to the amount charged, regardless of cost.
Disease Management
A broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from more expensive inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. This concept includes implications of appropriate versus inappropriate therapy on the overall cost and clinical outcome of a particular disease. (From Hosp Pharm 1995 Jul;30(7):596)
Organizational Objectives
Retrospective Studies
Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons.
Provider-Sponsored Organizations
Efficiency, Organizational
Financing, Personal
Payment by individuals or their family for health care services which are not covered by a third-party payer, either insurance or medical assistance.
Poverty
Group Practice
Any group of three or more full-time physicians organized in a legally recognized entity for the provision of health care services, sharing space, equipment, personnel and records for both patient care and business management, and who have a predetermined arrangement for the distribution of income.
Social Justice
Fees, Pharmaceutical
Policy Making
Public Health Nursing
A nursing specialty concerned with promoting and protecting the health of populations, using knowledge from nursing, social, and public health sciences to develop local, regional, state, and national health policy and research. It is population-focused and community-oriented, aimed at health promotion and disease prevention through educational, diagnostic, and preventive programs.
Maternal Health Services
Organized services to provide health care to expectant and nursing mothers.
Cost-Benefit Analysis
A method of comparing the cost of a program with its expected benefits in dollars (or other currency). The benefit-to-cost ratio is a measure of total return expected per unit of money spent. This analysis generally excludes consideration of factors that are not measured ultimately in economic terms. Cost effectiveness compares alternative ways to achieve a specific set of results.
Health Occupations
Professions or other business activities directed to the cure and prevention of disease. For occupations of medical personnel who are not physicians but who are working in the fields of medical technology, physical therapy, etc., ALLIED HEALTH OCCUPATIONS is available.
Cooperative Behavior
Cohort Studies
Studies in which subsets of a defined population are identified. These groups may or may not be exposed to factors hypothesized to influence the probability of the occurrence of a particular disease or other outcome. Cohorts are defined populations which, as a whole, are followed in an attempt to determine distinguishing subgroup characteristics.
Contracts
Insurance Pools
Budgets
Minnesota
I'm sorry for any confusion, but "Minnesota" is a state located in the Midwestern United States and not a term with a medical definition. If you have any medical questions or terms you would like defined, I'd be happy to help!
Chronic Disease
Diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care. (Dictionary of Health Services Management, 2d ed)
Hospitals, Voluntary
Prevalence
Hospital-Physician Joint Ventures
A formal financial agreement made between one or more physicians and a hospital to provide ambulatory alternative services to those patients who do not require hospitalization.
Mental Disorders
Databases, Factual
Extensive collections, reputedly complete, of facts and data garnered from material of a specialized subject area and made available for analysis and application. The collection can be automated by various contemporary methods for retrieval. The concept should be differentiated from DATABASES, BIBLIOGRAPHIC which is restricted to collections of bibliographic references.
Occupational Health Services
Mass Screening
Program Development
The process of formulating, improving, and expanding educational, managerial, or service-oriented work plans (excluding computer program development).
Age Factors
Age as a constituent element or influence contributing to the production of a result. It may be applicable to the cause or the effect of a circumstance. It is used with human or animal concepts but should be differentiated from AGING, a physiological process, and TIME FACTORS which refers only to the passage of time.
Universal Coverage
Health insurance coverage for all persons in a state or country, rather than for some subset of the population. It may extend to the unemployed as well as to the employed; to aliens as well as to citizens; for pre-existing conditions as well as for current illnesses; for mental as well as for physical conditions.
Competitive Bidding
Needs Assessment
Privatization
Process of shifting publicly controlled services and/or facilities to the private sector.
Medically Uninsured
Individuals or groups with no or inadequate health insurance coverage. Those falling into this category usually comprise three primary groups: the medically indigent (MEDICAL INDIGENCY); those whose clinical condition makes them medically uninsurable; and the working uninsured.
Data Collection
Systematic gathering of data for a particular purpose from various sources, including questionnaires, interviews, observation, existing records, and electronic devices. The process is usually preliminary to statistical analysis of the data.
Health Services for the Aged
Services for the diagnosis and treatment of diseases in the aged and the maintenance of health in the elderly.
Health Facility Merger
The combining of administrative and organizational resources of two or more health care facilities.
Decision Making
Health Services Administration
Interinstitutional Relations
Public Health Informatics
National Institutes of Health (U.S.)
An operating division of the US Department of Health and Human Services. It is concerned with the overall planning, promoting, and administering of programs pertaining to health and medical research. Until 1995, it was an agency of the United States PUBLIC HEALTH SERVICE.
Ethnic Groups
Cost of Illness
The personal cost of acute or chronic disease. The cost to the patient may be an economic, social, or psychological cost or personal loss to self, family, or immediate community. The cost of illness may be reflected in absenteeism, productivity, response to treatment, peace of mind, or QUALITY OF LIFE. It differs from HEALTH CARE COSTS, meaning the societal cost of providing services related to the delivery of health care, rather than personal impact on individuals.
Ambulatory Care
Health care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may be provided at a free-standing facility.
Total Quality Management
Organizational Policy
A course or method of action selected, usually by an organization, institution, university, society, etc., from among alternatives to guide and determine present and future decisions and positions on matters of public interest or social concern. It does not include internal policy relating to organization and administration within the corporate body, for which ORGANIZATION AND ADMINISTRATION is available.