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)

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)

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)

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.

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.

The effort of two or more parties to secure the business of a third party by offering, usually under fair or equitable rules of business practice, the most favorable terms.

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.

Economic sector concerned with the provision, distribution, and consumption of health care services and related products.

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)

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)

Adverse or favorable selection bias exhibited by insurers or enrollees resulting in disproportionate enrollment of certain groups of people.

Amounts charged to the patient as payer for medical services.

The combining of administrative and organizational resources of two or more health care facilities.

The geographic area of the northwestern region of the United States. The states usually included in this region are Idaho, Montana, Oregon, Washington, and Wyoming.

Health insurance plans for employees, and generally including their dependents, usually on a cost-sharing basis with the employer paying a percentage of the premium.

That portion of total HEALTH CARE COSTS borne by an individual's or group's employing organization.

The levels of excellence which characterize the health service or health care provided based on accepted standards of quality.

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 providing coverage of medical, surgical, or hospital care in general or for which there is no specific heading.

The level of health of the individual, group, or population as subjectively assessed by the individual or by more objective measures.

Care which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (JAMA 1995;273(3):192)

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)

An organized group of three or more full-time physicians rendering services for a fixed prepayment.

The concept concerned with all aspects of providing and distributing health services to a patient population.

Statistical measures of utilization and other aspects of the provision of health care services including hospitalization and ambulatory care.

Application of marketing principles and techniques to maximize the use of health care resources.

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)

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.

Insurance providing benefits for the costs of care by a physician which can be comprehensive or limited to surgical expenses or for care provided only in the hospital. It is frequently called "regular medical expense" or "surgical expense".

An organized procedure carried out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use.

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.

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.

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.

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.

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)

Compensatory plans designed to motivate physicians in relation to patient referral, physician recruitment, and efficient use of the health facility.

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.

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.

Economic aspects of the field of medicine, the medical profession, and health care. It includes the economic and financial impact of disease in general on the patient, the physician, society, or government.

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.

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.

Organizations which are not operated for a profit and may be supported by endowments or private contributions.

Payments or services provided under stated circumstances under the terms of an insurance policy. In prepayment programs, benefits are the services the programs will provide at defined locations and to the extent needed.

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.

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.

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)

Services designed for HEALTH PROMOTION and prevention of disease.

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.

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.

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).

Hospitals owned and operated by a corporation or an individual that operate on a for-profit basis, also referred to as investor-owned hospitals.

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)

The remuneration paid or benefits granted to an employee.

Research aimed at assessing the quality and effectiveness of health care as measured by the attainment of a specified end result or outcome. Measures include parameters such as improved health, lowered morbidity or mortality, and improvement of abnormal states (such as elevated blood pressure).

Amounts charged to the patient as payer for health care services.

Services for the diagnosis and treatment of disease and the maintenance of health.

Attitudes of personnel toward their patients, other professionals, toward the medical care system, etc.

Management of the internal organization of the hospital.

Absolute, comparative, or differential costs pertaining to services, institutions, resources, etc., or the analysis and study of these costs.

Encouraging consumer behaviors most likely to optimize health potentials (physical and psychosocial) through health information, preventive programs, and access to medical care.

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.

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.

Reductions in all or any portion of the costs of providing goods or services. Savings may be incurred by the provider or the consumer.

A traditional term for all the activities which a physician or other health care professional normally performs to insure the coordination of the medical services required by a patient. It also, when used in connection with managed care, covers all the activities of evaluating the patient, planning treatment, referral, and follow-up so that care is continuous and comprehensive and payment for the care is obtained. (From Slee & Slee, Health Care Terms, 2nd ed)

Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.

Patterns of practice related to diagnosis and treatment as especially influenced by cost of the service requested and provided.

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.

Excessive, under or unnecessary utilization of health services by patients or physicians.

Organized services to provide health care for children.

An occupation limited in scope to a subsection of a broader field.

The art and science of studying, performing research on, preventing, diagnosing, and treating disease, as well as the maintenance of health.

Individuals licensed to practice medicine.

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.

Processes or methods of reimbursement for services rendered or equipment.

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.

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.

The seeking and acceptance by patients of health service.

Directions written for the obtaining and use of DRUGS.

Predetermined sets of questions used to collect data - clinical data, social status, occupational group, etc. The term is often applied to a self-completed survey instrument.

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.

Norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.

Social and economic factors that characterize the individual or group within the social structure.

Procedures for finding the mathematical function which best describes the relationship between a dependent variable and one or more independent variables. In linear regression (see LINEAR MODELS) the relationship is constrained to be a straight line and LEAST-SQUARES ANALYSIS is used to determine the best fit. In logistic regression (see LOGISTIC MODELS) the dependent variable is qualitative rather than continuously variable and LIKELIHOOD FUNCTIONS are used to find the best relationship. In multiple regression, the dependent variable is considered to depend on more than a single independent variable.

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.

Customer satisfaction or dissatisfaction with a benefit or service received.

Community or individual involvement in the decision-making process.

A systematic collection of factual data pertaining to health and disease in a human population within a given geographic area.

Studies in which the presence or absence of disease or other health-related variables are determined in each member of the study population or in a representative sample at one particular time. This contrasts with LONGITUDINAL STUDIES which are followed over a period of time.

The state wherein the person is well adjusted.

Organized periodic procedures performed on large groups of people for the purpose of detecting disease.

Public attitudes toward health, disease, and the medical care system.

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.

Recording of pertinent information concerning patient's illness or illnesses.

The state of the organism when it functions optimally without evidence of disease.

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.

A heterogeneous group of disorders characterized by HYPERGLYCEMIA and GLUCOSE INTOLERANCE.

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.

The confinement of a patient in a hospital.

A specialized agency of the United Nations designed as a coordinating authority on international health work; its aim is to promote the attainment of the highest possible level of health by all peoples.

Statistical interpretation and description of a population with reference to distribution, composition, or structure.

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.

Personal satisfaction relative to the work situation.

Insurance providing for payment of services rendered by the pharmacist. Services include the preparation and distribution of medical products.

Planning for needed health and/or welfare services and facilities.

Those physicians who have completed the education requirements specified by the American Academy of Family Physicians.

A set of techniques used when variation in several variables has to be studied simultaneously. In statistics, multivariate analysis is interpreted as any analytic method that allows simultaneous study of two or more dependent variables.

The ratio of two odds. The exposure-odds ratio for case control data is the ratio of the odds in favor of exposure among cases to the odds in favor of exposure among noncases. The disease-odds ratio for a cohort or cross section is the ratio of the odds in favor of disease among the exposed to the odds in favor of disease among the unexposed. The prevalence-odds ratio refers to an odds ratio derived cross-sectionally from studies of prevalent cases.

The use of severity-of-illness measures, such as age, to estimate the risk (measurable or predictable chance of loss, injury or death) to which a patient is subject before receiving some health care intervention. This adjustment allows comparison of performance and quality across organizations, practitioners, and communities. (from JCAHO, Lexikon, 1994)

Studies in which a number of subjects are selected from all subjects in a defined population. Conclusions based on sample results may be attributed only to the population sampled.

Elements of limited time intervals, contributing to particular results or situations.

The total number of cases of a given disease in a specified population at a designated time. It is differentiated from INCIDENCE, which refers to the number of new cases in the population at a given time.

The concept pertaining to the health status of inhabitants of the world.

Maleness or femaleness as a constituent element or influence contributing to the production of a result. It may be applicable to the cause or effect of a circumstance. It is used with human or animal concepts but should be differentiated from SEX CHARACTERISTICS, anatomical or physiological manifestations of sex, and from SEX DISTRIBUTION, the number of males and females in given circumstances.

Studies designed to assess the efficacy of programs. They may include the evaluation of cost-effectiveness, the extent to which objectives are met, or impact.

The teaching or training of patients concerning their own health needs.

Voluntary cooperation of the patient in following a prescribed regimen.

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).

Conversations with an individual or individuals held in order to obtain information about their background and other personal biographical data, their attitudes and opinions, etc. It includes school admission or job interviews.

Radiographic examination of the breast.

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)

Observation of a population for a sufficient number of persons over a sufficient number of years to generate incidence or mortality rates subsequent to the selection of the study group.

An aspect of personal behavior or lifestyle, environmental exposure, or inborn or inherited characteristic, which, on the basis of epidemiologic evidence, is known to be associated with a health-related condition considered important to prevent.

Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient.

The utilization of drugs as reported in individual hospital studies, FDA studies, marketing, or consumption, etc. This includes drug stockpiling, and patient drug profiles.

Education that increases the awareness and favorably influences the attitudes and knowledge relating to the improvement of health on a personal or community basis.

An infant during the first month after birth.

Performance of activities or tasks traditionally performed by professional health care providers. The concept includes care of oneself or one's family and friends.

Conformity in fulfilling or following official, recognized, or institutional requirements, guidelines, recommendations, protocols, pathways, or other standards.

Directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery.

A range of values for a variable of interest, e.g., a rate, constructed so that this range has a specified probability of including the true value of the variable.

The optimal state of the mouth and normal functioning of the organs of the mouth without evidence of disease.

A group of people with a common cultural heritage that sets them apart from others in a variety of social relationships.

Evaluation undertaken to assess the results or consequences of management and procedures used in combating disease in order to determine the efficacy, effectiveness, safety, and practicability of these interventions in individual cases or series.

Studies determining the effectiveness or value of processes, personnel, and equipment, or the material on conducting such studies. For drugs and devices, CLINICAL TRIALS AS TOPIC; DRUG EVALUATION; and DRUG EVALUATION, PRECLINICAL are available.

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)

Management of public health organizations or agencies.

Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record.

Studies in which variables relating to an individual or group of individuals are assessed over a period of time.

Revenues or receipts accruing from business enterprise, labor, or invested capital.

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.

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)

The probability that an event will occur. It encompasses a variety of measures of the probability of a generally unfavorable outcome.

The promotion and maintenance of physical and mental health in the work environment.

The science of controlling or modifying those conditions, influences, or forces surrounding man which relate to promoting, establishing, and maintaining health.

Variation in rates of disease occurrence and disabilities between population groups defined by socioeconomic characteristics such as age, ethnicity, economic resources, or gender and populations identified geographically or similar measures.

The status during which female mammals carry their developing young (EMBRYOS or FETUSES) in utero before birth, beginning from FERTILIZATION to BIRTH.

A medical specialty concerned with the provision of continuing, comprehensive primary health care for the entire family.

Inhaling and exhaling the smoke of burning TOBACCO.

Studies in which individuals or populations are followed to assess the outcome of exposures, procedures, or effects of a characteristic, e.g., occurrence of disease.

Components of a national health care system which administer specific services, e.g., national health insurance.

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)

Studies which start with the identification of persons with a disease of interest and a control (comparison, referent) group without the disease. The relationship of an attribute to the disease is examined by comparing diseased and non-diseased persons with regard to the frequency or levels of the attribute in each group.

Planning for the equitable allocation, apportionment, or distribution of available health resources.

Preferentially rated health-related activities or functions to be used in establishing health planning goals. This may refer specifically to PL93-641.

The activities and endeavors of the public health services in a community on any level.

Organized services to provide mental health care.

A distribution in which a variable is distributed like the sum of the squares of any given independent random variable, each of which has a normal distribution with mean of zero and variance of one. The chi-square test is a statistical test based on comparison of a test statistic to a chi-square distribution. The oldest of these tests are used to detect whether two or more population distributions differ from one another.

Diagnostic, therapeutic and preventive health services provided for individuals in the community.

Tumors or cancer of the human BREAST.

A form of bronchial disorder with three distinct components: airway hyper-responsiveness (RESPIRATORY HYPERSENSITIVITY), airway INFLAMMATION, and intermittent AIRWAY OBSTRUCTION. It is characterized by spasmodic contraction of airway smooth muscle, WHEEZING, and dyspnea (DYSPNEA, PAROXYSMAL).