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)
Insurance, Long-Term Care
Health insurance to provide full or partial coverage for long-term home care services or for long-term nursing care provided in a residential facility such as a nursing home.
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.
The level of health of the individual, group, or population as subjectively assessed by the individual or by more objective measures.
Delivery of Health Care
The concept concerned with all aspects of providing and distributing health services to a patient population.
Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.
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.
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.
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.
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.
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.
National Health Programs
Health Benefit Plans, Employee
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.
Health Care Surveys
Statistical measures of utilization and other aspects of the provision of health care services including hospitalization and ambulatory care.
Health insurance providing benefits to cover or partly cover hospital expenses.
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.
Insurance Selection Bias
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.
A systematic collection of factual data pertaining to health and disease in a human population within a given geographic area.
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.
Services for the diagnosis and treatment of disease and the maintenance of health.
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.
Quality of Health Care
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)
Primary Health Care
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)
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)
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.
Fees and Charges
Amounts charged to the patient as payer for health care services.
Health Care Sector
Economic sector concerned with the provision, distribution, and consumption of health care services and related products.
Attitude to Health
Public attitudes toward health, disease, and the medical care system.
A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.
Child Health Services
Organized services to provide health care for children.
Costs and Cost Analysis
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.
Planning for needed health and/or welfare services and facilities.
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.
Insurance, Major Medical
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, Pharmaceutical Services
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.
Insurance, Physician Services
Payment by individuals or their family for health care services which are not covered by a third-party payer, either insurance or medical assistance.
Patient Acceptance of Health Care
The seeking and acceptance by patients of health service.
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)
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).
The concept pertaining to the health status of inhabitants of the world.
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).
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.
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.
Education that increases the awareness and favorably influences the attitudes and knowledge relating to the improvement of health on a personal or community basis.
Attitude of Health Personnel
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)
Health Status Disparities
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.
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)
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)
Public Health Administration
Management of public health organizations or agencies.
Community Health Services
Diagnostic, therapeutic and preventive health services provided for individuals in the community.
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.
The promotion and maintenance of physical and mental health in the work environment.
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)
A situation in which the level of living of an individual, family, or group is below the standard of the community. It is often related to a specific income level.
Health Care Rationing
Planning for the equitable allocation, apportionment, or distribution of available health resources.
Rural Health Services
Health services, public or private, in rural areas. The services include the promotion of health and the delivery of health care.
Mental Health Services
Organized services to provide mental health care.
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.
Outcome Assessment (Health Care)
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)
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.
The science of controlling or modifying those conditions, influences, or forces surrounding man which relate to promoting, establishing, and maintaining health.
Centers for Medicare and Medicaid Services (U.S.)
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.
The status of health in rural populations.
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.
Community Health Centers
Facilities which administer the delivery of health care services to people living in a community or neighborhood.
Prospective Payment System
Marketing of Health Services
Application of marketing principles and techniques to maximize the use of health care resources.
The status of health in urban populations.
Available manpower, facilities, revenue, equipment, and supplies to produce requisite health care and services.
Detailed financial plans for carrying out specific activities for a certain period of time. They include proposed income and expenditures.
Current Procedural Terminology
Descriptive terms and identifying codes for reporting medical services and procedures performed by PHYSICIANS. It is produced by the AMERICAN MEDICAL ASSOCIATION and used in insurance claim reporting for MEDICARE; MEDICAID; and private health insurance programs (From CPT 2002).
Physician's Practice Patterns
Preventive Health Services
Services designed for HEALTH PROMOTION and prevention of disease.
The expenses incurred by a hospital in providing care. The hospital costs attributed to a particular patient care episode include the direct costs plus an appropriate proportion of the overhead for administration, personnel, building maintenance, equipment, etc. Hospital costs are one of the factors which determine HOSPITAL CHARGES (the price the hospital sets for its services).
Health Insurance Exchanges
State-provided health insurance marketplaces established under the PATIENT PROTECTION AND AFFORDABLE CARE ACT.
Government sponsored social insurance programs.
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)
World Health Organization
Medical services for which no payment is received. Uncompensated care includes charity care and bad debts.
Interviews as Topic
Insurance designed to compensate persons who lose wages because of illness or injury; insurance providing periodic payments that partially replace lost wages, salary, or other income when the insured is unable to work because of illness, injury, or disease. Individual and group disability insurance are two types of such coverage. (From Facts on File Dictionary of Health Care Management, 1988, p207)
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.
Practice Management, Medical
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.
Urban Health Services
Health services, public or private, in urban areas. The services include the promotion of health and the delivery of health care.
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.
Comprehensive Health Care
Providing for the full range of personal health services for diagnosis, treatment, follow-up and rehabilitation of patients.
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.
Health Plan Implementation
Those actions designed to carry out recommendations pertaining to health plans or programs.
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.
Employer Health Costs
That portion of total HEALTH CARE COSTS borne by an individual's or group's employing organization.
Regional Health Planning
Planning for health resources at a regional or multi-state level.
Salaries and Fringe Benefits
The remuneration paid or benefits granted to an employee.
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.
Health Services Administration
The organization and administration of health services dedicated to the delivery of health care.
Quality Indicators, Health Care
Norms, criteria, standards, and other direct qualitative and quantitative measures used in determining the quality of health care.
Practice of a health profession by an individual, offering services on a person-to-person basis, as opposed to group or partnership practice.
Financial Management, Hospital
Economic aspects of the fields of pharmacy and pharmacology as they apply to the development and study of medical economics in rational drug therapy and the impact of pharmaceuticals on the cost of medical care. Pharmaceutical economics also includes the economic considerations of the pharmaceutical care delivery system and in drug prescribing, particularly of cost-benefit values. (From J Res Pharm Econ 1989;1(1); PharmacoEcon 1992;1(1))
Medicare Part A
The compulsory portion of Medicare that is known as the Hospital Insurance Program. All persons 65 years and older who are entitled to benefits under the Old Age, Survivors, Disability and Health Insurance Program or railroad retirement, persons under the age of 65 who have been eligible for disability for more than two years, and insured workers (and their dependents) requiring renal dialysis or kidney transplantation are automatically enrolled in Medicare Part A.
Status not subject to taxation; as the income of a philanthropic organization. Tax-exempt organizations may also qualify to receive tax-deductible donations if they are considered to be nonprofit corporations under Section 501(c)3 of the United States Internal Revenue Code.
Aid to Families with Dependent Children
Financial assistance provided by the government to indigent families with dependent children who meet certain requirements as defined by the Social Security Act, Title IV, in the U.S.
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.
Maternal Health Services
Organized services to provide health care to expectant and nursing mothers.
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.
Outcome and Process Assessment (Health Care)
An approach to health care financing with only one source of money for paying health care providers. The scope may be national (the Canadian System), state-wide, or community-based. The payer may be a governmental unit or other entity such as an insurance company. The proposed advantages include administrative simplicity for patients and providers, and resulting significant savings in overhead costs. (From Slee and Slee, Health Care Reform Terms, 1993, p106)
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.
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.
Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization.
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.
Medicare Part B
The voluntary portion of Medicare, known as the Supplementary Medical Insurance (SMI) Program, that includes physician's services, home health care, medical services, outpatient hospital services, and laboratory, pathology, and radiology services. All persons entitled to Medicare Part A may enroll in Medicare Part B on a monthly premium basis.
Process of shifting publicly controlled services and/or facilities to the private sector.
Health Facility Merger
The combining of administrative and organizational resources of two or more health care facilities.
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.
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)