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)

A component of the Department of Health and Human Services to oversee and direct the Medicare and Medicaid programs and related Federal medical care quality control staffs. Name was changed effective June 14, 2001.

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.

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.

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)

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

Processes or methods of reimbursement for services rendered or equipment.

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.

A system wherein reimbursement rates are set, for a given period of time, prior to the circumstances giving rise to actual reimbursement claims.

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.

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.

The Commission was created by the Balanced Budget Act of 1997 under Title XVIII. It is specifically charged to review the effect of Medicare+Choice under Medicare Part C and to review payment policies under Parts A and B. It is also generally charged to evaluate the effect of prospective payment policies and their impact on health care delivery in the US. The former Prospective Payment Assessment Commission (ProPAC) and the Physician Payment Review Commission (PPRC) were merged to form MEDPAC.

A supplemental health insurance policy sold by private insurance companies and designed to pay for health care costs and services that are not paid for either by Medicare alone or by a combination of Medicare and existing private health insurance benefits. (From Facts on File Dictionary of Health Care Management, 1988)

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)

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.

A listing of established professional service charges, for specified dental and medical procedures.

A method of examining and setting levels of payments.

Criteria to determine eligibility of patients for medical care programs and services.

Economic aspects related to the management and operation of a hospital.

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)

Extended care facilities which provide skilled nursing care or rehabilitation services for inpatients on a daily basis.

Exploitation through misrepresentation of the facts or concealment of the purposes of the exploiter.

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.

Pricing statements presented by more than one party for the purpose of securing a contract.

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

The design, completion, and filing of forms with the insurer.

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.

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 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.

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.

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.

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 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 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.

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.

Payment by individuals or their family for health care services which are not covered by a third-party payer, either insurance or medical assistance.

The assignment, to each of several particular cost-centers, of an equitable proportion of the costs of activities that serve all of them. Cost-center usually refers to institutional departments or services.

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)

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.

Coded listings of physician or other professional services using units that indicate the relative value of the various services they perform. They take into account time, skill, and overhead cost required for each service, but generally do not consider the relative cost-effectiveness. Appropriate conversion factors can be used to translate the abstract units of the relative value scales into dollar fees for each service based on work expended, practice costs, and training costs.

The charge levied on the consumer for drugs or therapy prescribed under written order of a physician or other health professional.

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)

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).

Detailed financial plans for carrying out specific activities for a certain period of time. They include proposed income and expenditures.

Facilities designed to serve patients who require surgical treatment exceeding the capabilities of usual physician's office yet not of such proportion as to require hospitalization.

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

Specialized health care, supportive in nature, provided to a dying person. A holistic approach is often taken, providing patients and their families with legal, financial, emotional, or spiritual counseling in addition to meeting patients' immediate physical needs. Care may be provided in the home, in the hospital, in specialized facilities (HOSPICES), or in specially designated areas of long-term care facilities. The concept also includes bereavement care for the family. (From Dictionary of Health Services Management, 2d ed)

Amounts charged to the patient as payer for medical services.

Outside services provided to an institution under a formal financial agreement.

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

Institutions with an organized medical staff which provide medical care to patients.

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).

A cancer registry mandated under the National Cancer Act of 1971 to operate and maintain a population-based cancer reporting system, reporting periodically estimates of cancer incidence and mortality in the United States. The Surveillance, Epidemiology, and End Results (SEER) Program is a continuing project of the National Cancer Institute of the National Institutes of Health. Among its goals, in addition to assembling and reporting cancer statistics, are the monitoring of annual cancer incident trends and the promoting of studies designed to identify factors amenable to cancer control interventions. (From National Cancer Institute, NIH Publication No. 91-3074, October 1990)

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

Referral by physicians to testing or treatment facilities in which they have financial interest. The practice is regulated by the Ethics in Patient Referrals Act of 1989.

The application of mathematical formulas and statistical techniques to the testing and quantifying of economic theories and the solution of economic problems.

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.

Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization.

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

The confinement of a patient in a hospital.

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

Directions written for the obtaining and use of DRUGS.

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).

Laws concerned with manufacturing, dispensing, and marketing of drugs.

Amounts charged to the patient or third-party payer for medication. It includes the pharmacist's professional fee and cost of ingredients, containers, etc.

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.

The obtaining and management of funds for hospital needs and responsibility for fiscal affairs.

Subsequent admissions of a patient to a hospital or other health care institution for treatment.

Statistical models of the production, distribution, and consumption of goods and services, as well as of financial considerations. For the application of statistics to the testing and quantifying of economic theories MODELS, ECONOMETRIC is available.

An increase in the volume of money and credit relative to available goods resulting in a substantial and continuing rise in the general price level.

Drugs that cannot be sold legally without a prescription.

Process of shifting publicly controlled services and/or facilities to the private sector.

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

Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals.

Medical and skilled nursing services provided to patients who are not in an acute phase of an illness but who require a level of care higher than that provided in a long-term care setting. (JCAHO, Lexikon, 1994)

Facilities or services which are especially devoted to providing palliative and supportive care to the patient with a terminal illness and to the patient's family.

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

A cabinet department in the Executive Branch of the United States Government concerned with administering those agencies and offices having programs pertaining to health and human services.

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.

Organizations of health care providers that agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it. Assigned means those beneficiaries for whom the professionals in the organization provide the bulk of primary care services. (www.cms.gov/OfficeofLegislation/Downloads/Accountable CareOrganization.pdf accessed 03/16/2011)

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.

A cabinet department in the Executive Branch of the United States Government concerned with overall planning, promoting, and administering programs pertaining to VETERANS. It was established March 15, 1989 as a Cabinet-level position.

The legal relation between an entity (individual, group, corporation, or-profit, secular, government) and an object. The object may be corporeal, such as equipment, or completely a creature of law, such as a patent; it may be movable, such as an animal, or immovable, such as a building.

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.

Services for the diagnosis and treatment of diseases in the aged and the maintenance of health in the elderly.

Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care.

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

A nursing specialty involved in the diagnosis and treatment of human responses of individuals and groups to actual or potential health problems with the characteristics of altered functional ability and altered life-style.

Hospitals located in a rural area.

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).

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.

An interval of care by a health care facility or provider for a specific medical problem or condition. It may be continuous or it may consist of a series of intervals marked by one or more brief separations from care, and can also identify the sequence of care (e.g., emergency, inpatient, outpatient), thus serving as one measure of health care provided.

In health care reimbursement, especially in the prospective payment system, those patients who require an unusually long hospital stay or whose stay generates unusually high costs.

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.

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

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.

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.

Activities concerned with governmental policies, functions, etc.

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.

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

Advanced technology that is costly, requires highly skilled personnel, and is unique in its particular application. Includes innovative, specialized medical/surgical procedures as well as advanced diagnostic and therapeutic equipment.

Persons admitted to health facilities which provide board and room, for the purpose of observation, care, diagnosis or treatment.

The administrative process of discharging the patient, alive or dead, from hospitals or other health facilities.

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.

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)

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

Public or private organizations that provide, either directly or through arrangements with other organizations, home health services in the patient's home. (Hospital Administration Terminology, 2d ed)

Government sponsored social insurance programs.

Drugs whose drug name is not protected by a trademark. They may be manufactured by several companies.

Differences in access to or availability of medical facilities and services.

Procedures used by chiropractors to treat neuromusculoskeletal complaints.

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.

Short-term debt obligations and assets occurring in the regular course of operational transactions.

Assistance in managing and monitoring drug therapy for patients receiving treatment for cancer or chronic conditions such as asthma and diabetes, consulting with patients and their families on the proper use of medication; conducting wellness and disease prevention programs to improve public health; overseeing medication use in a variety of settings.

Organizations representing designated geographic areas which have contracts under the PRO program to review the medical necessity, appropriateness, quality, and cost-effectiveness of care received by Medicare beneficiaries. Peer Review Improvement Act, PL 97-248, 1982.

Purchasers are provided information on the quality of health care, including patient outcomes and health status, with data on the dollar outlays going towards health. The focus is on managing the use of the health care system to reduce inappropriate care and to identify and reward the best-performing providers. (from http://www.ahrq.gov/qual/meyerrpt.htm accessed 11/25/2011)

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

The period of confinement of a patient to a hospital or other health facility.

The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival.

Customer satisfaction or dissatisfaction with a benefit or service received.

The decision process by which individuals, groups or institutions establish policies pertaining to plans, programs or procedures.

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

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 provided to individuals.

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

Prepaid health and hospital insurance plan.

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.

Individuals whose ancestral origins are in the continent of Europe.

That distinct portion of the institutional, industrial, or economic structure of a country that is controlled or owned by non-governmental, private interests.

Federal, state, or local government organized methods of financial assistance.

Hospitals providing medical care to veterans of wars.

PL97-248. Title II of the Act specifies "provisions relating to savings in health and income security programs." This includes changes in payment for services, benefits and premiums of Medicare as well as changes in provisions under Medicaid and other specific programs covered by Social Security. Title II includes various revenue measures.