State Health Plans
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.
State Health Planning and Development Agencies
Public Health Administration
Management of public health organizations or agencies.
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
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.
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.
Decisions, usually developed by government policymakers, for determining present and future objectives pertaining to the health care system.
Delivery of Health Care
The concept concerned with all aspects of providing and distributing health services to a patient population.
Health Systems Agencies
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 Surveys
Statistical measures of utilization and other aspects of the provision of health care services including hospitalization and ambulatory care.
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.
Public Health Practice
The activities and endeavors of the public health services in a community on any level.
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 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.
A systematic collection of factual data pertaining to health and disease in a human population within a given geographic area.
Planning for needed health and/or welfare services and facilities.
Administrative units of government responsible for policy making and management of governmental activities.
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)
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.
Centers for Disease Control and Prevention (U.S.)
Health Care Sector
Economic sector concerned with the provision, distribution, and consumption of health care services and related products.
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)
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)
Field of medicine concerned with the determination of causes, incidence, and characteristic behavior of disease outbreaks affecting human populations. It includes the interrelationships of host, agent, and environment as related to the distribution and control of disease.
Medical Savings Accounts
Primary Health Care
Services for the diagnosis and treatment of disease and the maintenance of health.
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.
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.
Preferentially rated health-related activities or functions to be used in establishing health planning goals. This may refer specifically to PL93-641.
Health Planning Technical Assistance
Preventive Health Services
Services designed for HEALTH PROMOTION and prevention 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.
Community Health Services
Societies having institutional membership limited to hospitals and other health care institutions.
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)
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.
Notification or reporting by a physician or other health care provider of the occurrence of specified contagious diseases such as tuberculosis and HIV infections to designated public health agencies. The United States system of reporting notifiable diseases evolved from the Quarantine Act of 1878, which authorized the US Public Health Service to collect morbidity data on cholera, smallpox, and yellow fever; each state in the US has its own list of notifiable diseases and depends largely on reporting by the individual health care provider. (From Segen, Dictionary of Modern Medicine, 1992)
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.
The concept pertaining to the health status of inhabitants of the world.
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)
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 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.
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.
Schools, Public Health
Educational institutions for individuals specializing in the field of public health.
Quality Indicators, Health Care
Health Care Rationing
Planning for the equitable allocation, apportionment, or distribution of available health resources.
Health Knowledge, Attitudes, Practice
National Health Programs
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.
Patient Acceptance of Health Care
The seeking and acceptance by patients of health service.
Public Health Informatics
Insurance, Pharmaceutical Services
Federal, state, or local government organized methods of financial assistance.
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)
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.
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.
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
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
The promotion and maintenance of physical and mental health in the work environment.
Health Plan Implementation
Those actions designed to carry out recommendations pertaining to health plans or programs.
Marketing of Health Services
Application of marketing principles and techniques to maximize the use of health care resources.
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.
The status of health in rural populations.
Physician Incentive Plans
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.
The status of health in urban populations.
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)
World Health Organization
Community Health Planning
Health Care Coalitions
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)
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.
Insurance, Health, Reimbursement
Fees and Charges
Amounts charged to the patient as payer for health care services.
Health Insurance Exchanges
Rural Health Services
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
Regional Health Planning
Planning for health resources at a regional or multi-state level.
United States Health Resources and Services Administration
Health Insurance Portability and Accountability Act
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.
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.
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
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)
Community Health Centers
Catchment Area (Health)
A geographic area defined and served by a health program or institution.
Organizational Case Studies
Descriptions and evaluations of specific health care organizations.
Women's Health Services
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.
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)
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.
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 number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from PREVALENCE, which refers to all cases, new or old, in the population at a given time.