Glossary of
Health Care Terms
By either or more likely passively developing a pool of
insured individuals with a higher than average expenditure of health
resources. Without the subsidy of
healthy workers an older and sicker insured population will face increasing
insurance premiums and thus be less able to afford healthcare. Insurance companies may passively avoid
marketing to certain high risk industries to avoid the potential for adverse
selection.
Average Adjusted
Per Capita Cast (AAPC):
Capitation arrangement between a Managed Care Organization (MCO) and
Medicare, in which the MCO agrees to accept a fee for Medicare patients
enrolled in its plan. This fee is an estimate of what Medicare would have spent
to provide care if the enrollee was in Medicare's FFS program. The payment for
capitated patients to the MCO is based upon national norms adjusted for certain
local conditions.
Assault –(
Legal) Intentional Tort
Placing someone in reasonable apprehension of immediate
battery
Balance Billing:
Practice of a provider billing patients for all charges not covered by
an insurance plan.
Battery- Legal) Intentional Tort
Harmful or offensive contact/touching
Bundled Fees:
Lump-sum payment that covers several health care services; examples
include per diems, DRGs (see below), and APGs (ambulatory patient group).
Carve Out:
A health benefit (perhaps mental health care or dental care) that is
removed from a larger benefit package and contracted separately to a
specialized managed care organization.
Case Management:
Monitoring and coordinating the delivery of health services
for individual patients to enhance care and manage costs; often used for
patients with specific diagnoses or who require high-cost or extensive health
care services.
Case-mix Index:
Measurement of the average severity of illness or disease of a
particular patient group; often used to determine reimbursement for long-term
care facilities.
Case Rate:
Method for controlling hospital costs in which HMOs and hospitals negotiate
a fixed fee for all care associated with a specific procedure, regardless of
the length of hospital stay
Clinical
Practice Guideline:
Systematically developed statement or algorithm that helps health care
providers prescribe appropriate care for specific clinical circumstances;
improves patient care and reduces duplication of procedures and risk
management.
Closed Panel
Model:
A managed health plan that contracts with physicians on an exclusive
basis. The physicians are not allowed to contract with other health plans.
Co-insurance:
Provision in managed health care member coverage that limits the plan's
coverage to a certain percentage of the cost of services (often 80%); the
member pays the remainder. This requires the member to have some financial
responsibility, again often 20%.
The risk for insuring a set of individuals is distributed
across a geographic community with representation of many industries and
employers. Within
each group (bankers, miners, clerks) the healthy use few benefits and subsidize
those that are ill. Among the groups,
bank managers who use smaller amounts than their premiums are worth help pay
for miners that use larger amounts than their premiums can buy. Federally Qualified HMOs by law must
community rate .
Concurrent
Review:
Ongoing review of inpatient during a patient's hospital stay to confirm
the need for continued care; one process used in utilization management.
Continuous
Quality Improvement (CQI):
Business management technique that assesses and tries to improve
internal operating procedures in an ongoing fashion.
Cost-to-charge
Ratio:
Price charged for a hospital service, including markup, compared with
the hospital's true cost for the service.
Deductible:
The amount of money an insured person must pay “at the front end”
before the insurer will pay. The reason
for introducing this concept into health care coverage is primarily to
discourage unnecessary use of services, and also to reduce insurance premiums,
as all claims have a minimum amount that the insurer will be spared on every
claim.
Defamation – (legal) Intentional Tort
Defamatory statement regarding a plaintiff that is published
(communicated) to a third party causing injury to reputation
Deselection I:
The process by which a provider's participation in a managed health
plan's network is terminated.
Deselection II:
Dismissal of a provider from a managed care group; quality of care,
interpersonal issues, patient satisfaction, and cost reasons may be cited as
grounds for deselection.
Diagnosis-Related
Group (DRG):
A Medicare prospective payment for a group of patients for whom
reimbursement for inpatient services is paid in one lump sum, based on the
diagnosis (e.g., stroke, pneumonia).
Direct Contract
HMO Model:
An HMO that contracts with physicians individually rather than through
an intermediary (an independent practice association) or group practice.
Discharge
Planning:
Coordination of care to achieve optimal post-hospital care. Often viewed
as a cost-control technique that determines appropriate patient aftercare
following discharge from the hospital.
Discounted FFS:
Similar to FF5, but when the provider submits its claim in full, the MCO
subtracts a certain percentage (specified in a contract) and pays the
discounted total.
Disenrollment:
The process by which a person's membership in a managed health plan is
terminated. A member may disenroll voluntarily, perhaps to join another managed
health plan or to return to fee-for-service medicine. A health plan may decide
to disenroll a member involuntarily if premiums are not paid for a lengthy
time.
ERISA - The Employee Retirement Income Security Act. ERISA exempts self-insured health plans from
state laws governing health insurance, including contribution to risk pools,
prohibitions against disease discrimination, and other state health reforms.
Risk is born within a group of employees from one company
and those who are sick are subsidized by those that remain well. Healthy Bankers are subsidizing sick bankers. This practice allows groups with lower overall
health claims costs to have lower health insurance premiums. Experience of the group directly impacts the
premium rates.
False Imprisonment- (legal) Intentional Tort
Confining someone, act of restrain
Fee-for-service
(FFS):
Traditional health care payment system in which physicians and hospitals
receive a direct payment for their billed charge, either from a patient or an
insurance company; also called standard indemnity; see also indemnity plan.
Fraud/ Misrepresentation –(legal) Intentional Tort
A person knew facts, intend to
induce reliance, plaintiff justifiably relies on statements to plaintiff's
detriment
Gatekeeper:
Primary care physician who serves as a patient's initial contact for
medical care, coordinates the patients overall care, and makes specialty
referrals; predominant feature of most managed care particularly HMOs.
Gross domestic product (GDP) ‑ GDP is the market value of the goods and
services produced by labor and property located in the United States. As long
as the labor and property are located in the United States, the suppliers (that
is, the workers and, for property, the owners) may be either U.S. residents or
residents of the rest of the world. See related Consumer Price Index; Health expenditures, national.
Group Model HMO:
An HMO that contracts with a large physician practice to provide medical
care to its members. The group may contract exclusively with and be partly
owned by the health maintenance organization.
Health Care Financing
Administration (HCFA):
Federal agency responsible for administering Medicare and overseeing
states' administration of Medicaid.
Health
Maintenance Organization (HMO):
A managed health plan that offers or arranges for health care to be
provided to its members for a fixed, prepaid payment. The plan may share
financial risk with some or all of its providers. There are four basic HMO
models: group, independent practice association, network, and staff
Health Plan
Employer Data and Information Set (HEDIS):
A series of data elements that enable interested parties to calculate
and compare numerous performance measures for HMOs. HEDIS is collected by the
National Committee for Quality Assurance, a nonprofit organization that
accredits HMOs that meet its quality-of-care standards. Version 2.5 has about
60 performance measures for such areas as quality, access, utilization, and
finance.
Home Health
Care:
Medical care provided in a patient's home that often replaces more
costly care in other settings, such as LTC facilities or hospitals.
Horizontal
Integration
Horizontal
Integration is aimed at identifying and exploiting interrelationships across
distinct but related business units.
Examples of this are ownership of many medical practices either in the same
or different specialties in one entity.
The sharing of activities like joint billing, management know-how or
laundry are examples of the benefits provided by this strategy which may
actually have potentially competing units sharing resources...
Indemnity Plan:
Insurance plan in which the insured person or provider is reimbursed for
all or part of covered expenses after a service is provided, following
submission of an insurance claim form; insured person can usually choose
whatever provider is desired; see also FFS.
Independent
Practice Association (IPA):
An HMO that contracts with numerous small independent group and solo
practices through the intermediary (i.e., Independent Practice Association)
that represents them. Physicians maintain their individual practices and
negotiate as a group with payors. The physicians may be compensated on a
capitated or fee-for-service basis.
International
Classification of Diseases, Ninth Revision (ICD‑9) ‑ The International Classification of Diseases (ICD) classifies mortality
information for statistical purposes. The ICD was first used in 1900 and has
been revised about every 10 years since then. The ICD‑9, published in
1977, is used to code
International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD.‑9‑CM)
‑ The ICD‑9‑CM
is based on and is completely compatible with the International Classification of Diseases, Ninth Revision. The ICD‑9‑CM
is used to code morbidity
Invasion of Privacy –(legal) Intentional Tort
Publish private facts about plaintiff that reasonable person would
object to being disseminated
Long-term Care
(LTC):
Health care for patients with chronic disabilities or who suffer from
serious cognitive impairment and require assistance with the routine activities
of daily living; types include: residential, intermediate, subacute, and elder
care.
Managed
Behavioral Health Organization (MBHO):
A managed care organization that specializes in mental health care,
which may be defined to include substance abuse services. An HMO may contract
directly with a payor to provide this single benefit or may subcontract with
another MCO for the mental health component of a comprehensive health benefit
package.
Managed Care:
The systematic integration and coordination of the financing and
delivery of health care. These activities are performed by health plans that
try to provide their members with prepaid access to high quality care at
relatively low cost and usually are at least partly at risk for the cost of
care. The health plans may rely on physician gatekeepers and prior
authorization mechanisms to minimize unnecessary or inappropriate utilization.
Managed Care
Organization (MCO):
An HMO, a preferred provider organization, provider-sponsored network or
any other health plan that integrates the financing and delivery of health
care.
Managed
Indemnity Plan:
A health plan that reimburses providers on a fee-for-service basis but
relies on preadmission certification, continued-stay review, second surgical
and other utilization management techniques to minimize unnecessary spending.
Utilization management is broader than exists under a typical indemnity plan.
Management
Services Organization (MSO):
An entity that performs claims processing, enrollment, marketing and
other management services for a health plan.
Medigap:
Private health insurance purchased by individuals to supplement services
not covered by Medicare (e.g., deductibles, copayments, and outpatient
prescription drugs); also called Medicare supplement policy
Medical
Savings Accounts
A
health insurance option consisting of a high-deductible insurance policy and a
tax-advantaged savings account.
Individuals would pay for their own health care up to the annual
deductible by withdrawing from the savings account of paying out of
pocket. The insurance policy would pay
for most or all costs of covered services once the deductible is met. Under a four-year pilot project, medical
savings accounts (MSAs) will be available to employees of small businesses (50
or fewer employees), and to individuals who are self-employed. Participants
must also have coverage under a qualifying high deductible health plan. MSA
contributions are tax-deductible. Fund withdrawals to pay for qualifying
medical expenses are not taxed; however, withdrawals for any other purposes are
taxed, and the account holder must also pay a 15 percent penalty. MSA balances
carry over from year to year, and the interest earned is not taxable. Promulgated under HIPAA.
Network Model
HMO:
An HMO that contracts with several large single or multispecialty
physician groups and hospitals to provide medical care to its members.
Open Enrollment
Period:
Designated period, perhaps 1 or 2 months a year, during which a health
plan's current members may switch health plans and non-members may apply for
membership. State law may require a health plan to accept all applicants
regardless of health status and prior coverage.
Open Panel
Model:
A managed health plan that contracts with physicians who render care in
their own offices. The physicians may contract with other health plans.
Outcomes
Management:
Method to improve
results of health care (outcomes) by identifying kinds of interventions that
have produced optimal patient outcomes on a consistent basis.
Outcomes
Research:
Research on the results of a given treatment regimen as measured in
clinical, patient quality, and economic terms.
Partial Risk:
The sharing of the financial risk associated with providing specific
health services. The risk may be spread among multiple parties, such as an MCO
and its physicians and hospitals. In contrast, full risk means that one entity
is financially liable for the total cost of rendering specific services.
Per Diem:
Type of bundled fee or prospective reimbursement that pays hospitals a
set amount per patient for each day of hospitalization, regardless of
diagnosis or the number of services provided.
Per Member Per
Month (PMPM):
The basis on which capitation rates ordinarily are quoted. As far as the
provider is concerned (hospital, physician, etc.), this is the amount of money
paid by the insurance carrier on a monthly basis.
Per Member Per
Year (PMPY):
The basis on which managed health plans ordinarily express their
members' annual utilization rates, e.g., four (4) physician encounters per
member per year. A related way to express utilization is in terms of the annual
units of service provided per 1,000 members, such as 4,000 physician encounters
per 1,000
members
per year.
Physician
Hospital Organization (PHO):
An entity that integrates and coordinates the health services that a
hospital and its medical staff have packaged together to contract with HMOs,
employers, and other payors. The entity may provide medical care,
administrative services, or both types of services. It usually is sponsored by
the hospital and members of its medical staff, who ordinarily continue to maintain
their individual practices.
Point-of-service
(POS) Product:
An insurance policy that allows a person to decide at the time service
is needed whether to go out-of-plan for treatment. The option may extend to
some, most, or all of the health services covered by the insurance policy The
individual pays an additional premium or cost-sharing amount for this option.
Preferred
Provider Organization (PPO):
A managed health plan that uses its provider network to render care to
patients who have signed up with the network. The network usually is limited in
size. Providers are paid discounted fees and may be financially at risk.
Utilization review may be used to manage patient care, but the methods are not
as vigorous as in HMOs, with risk-bearing primary care physicians serving as
gatekeepers.
Premium:
Amount paid to an insurer or health care plan for providing coverage for
a specific level of services during a set time period (e.g., a month or year);
can be paid by the patient, employer, or shared by both patient and employer.
Primary Care
Network (PCN):
A panel of physicians, non-physician practitioners, and health centers
specializing in primary care services. Primary care physicians ordinarily are
defined as family practitioners, general practitioners, internists, and
pediatricians. Sometimes the definition includes obstetricians/gynecologists
for some (e.g., prenatal care) or all of their services.
Provider-sponsored
Network (PSN):
A single system or multiple affiliated providers that render a
prescribed benefit package on a prepaid basis. The PSN may contract with payors
or an MCO; it is at financial risk for the benefit package.
The Health Insurance Portability and
Accountability Act (HIPAA) helps assure continued health insurance
coverage. Starting July 1, 1997, insurers could impose only one 12-month
waiting period for any preexisting condition treated or diagnosed in the
previous six months. Prior health insurance coverage will be credited toward
the preexisting condition exclusion period as long as you have
maintained continuous coverage without a break of more than 62 days. Pregnancy
is not considered a preexisting condition, and newborns and adopted children
who are covered within 30 days are not subject to the 12-month waiting
period. If you have had group health
coverage for two years, and you switch jobs and go to another plan, that new
health plan cannot impose another preexisting condition exclusion period. If,
for example, you have had prior coverage of only eight months, you may be
subject to a four-month, preexisting condition exclusion period when you switch
jobs. If you’ve never been covered by an employer’s group plan, and you get a
job that offers such coverage, you may be subject to a 12-month, preexisting
condition waiting period. Federal law also makes it easier for you to get
individual insurance under certain situations, including if you have left a job
where you had group health insurance, or had another plan for more than 18
months without a break of more than 62 days.
Resource-Based
Relative Value Scale (RBRVS):
System developed by the federal government that has reduced Medicare
reimbursement for specialty services, while raising it for primary care.
Resource
Utilization Group (RUG):
Patient severity category that reflects the level of nursing care and
assistance with activities in daily living required for an UC facility patient;
used to calculate case-mix index and determine reimbursement.
Reverse
Capitation:
Reimbursement method that pays specialists by capitation and primary
care physicians by FFS; the reverse of traditional capitation arrangement.
Risk Pool:
An accounting fund that contains a withhold portion of providers' fees
and capitation rates. Withheld amounts are at risk and are returned to the
providers only if specific performance goals are met.
Risk Sharing:
Feature of the managed care environment requiring managed care plans and
their providers to share financial risk through mechanisms such as capitation,
risk pools, and per diem contracts.
Staff Model HMO:
An HMO that relies on employee or staff physicians to provide most of
the medical care its members need. The physicians are salaried and may receive
bonuses annually if performance goals are met.
Stop Loss:
The dollar threshold at which the provider's financial liability for
additional care is greatly reduced or eliminated. The threshold may apply to
each member individually or to all members combined. The threshold commonly is
expressed on an annual basis. Once it is reached, the provider may be liable
for only a small portion of all remaining costs.
Super-IPA or
Super PHO Model:
Several IPAs or PHOs that join forces to provide health care over a
large geographic region.
Usual,
Customary, and Reasonable Charge (UCR):
Commonly charged or prevailing fees for health services within a
geographic area.
Utilization
Management (UM):
Strategy used by health care plans to control costly medical
interventions by ensuring that physicians reserve expensive interventions for
appropriate patients; examples include UR, case management, preadmission
certification, and second opinions.
Utilization
Review:
Tool of utilization management in which health care plans review
services delivered by providers to control the use of costly medical
interventions.
Vertical
integration.
Healthcare Vertical
integration is incorporating many levels of care into one delivery system (a
Vertically Integrated Delivery System - VIDS or IDS) in order to more closely
control the flow of patients and services provided at each level. An example involves a hospital that buys both
primary care and specialist so that
primary care patients are referred to specific specialist who in turn feed tests and procedures and admissions to
the hospital. This decision to
vertically integrate is of critical importance in defining what the
organization is and is not, what critical assets and capabilities should reside
within the System, and what type of contracts the System should establish to
deal with its external constituencies, the non-owned providers, the payers, the
regulators and the patients.
Withhold:
The dollar amount that a MCO deducts from a provider's fees. The
withheld amount is set aside in a risk-sharing fund and is returned to the
provider if certain preset goals are met.
Portions adapted from:
D.B. Nash, The Managed Care Manual
P.L. Grimaldi Managed Care Primer;
Chapman R W and Lazarus G.S., Understanding Today’s
U.S. Healthcare System
Your comments are appreciated. What is unclear? Ask me!
Definitions
from Legal Lecture
Intentional Torts:
Assault - placing someone in reasonable
apprehension of immediate battery
Battery - harmful or offensive
contact/touching
False Imprisonment - confining someone, act
of restraint
Defamation - defamatory statement regarding
a plaintiff that is published (communicated) to a third party causing injury to
reputation
Invasion of Privacy - publish private facts
about plaintiff that reasonable person would object to dissemination
Fraud/ Misrepresentation - knew facts,
intend to induce reliance, plaintiff justifiably relies on statements to
plaintiff's detriment
SUPPLEMENTARY
GLOSSARY
Academic Medical Center (AMC) - A group of related
institutions including a teaching hospital or hospitals, a medical school and
its affiliated faculty practice plan, and other health professional schools.
Community
hospitals ‑
Compensation ‑ See Employer costs for employee compensation.
Competitive
Medical Plan (CMP):
A managed health
plan that qualifies for a Medicare risk contract without meeting some of the
requirements required to qualify as a
health maintenance organization. It is somewhat easier for a health plan to
qualify as a CMP than as an HMO.
Condition ‑ A health condition is a departure from
a state of physical or mental well‑being. An impairment is a health
condition that includes chronic or permanent health defects resulting from
disease, injury, or congenital malformations. All health conditions, except
impairments, are coded according to the International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD‑9‑CM).
Based on duration,
there are two categories of conditions, acute and chronic. In the National
Health Interview Survey, an acute
condition is a condition that has lasted less than 3 months and has
involved either a physician visit (medical attention) or restricted activity. A
chronic condition refers to any
condition lasting 3 months or more or is a condition classified as chronic
regardless of its time of onset (for example, diabetes, heart conditions,
emphysema, and arthritis). The National Nursing Home Survey uses a specific
list of chronic conditions, also disregarding time of onset. See related International Classification of Diseases,
Ninth Revision, Clinical Modification.
Consumer Price Index (CPI) ‑ CPI is prepared by the U.S. Bureau of Labor
Statistics. It is a monthly measure of the average change in the prices paid by
urban consumers for a fixed market basket of goods and services. The medical
care component of CPI shows trends in medical care prices based on specific
indicators of hospital, medical, dental, and drug prices. A revision of the
definition of CPI has been in use since January 1988. See related Gross domestic product; Health expenditures,
national.
Copayment – A fixed amount of money paid by a health care plan enrollee
(beneficiary) at the time of service.
The health plan pays the remainder of the charge directly to the
provider. This is a method of cost
sharing between the enrollee and the plan and serves as an incentive for the
enrollee to use health care resources.
Diagnosis ‑ See First‑listed
diagnosis.
Diagnosis-Related
Group (DRG) – A hospital
patient classification system developed at
Diagnostic and other nonsurgical procedures ‑
See Procedure.
Discharge ‑ The National Health Interview Survey
defines a hospital discharge as the completion of any continuous period of stay
of one night or more in a hospital as an inpatient. According to the National
Hospital Discharge Survey and the American Hospital Association, discharge is
the formal release of an inpatient by a hospital (excluding newborn infants),
that is, the termination of a period of hospitalization (including stays of 0
nights) by death or by disposition to a place of residence, nursing home, or
another hospital. See related Admission;
Average length of stay; Days of care; Patient.
Domiciliary care homes ‑ See Nursing
home.
Exclusive
Provider Organization (EPO):
A preferred provider organization that requires its members to receive
health care exclusively from its provider network. Members usually are liable
for out-of-plan utilization except for emergency care.
Fee-For-Service (FFS) – A method of paying the provider whatever fee he
or she charges on completion of a specific service.
General
hospitals ‑
General hospitals providing separate
psychiatric services ‑ See mental health organization.
Health Care
Provider – An individual of
institution that provides direct medical services (e.g., physician, hospital,
laboratory). This term should not be
confused with an insurance company, which “ provides” insurance.
Health
expenditures, national ‑
See related Consumer Price Index; Gross
domestic product.
Health services and supplies expenditures ‑ These are outlays for goods and services relating directly to patient
care plus expenses for administering health insurance programs and government
public health activities. This category is equivalent to total national health
expenditures minus expenditures for research and construction.
National health expenditures ‑ This measure estimates the amount
spent for all health services and supplies and health‑related research
and construction activities consumed in the United States during the calendar
year. Detailed estimates are available by source of expenditures (for example,
out‑of‑pocket payments, private health insurance, and government
programs), type of expenditures (for example, hospital care, physician
services, and drugs), and are in current dollars for the year of report. Data
are compiled from a variety of sources.
Nursing home expenditures ‑ These cover care
rendered in skilled nursing and intermediate care facilities, including those
for the mentally retarded. The costs of long‑term care provided by
hospitals are excluded.
Personal health care expenditures ‑ These are outlays for goods and
services relating directly to patient care. The expenditures in this category
are total national health expenditures minus expenditures for research and
construction, expenses for administering health insurance programs, and
government public health activities.
Private expenditures ‑'These are outlays for services provided or paid for by
nongovernmental sources‑‑consumers, insurance companies, private
industry, philanthropic, and other nonpatient care sources.
Public expenditures‑These are outlays for services provided or paid for by Federal,
State, and local government agencies or expenditures required by governmental
mandate (such as, workmen's compensation insurance payments).
Health insurance coverage ‑ National Health Interview Survey (NHIS) respondents
were asked about their health insurance coverage at the time of the interview
in 1984, 1989, and 1997 and in the previous month in 1993‑96. Questions
on health insurance coverage were expanded starting in 1993 compared with
previous years. In 1997 the entire questionnaire was redesigned and data were
collected using a computer assisted personal interview (CAPI).
Respondents
are covered by private health insurance if they indicate private health
insurance or if they are covered by a single service hospital plan, except in
1997 when no information on single service plans was obtained. Private health
insurance includes managed care such as health maintenance organizations
(HMO's).
Until 1996 persons
were defined as having Medicaid or other public assistance coverage if they
indicated that they had either Medicaid or other public assistance, or if they
reported receiving Aid to Families with Dependent Children (AFDC) or
Supplementary Security Income (SSI). After welfare reform in late 1996,
Medicaid was delinked from AFDC and SSI. In 1997 persons were considered to be
covered by Medicaid if they reported Medicaid or a State‑sponsored health
program.
Medicare or
military health plan coverage is also determined in the interview, and in 1997
other government‑sponsored program was determined.
If respondents do
not report coverage under one of the above types of plans and they have unknown
coverage on either private health insurance or Medicaid then they are
considered to have unknown coverage.
The remaining
respondents are considered uninsured. The uninsured are persons who do not have
coverage under private health insurance, Medicare, Medicaid, public assistance,
a State‑sponsored health plan, other government‑sponsored programs,
or a military health plan. Persons with only Indian Health Service coverage are
considered uninsured. Estimates of the percent of persons who are uninsured
based on the NHIS (table 128) are slightly higher than those based on the March
Current Population Survey (CPS) (table 146). The NHIS asks about coverage at
the time of the survey (or in some survey years, coverage during the previous
month), whereas the CPS asks about coverage over the previous calendar year.
This may result in higher estimates of Medicaid and other health insurance
coverage and correspondingly lower estimates of persons without health care
coverage in the CPS compared with the NHIS. In addition, the CPS estimate is
for persons of all ages whereas the NHIS estimate is for persons under age 65.
See related Fee‑for‑service health insurance; Health maintenance
organization; Managed care; Medicaid; Medicare.
Health Maintenance Organization (HMO) ‑ An HMO is a prepaid health plan
delivering comprehensive care to members through designated providers, having a
fixed monthly payment for health care services, and requiring members to be in
a plan for a specified period of time (usually 1 year). Pure HMO enrollees use
only the prepaid capitated health services of the HMO's panel of medical care
providers. Open‑ended HMO enrollees use the prepaid HMO health services
but in addition may receive medical care from providers who are not part of the
HMO's panel. There is usually a substantial deductible, copayment, or
coinsurance associated with the use of nonpanel providers. These open‑ended
products are governed by State HMO regulations. HMO model types are:
Group‑An HMO that delivers health services through
a physician group that is controlled by the HMO unit or an HMO that contracts
with one or more independent group practices to provide health services.
Individual practice association (IPA)‑An HMO that contracts directly with
physicians in independent practice, and/or contracts with one or more
associations of physicians in independent practice, and/or contracts with one
or more multispecialty group practices. The plan is predominantly organized
around solo‑single‑specialty practices.
Mixed ‑ An HMO that combines features of group and IPA. This category was
introduced in mid‑1990 because HMO's are continually changing and many
now combine features of group and IPA plans in a single plan.
See related Managed care.
Health Plan – An organization that acts as an insurer for an
enrolled population.
Health services and supplies expenditures ‑ These are outlays for goods and
services relating directly to patient care plus expenses for administering
health insurance programs and government public health activities. This
category is equivalent to total national health expenditures minus expenditures
for research and construction.
Home Health Care ‑
Home health care as defined by the National Home and Hospice Care Survey is
care provided to individuals and families in their place of residence for
promoting, maintaining, or restoring health; or for minimizing the effects of
disability and illness including terminal illness.
Home visits ‑ Starting with 1997 the National
Health Interview Survey is collecting information on home visits received
during the past 12 months. Respondents are asked: "During the past 12
months, did you receive care at home from a nurse or other health care
professional? What was the total number of home visits received?" These
data are combined with data on visits to doctor's offices, clinics, and
emergency departments to provide a summary measure of health care visits. See
related Emergency department visit; Health care contact.
Hospice care ‑ Hospice care as defined by the
National Home and Hospice Care Survey is a program of palliative and supportive
care services providing physical, psychological, social, and spiritual care for
dying persons, their families, and other loved ones. Hospice services are
available in home and inpatient settings.
Hospital ‑ According to the American Hospital
Association, hospitals are licensed institutions with at least six beds whose
primary function is to provide diagnostic and therapeutic patient services for
medical conditions by an organized physician staff, and have continuous nursing
services under the supervision of registered nurses. The World Health
Organization considers an establishment to be a hospital if it is permanently
staffed by at least one physician, can offer inpatient accommodation, and can
provide active medical and nursing care. Hospitals may be classified by type of
service, ownership, size in terms of number of beds, and length of stay. In the
National Hospital Ambulatory Medical Care Survey (NHAMCS) hospitals include all
those with an average length of stay for all patients of less than 30 days
(short‑stay) or hospitals whose specialty is general (medical or
surgical) or children's general. Federal hospitals and hospital units of institutions
and hospitals with fewer than six beds staffed for patient use are excluded.
See related Average length of stay; Bed;
Days of care; Emergency department; Outpatient department; Patient.
Community hospitals traditionally included all non‑Federal
short‑stay hospitals except facilities for the mentally retarded. In the
revised definition the following additional sites are excluded: hospital units
of institutions, and alcoholism and chemical dependency facilities.
Federal hospitals are operated by the Federal Government.
For profit hospitals are operated for profit by individuals,
partnerships, or corporations.
General hospitals provide diagnostic, treatment, and surgical
services for patients with a variety of medical conditions. According to the World
Health Organization, these hospitals provide medical and nursing care for more
than one category of medical discipline (for example, general medicine,
specialized medicine, general surgery, specialized surgery, and obstetrics).
Excluded are hospitals, usually in rural areas, that provide a more limited
range of care.
Nonprofit hospitals are operated by a church or other nonprofit
organization.
Psychiatric hospitals are ones whose major type of service is
psychiatric care. See mental health
organization.
Registered hospitals are hospitals registered with the American
Hospital Association. About 98 percent of hospitals are registered.
Short‑stay hospitals in the National Hospital Discharge Survey
are those in which the average length of stay is less than 30 days. The
National Health Interview Survey defines short‑stay hospitals as any
hospital or hospital department in which the type of service provided is
general; maternity; eye, ear, nose, and throat; children's; or osteopathic.
Specialty hospitals, such as psychiatric, tuberculosis, chronic
disease, rehabilitation, maternity, and alcoholic or narcotic, provide a
particular type of service to the majority of their patients.
Hospital‑based physician ‑ See Physician.
Hospital days ‑ See Days
of care.
ICD; ICD codes ‑ See Cause of death; International Classification
of Diseases, Ninth Revision.
Incidence ‑ Incidence is the number of cases of
disease having their onset during a prescribed period of time. It is often
expressed as a rate (for example, the incidence of measles per 1,000 children 5‑15
years of age during a specified year). Incidence is a measure of morbidity or
other events that occur within a specified period of time. See related Prevalence.
Individual
Practice Association (IPA) ‑ An HMO that contracts directly with physicians in independent practice,
and/or contracts with one or more associations of physicians in independent
practice, and/or contracts with one or more multispecialty group practices. The
plan is predominantly organized around solo‑single‑specialty
practices.
Inpatient care ‑ See Mental health service type.
Inpatient days ‑ See Days of care.
Insured ‑ See Health insurance coverage.
Intermediate
care facilities ‑ See
Nursing home.
Managed Care – Any system of health payment or delivery
arrangements where the plan attempts to control or coordinate use of health
services by its enrolled members in order to contain health expenditures,
improve quality, or both. Arrangements
often involve a defined delivery system of providers with some form of
contractual arrangement with the plan.
Medicare – The federal health benefit program for
the elderly and disabled that covers 35 million Americans or about 14 percent
of the population for an annual cost of over $120 billion.
Medigap
Insurance – Privately
purchased individual or group health insurance policies designed to supplement
Medicare coverage. Benefits may include
payment of Medicare deductibles and coinsurance and balance bills, as well as
payment for services not covered by Medicare.
Medigap insurance must conform to one of ten federally standardized
benefit packages.
Mental health organization ‑ The Center for Mental Health Services defines a
mental health Organization as an administratively distinct public or vale agency
or institution whose primary concern is the provision of direct mental health
services to the mentally ill or emotionally disturbed. Excluded are private
office‑based practices of psychiatrists, psychologists, and other mental
health providers; psychiatric services of all types of hospitals or outpatient
clinics operated by Federal agencies other than the Department of Veterans
Affairs (for example, Public Health Service, Indian Health Service, Department
of Defense, and Bureau of Prisons); general hospitals that have no separate
psychiatric services, but admit psychiatric patients to nonpsychiatric units;
and psychiatric services of schools, colleges, halfway houses, community
residential organizations, local and county jails, State prisons, and other human
service providers. The major types of mental health organizations are described
below.
Freestanding psychiatric
outpatient clinics provide only outpatient services on either a regular or emergency basis.
The medical responsibility for services is generally assumed by a psychiatrist.
General hospitals
providing separate psychiatric services are non‑Federal general hospitals that provide psychiatric
services in either a separate psychiatric inpatient, outpatient, or partial
hospitalization service with assigned staff and space.
Multiservice mental health
organizations directly provide two or more of the program elements defined under
Mental health service type and are not classifiable as a psychiatric hospital,
general hospital, or a residential treatment center for emotionally disturbed
children. (The classification of a psychiatric or general hospital or a
residential treatment center for emotionally disturbed children takes
precedence over a multiservice classification, even if two or more services are
offered.)
Partial care organizations provide a program of ambulatory mental
health services.
Private mental hospitals are operated by a sole proprietor,
partnership, limited partnership, corporation, or nonprofit organization,
primarily for the care of persons with mental disorders.
Psychiatric hospitals are hospitals primarily concerned with
providing inpatient care and treatment for the mentally ill. Psychiatric
inpatient units of Department of Veterans Affairs general hospitals and
Department of Veterans Affairs neuropsychiatric hospitals are combined into the
category Department of Veterans Affairs psychiatric hospitals because of their
similarity in size, operation, and length of stay.
Residential treatment centers
for emotionally disturbed children must meet all of the following criteria: (a)
Not licensed as a psychiatric hospital and primary purpose is to provide
individually planned mental health treatment services in conjunction with
residential care; (b) Include a clinical program that is directed by a
psychiatrist, psychologist, social worker, or psychiatric nurse with a graduate
degree; (c) Serve children and youth primarily under the age of 18; and (d)
Primary diagnosis for the majority of admissions is mental illness, classified
as other than mental retardation, developmental disability, and substance‑related
disorders, according to DSM‑IVICDA‑8 or DSM‑IIIR/ICD‑9‑CM
codes.
State and county mental
hospitals are under the auspices of a State or county government or operated
jointly by a State and county government.
See related Addition; Mental
health service type.
Mental health service type ‑ refers to the following kinds of mental health
services:
Inpatient
care is the provision of 24‑hour
mental health care in a mental health hospital setting.
Outpatient care is the provision of ambulatory mental health
services for less than 3 hours at a single visit on an individual, group, or
family basis, usually in a clinic or similar organization. Emergency care on a
walk‑in basis, as well as care provided by mobile teams who visit
patients outside these organizations are included. "Hotline" services
are excluded.
Partial care treatment is a planned program of mental health treatment
services generally provided in visits of 3 or more hours to groups of patients.
Included are treatment programs that emphasize intensive short‑term
therapy and rehabilitation; programs that focus on recreation, and/or
occupational program activities, including sheltered workshops; and education
and training programs, including special education classes, therapeutic nursery
schools, and vocational training.
Residential treatment care is
the provision of overnight
mental health care in conjunction with an intensive treatment program in a
setting other than a hospital. Facilities may offer care to emotionally
disturbed children or mentally ill adults. See related Addition; Mental health organization.
Metropolitan statistical area (MSA) ‑ MSA's are defined by the U.S. Office of Management and Budget
(OMB). The MSA standards are revised before each decennial Census. When Census
data become available, the standards are applied to define the actual MSA's. An
MSA is a county or group of contiguous counties that contains at least one city
with a population of 50,000 or more or includes a Census Bureau‑defined
urbanized area of at least 50,000 with a metropolitan population of at least
100,000. In addition to the county containing the main city or urbanized area,
an MSA may contain other counties that are metropolitan in character and are
economically and socially integrated with the central counties. In
Multiservice
mental health organizations ‑
See Mental health organization.
Network-Model
HMO – An HMO that contracts
with several different medical groups, often at a capitated rate. Groups may use different methods to pay their
physicians.
Nonpatient
revenue ‑ Nonpatient
revenues are those revenues received for which no direct patient care services
are rendered. The most widely recognized source of nonpatient revenues is philanthropy.
Philanthropic support may be direct from individuals or may be obtained through
philanthropic fund raising organizations such as the
Nonprofit
hospitals ‑
Nursing care ‑ The following definition of nursing
care applies to data collected in National Nursing Home Surveys through 1977.
Nursing care is the provision of any of the following services: application of
dressings or bandages; bowel and bladder retraining; catheterization; enema;
full bed bath; hypodermic, intramuscular, or intravenous injection; irrigation;
nasal feeding; oxygen therapy; and temperature‑pulse‑respiration or
blood pressure measurement. See related Nursing
home.
Nursing care
homes ‑ See Nursing home.
Nursing home ‑ In the Online Survey Certification
and Reporting database, a nursing home is a facility that is certified and
meets the Health Care Financing Administration's long‑term care
requirements for Medicare and Medicaid eligibility. In the National Master
Facility Inventory and the National Nursing Home Survey, a nursing home is an
establishment with three or more beds that provides nursing or personal care
services to the aged, infirm, or chronically ill. The following definitions of
nursing home types apply to data collected in National Nursing Home Surveys
through 1977.
Nursing care homes must employ one or more full‑time
registered or licensed practical nurses and must provide nursing care to at
least one‑half the residents.
Personal care homes with
nursing have some but fewer than one‑half the residents receiving nursing
care. In addition, such homes must employ one or more registered or licensed
practical nurses or must provide administration of medications and treatments
in accordance with physicians' orders, supervision of self‑administered
medications, or three or more personal services.
Personal care homes without
nursing have no residents who are receiving nursing care. These homes provide
administration of medications and treatments in accordance with physicians'
orders, supervision of self‑administered medications, or three or more
personal services.
Domiciliary care homes primarily provide supervisory care but also
provide one or two personal services.
Nursing homes are certified by the Medicare and/or Medicaid program. The
following definitions of certification levels apply to data collected in
National Nursing Home Surveys of 1973‑74, 1977, and 1985.
Skilled nursing facilities provide the most intensive nursing care
available outside of a hospital. Facilities certified by Medicare provide post
hospital care to eligible Medicare enrollees. Facilities certified by Medicaid
as skilled nursing facilities provide skilled nursing services on a daily basis
to individuals eligible for Medicaid benefits.
Intermediate care facilities are certified by the Medicaid program to
provide health‑related services on a regular basis to Medicaid eligibles
who do not require hospital or skilled nursing facility care but do require
institutional care above the level of room and board.
Not certified facilities are not certified as providers of care by
Medicare or Medicaid.
See related Nursing care;
Resident.
Nursing home
expenditures ‑ See Health expenditures, national.
Nursing home
expenditures ‑ These
cover care rendered in skilled nursing and intermediate care facilities,
including those for the mentally retarded. The costs of long‑term care
provided by hospitals are excluded.
Occupancy
rate ‑
The American Hospital Association defines hospital occupancy rate as the
average daily census divided by the average number of hospital beds during a
reporting period. Average daily census is defined by the American Hospital
Association as the average number of inpatients, excluding newborns, receiving
care each day during a reporting period. The occupancy rate for facilities
other than hospitals is calculated as the number of residents reported at the
time of the interview divided by the number of beds reported. In the Online
Survey Certification and Reporting database, occupancy is the total number of
residents on the day of certification inspection divided by the total number of
beds on the day of certification.
Office‑based
physician ‑ See Physician.
Office visit ‑ In the National Ambulatory Medical
Care Survey, an office visit is any direct personal exchange between an
ambulatory patient and a physician or members of his or her staff for the
purposes of seeking care and rendering health services. See related Outpatient visit.
Operations ‑ See Procedure.
Outpatient
department ‑ According to the National Hospital
Ambulatory Medical Care Survey (NHAMCS), an outpatient department (OPD) is a
hospital facility where nonurgent ambulatory medical care is provided. The
following are examples of the types of OPD's excluded from the NHAMCS:
ambulatory surgical centers, chemotherapy, employee health services, renal
dialysis, methadone maintenance, and radiology. See related Emergency department; Outpatient visit.
Outpatient surgery ‑ According to the American Hospital Association,
outpatient surgery is performed on patients who do not remain in the hospital
overnight and occurs in inpatient operating suites, outpatient surgery suites,
or procedure rooms within an outpatient care facility. Outpatient surgery is a
surgical operation, whether major or minor, performed in operating or procedure
rooms. A surgical operation involving more than one surgical procedure is
considered one surgical operation. See related Ambulatory surgery; Procedure.
Outpatient visit ‑ The American Hospital Association defines
outpatient visits as visits for receipt of medical, dental, or other services
by patients who are not lodged in the hospital. Each appearance by an
outpatient to each unit of the hospital is counted individually as an
outpatient visit. In the National Hospital Ambulatory Medical Care Survey an
outpatient department visit is a direct personal exchange between a patient and
a physician or other health care provider working under the physician's
supervision for the purpose of seeking care and receiving personal health
services. See related Emergency
department visit; Outpatient department.
Part A Medicare – Medical Hospital Insurance (HI) under Part
A of Title XVIII of the Social Security Act, which covers beneficiaries for
impatient hospital, home health, hospice, and limited SNF services. Beneficiaries are responsible for deductibles
and copayments.
Part B Medicare – Medicare Supplementary Medical Insurance
(SMI) under Part B of Title XVII of the Social Security Act, which covers
Medicare beneficiaries for physician services, medical supplies, and other outpatient
treatment. Beneficiaries are responsible
for monthly premiums, copayments, deductibles, and balance billing.
Partial care organization ‑ See Mental
health organization.
Partial care
treatment ‑ See Mental health service type.
Patient ‑ A patient is a person who is
formally admitted to the inpatient service of a hospital for observation, care,
diagnosis, or treatment. See related Admission;
Average length of stay; Days of care; Discharge; Hospital.
Percent change ‑ See Average annual rate of change.
Per Diem
Payments – Fixed daily
payments that do not vary with the level of services used by the patient. This method generally is used to pay
institutional providers, such as hospitals and nursing facilities.
Personal care
homes with or without nursing ‑
See Nursing home.
Personal health
care expenditures ‑
These are outlays for goods and services relating directly to patient care. The
expenditures in this category are total national health expenditures minus
expenditures for research and construction, expenses for administering health
insurance programs, and government public health activities.
Physician ‑ Physicians, through self‑reporting,
are Classified by the American Medical Association and others as licensed
doctors of medicine or osteopathy, is follows:
Active (or professionally
active) physicians are currently practicing medicine for a minimum of 20 hours per week.
Excluded are physicians who are not practicing, practicing medicine less than
20 hours per week, have unknown addresses, or specialties not classified (when
specialty information is presented).
Federal physicians are employed by the Federal Government; non‑Federal
or civilian physicians are not.
Hospital‑based
physicians spend the plurality of their time as salaried physicians in hospitals.
Office‑based physicians spend the plurality of their time working in
practices based in private offices.
Data for physicians are presented by type of education (doctors of
medicine and doctors of osteopathy); place of education (
Physician
specialty ‑ A physician specialty is any specific
branch of medicine in which a physician may concentrate. Data are based on
physician self‑reports of their primary area of specialty. Physician data
are broadly categorized into two general areas of practice: generalists and
specialists.
Generalist physicians are synonymous with primary care generalists
and only include physicians practicing in the general fields of family and
general practice, general internal medicine, and general pediatrics. They
specifically exclude primary care specialists.
Primary care specialists practice in the subspecialties of general
and family practice, internal medicine, and pediatrics. The primary care
subspecialties for family practice include geriatric medicine and sports
medicine. Primary care subspecialties for internal medicine include diabetes,
endocrinology and metabolism, hematology, hepatology, cardiac electro
physiology, infectious diseases, diagnostic laboratory immunology, geriatric
medicine, sports medicine, nephrology, nutrition, medical oncology, and
rheumatology. Primary care subspecialties for pediatrics include adolescent
medicine, critical care pediatrics, neonatal‑perinatal medicine,
pediatric allergy, pediatric cardiology, pediatric endocrinology, pediatric
pulmonology, pediatric emergency medicine, pediatric gastroenterology,
pediatric hematology/oncology, diagnostic laboratory immunology, pediatric
nephrology, pediatric rheumatology, and sports medicine.
Specialist physicians practice in the primary care specialties, in
addition to all other specialist fields not included in the generalist
definition. Specialist fields include allergy and immunology, aerospace
medicine, anesthesiology, cardiovascular diseases, child and adolescent
psychiatry, colon and rectal surgery, dermatology, diagnostic radiology,
forensic pathology, gastroenterology, general surgery, medical genetics,
neurology, nuclear medicine, neurological surgery, obstetrics and gynecology,
occupational medicine, ophthalmology, orthopedic surgery, otolaryngology,
psychiatry, public health and general preventive medicine, physical medicine
and rehabilitation, plastic surgery, anatomic and clinical pathology, pulmonary
diseases, radiation oncology, thoracic surgery, urology, addiction medicine,
critical care medicine, legal medicine, and clinical pharmacology. See related Physician.
Point-of-Service
(POS) Plan – A health plan
with a network of providers whose services are available to enrollees at a
lower cost that the services of nonnetwork providers. POS enrollees must receive authorization form
a primary care physician in order to use network services. POS plans typically do not pay for
out-of-network referrals for primary care services.
Poverty level ‑
Poverty statistics are
based on definitions originally developed by the Social Security
Administration. These include a set of money income thresholds that vary by
family size and composition. Families or individuals with income below their
appropriate thresholds are classified as below the poverty level. These
thresholds are updated annually by the U.S. Bureau of the Census to reflect
changes in the Consumer Price Index for all urban consumers (CPI‑U). For
example, the average poverty threshold for a family of four was $16,400 in 1997
and $13,359 in 1990. For more information, see U.S. Bureau of the Census: Money Income of Households, Families, and
Persons in the
Prevalence ‑
Prevalence is the number of
cases of a disease, infected persons, or persons with some other attribute
present during a particular interval of time. It is often expressed as a rate
(for example, the prevalence of diabetes per 1,000 persons during a year). See
related Incidence.
Primary
admission diagnosis ‑
In the National Home and Hospice Care Survey the primary admission diagnosis is
the first‑listed diagnosis at admission on the patient's medical record
as provided by the agency staff member most familiar with the care provided to
the patient.
Primary Care – Primary care is the provision of 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.
Primary care specialties ‑ See Physician
specialty.
Private
expenditures ‑ 'These
are outlays for services provided or paid for by nongovernmental sources‑‑consumers,
insurance companies, private industry, philanthropic, and other nonpatient care
sources.
Procedure ‑
The National Hospital
Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS)
define a procedure as a surgical or nonsurgical operation, diagnostic
procedure, or therapeutic procedure (such as respiratory therapy) recorded on
the medical record of discharged patients. A maximum of four procedures per
discharge in NHDS and up to six procedures per discharge in NSAS were recorded
and coded to the International
Classification of Diseases, Ninth Revision, Clinical Modification. Previous
editions of
Proprietary hospitals ‑
Prospective
Payment – A method of
paying health care providers in which rates are established in advance. Providers are paid these rates regardless of
the costs they actually incur.
Psychiatric
hospitals ‑
Public
expenditures ‑ These
are outlays for services provided or paid for by Federal, State, and local
government agencies or expenditures required by governmental mandate (such as,
workmen's compensation insurance payments).
Public Health – Activities that society does collectively
to ensure conditions in which people can be healthy. This includes organized community efforts to
prevent, identify, pre-empt, and counter threats to the public’s health.
Public
expenditures ‑ See Health expenditures, national.
Public health
activities ‑ Public
health activities may include any of the following essential services of public
health‑surveillance, investigations, education, community mobilization,
workforce training, research, and personal care services delivered or funded by
governmental agencies.
Race ‑ In 1977 the Office of Management
and Budget (OMB) issued Race and Ethnic Standards for Federal Statistics and
Administrative reporting in order to promote comparability of data among
Federal data systems. The 1977 standards called for the Federal Government's
data systems to classify individuals into the following four racial groups:
American Indian or Alaska Native, Asian or Pacific Islander, black, and white. Depending on the data source, the
classification by race was based on self-classification or on observation by an
interviewer or other person filling out the questionnaire.
In 1997 new
standards were announced for classification of individuals by race within the
Federal Government’s data systems (Federal Register, 62FR58781-58790). The 1997 standards have five racial groups:
American Indian or Alaska Native, Asian, Black or African American, Native
Hawaiian or other Pacific Islander, and White.
These five categories are the minimum set for data on race for Federal
statistics. The 1997 standards also
offer an opportunity for respondents to select more than one of the five
groups, leading to many possible multiple race categories. As with the single race groups, data for the
multiple race groups are to be reported when estimates meet agency requirements
for reliability and confidentiality. The 1997 standards allow for observer or
proxy identification of race but clearly state a preference for self-classification.
All Federal data
systems are required to be compliant with the 1997 standards by 2003. Although some data systems already permit
tabulation of race-specific estimates under the 1997 standards, most do not. In order to facilitate comparisons of race-specific
estimates across the various data systems presented in
Additional
information is provided in Appendix I under National Vital Statistics
System. Also see related Hispanic
origin.
Registered
hospitals ‑
Registered nursing education – Registered nursing data are shown by level of
educational preparation. Baccalaureate education requires at least 4 years of
college or university; associate degree programs are based in community
colleges and are usually 2 years in length; and diploma programs are based in
hospitals and are usually 3 years in length.
Relative Value
Scale (RVS) – An index that
assigns weights to each medical service.
The weights represent the relative amount to be paid for each
service. The RVS used in the development
of the Medicare Fee Schedule consists of three cost components: physician work,
practice expense, and malpractice expense.
Residential treatment
care ‑ See Mental health service type.
Residential
treatment centers for emotionally disturbed children ‑ See Mental health organization.
Resource-Based
Relative Value Scale (RBRVS) –
A relative value scale that is based on the resources involved in providing a
service.
Risk Selection – Enrollment
choices made by health plans or enrollees on the basis of perceived risk
relative to the premium to be paid.
Self‑assessment
of health ‑ See Health status, respondent‑assessed.
Short‑stay
hospitals ‑
Skilled nursing
facilities (SNF) – An
institution that has a transfer agreement with one or more hospitals, provides
primarily inpatient skilled nursing care and rehabilitative services, and meets
other specific certification requirements.
Solo Practice – A physician who practices alone or with
others but does not pool income or expenses.
Specialty
hospitals ‑
Staff-Model HMO – An HMO in which physicians practice solely
as employees of the HMO and usually are paid a salary. See HMO.
Supplemental
Insurance – Any private
health insurance plan held by a Medicare beneficiary, including Medigap
policies and postretirement health benefits.
Supplemental
Medical Insurance (SMI) –
The part of Medicare through which persons entitled to Part A Medicare, the
Hospital Insurance Program, may obtain assistance with payment for physician’s
services, diagnostic tests, and other outpatient services. Individuals participate voluntarily through
enrollment and the payment of a monthly fee.
Surgical
operations ‑ See Procedure.
Surgical
specialties ‑ See Physician specialty.
Tertiary Care – Care of highly technical and specialized
nature, provided in a medical center – usually one affiliated with a university
– for patients with unusually severe, complex, or unusual disorders. Tertiary care is the highest level of care.
Third-Party
Payer – An organization,
private or public, that pays for or insures at least some of the health care
expenses of its beneficiaries.
Third-party payers include commercial health insurers, Medicare, and
Medicaid.
Uninsured ‑ See Health insurance coverage.
Utilization
Review (
Sources:
Health United Sates, 2000
Health and Health Care 2010, The Forecast, The Challenge. Institute for
the Future, 2000.