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220 Cards in this Set

  • Front
  • Back
A reimbursement mechanism under which the provider is paid a set monthly fee per enrollee (sometimes referred to as per member per month or PMPM rate) regardless of whether or not an enrollee sees the provider and regardless of how often an enrollee sees the provider
Capitation

A variety of individualized, well‐coordinated services that are designed to promote the maximum possible independence for people with functional limitations. These
services are provided over an extended period to meet the patients' physical,
mental, social, and spiritual needs, while maximizing quality of life
Long-term care

A system of health care delivery that (1) seeks to achieve efficiencies by integrating the four functions of health care delivery, (2) employs mechanisms to control
(manage) utilization of medical services, and (3) determines how much the
providers get paid.
Managed care

A distributional principle according to which health care is most equitably
distributed through the market forces of supply and demand rather than
government interventions. See social justice.
Market justice

a joint federal-state program of helath insurance for the poor
Medicaid

a federal program of health insuracne for the elderly, certain disabled individuals and people with end-stage renal disease
Medicare

This state of wanting health services (in contrast to demand for health services) is
based on individual judgment of the patient or a health care professional
Need

bundling of fees for an entire package of related services
Package pricing

Artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes.
Provider‐induced demand

A wide variety of activities undertaken by state and local governments to ensure
conditions that promote optimum health for society as a whole
Public Health

a system whose mission is to improve and protect community health
Public health system

Those with health needs but with inadequate resources to address those needs
Special populations

An insurance program financed by the U.S. Department of defense to permit
beneficiaries to receive care from both private and military medical care facilities

Veterans Integrated Service Network-Components of the Veterans Administration system. There are 21 geographically distributed networks that are responsible for coordinating the activities of the hospitals and other facilities located within its jurisdiction.
TriCare

Short‐term, intense medical care for an illness or injury usually requiring
hospitalization. See subacute care
Acute condition

Individual lifestyles that include diet, exercise, a stress‐free lifestyle, risky or
unhealthy behaviors, and other individual choices that may contribute to significant
health problems
Behavioral factors

Political and economic system that relies primarily on market forces in the
production and distribution of goods and private ownership, as opposed to socialism
where collective or governmental forces prevail
Capitalism

Barriers to obtaining health care faced by individuals who do not have sufficient income to pay for services or purchase health insurance.
Demand‐side rationing

Condition determined by a medical professional's evaluation, unlike an illness,
which is based on the patient's assessment. See illness.
Disease

Factors that encompass the physical, socioeconomic, sociopolitical, and sociocultural dimensions of life.
Environmental factors

The provision of medical care or illness care.
Health care delivery

Organizations, personnel, and activities associated with promoting, restoring, and
maintaining health.
Health care system

A key determinant of health that predisposes individuals to certain diseases.
Heredity

A philosophy of health care that emphasizes the well‐being of every aspect of a person, including the physical, mental, social, and spiritual aspects of health.
Holistic medicine

A distribution principle according to which health care is most equitably distributed
by a government‐run national health care program. See market justice.
Social justice

Political and economic system that advocates collective or governmental ownership
and administration of the means of production and distribution of goods, as opposed
to capitalism where private and market forces dominate.
Socialism

Technically complex services that are beyond traditional skilled nursing care.
Subacute condition

Also called planned rationing; rationing that is generally carried out by a
government to limit the availability of health care services, particularly expensive
technology.
Supply‐side rationing

Factors that contribute to the general well‐being of individuals and populations.
Health determinants


Also a poorhouse, was an unspecialized institution existing during the 18th and mid‐19th centuries that mainly served general welfare functions, essentially providing
shelter to the homeless, the insane, the elderly, orphans, and the sick who had no
family to care for them.
Almshouse

Forerunner of today's inpatient psychiatric facilities. Built by state governments for
patients with untreatable, chronic medical illness.
Asylum

A recent period in the evolution of the U.S. medical delivery system that is
characterized by the domination of corporations rather than individuals in decision
making regarding care delivery and payment.
Corporate era

Health care information and services offered over the Internet by professionals and
nonprofessionals alike.
E‐health

Various forms of cross‐border economic activities driven by global exchange of
information, production of goods and services more economically in developing
countries, and increased interdependence of mature and emerging world
economies.
Globalization

A state of physical, mental, and social well‐being (WHO 1948).
Health

Systematic changes in how medical care is financed or delivered.
Health care reform

Concerted activities of physicians, mainly to protect their own interests, through such associations as the American Medical Association (AMA).
Organized medicine

A part of Medicare which mainly covers hospital care and limited nursing home care.
Medicare Part A

A part of Medicare in which government‐subsidized voluntary insurance covers
physician services and outpatient services.
Medicare Part B

An institution that existed in preindustrial America to quarantine people with
contagious diseases such as cholera, smallpox, or typhoid.
Pesthouse

Phase of the medical delivery system that began in the late 19th century. The
medical profession grew as a result of urbanization, new scientific discoveries, and
reforms in medical education.
Postindustrial era

Phase of the medical delivery system from the middle part of the 18th century until the latter part of the 19th century. Health care was not grounded in science and
was delivered in a free market.
Preindustrial era

Any large‐scale government‐sponsored expansion of health insurance or intrusion in the private practice of medicine.
Socialized medicine

Use of telecommunications technology that enables physicians to conduct two‐way, interactive video consultations or transmit digital images, such as X‐rays and MRIs,
to other sites.
Telemedicine

The Medicaid program. More precisely known as Title XIX (19) of the Social Security
Amendment of 1965.
Title 19

Private health insurance (in contrast to government‐sponsored compulsory health insurance).
Voluntary health insurance

In this text, the ways in which health care delivery in the United States has become the domain of large organizations.
Corporatization

A clinic during the Preindustrial period that provided charity care in urban areas.
Dispensary

A general name for nurses who have education and clinical experience beyond that
required of a registered nurse (RN). APNs include four areas of specialization in
nursing- clinical nurse specialists (CNSs), certified registered nurse anesthetists
(CRNAs), nurse practitioners (NPs), and certified nurse midwives (CNMs).
Advanced‐practice nurse

A professional who is educated and trained in a specialized field of health care and
has responsibility for the delivery of services associated with medical care.
Allied health professional

A philosophy of medicine that views medical treatment as active intervention to
counteract the effects of disease through medical and surgical procedures that
produce effects opposite those of the disease. See osteopathic medicine.
Allopathic medicine

A physician in family practice, general internal medicine, or general pediatrics. See
specialist.
Generalist

A physician who specializes in the care of hospitalized patients.
Hospitalist

Clinical professionals, such as nurse practitioners and physician assistants, who practice in many areas similar to those in which physicians practice but who do not have an MD or a DO degree.
Nonphysician practitioners

A medical philosophy based on the holistic approach to treatment that also
emphasizes correction of the position of the joints or tissues and diet and
environment as factors that might destroy natural resistance. See allopathic
medicine.
Osteopathic medicine



A mode of pharmacy practice in which the pharmacist not only dispenses drugs but
also informs patients on the proper use of drugs and their potential misuse. When
asked, the pharmacist also assists prescribers in appropriate drug choices.
Pharmaceutical care

Graduate medical education in a specialty that takes the form of paid on‐the‐job
training, usually in a hospital.
Residency

A physician who specializes in specific health care problems, for example,
anesthesiologists, cardiologists, and oncologists. See generalist.
Specialist

Designed to assist in carrying out financial and administrative support activities such
as payroll, patient accounting, materials management, and office automation.
Administrative information systems

Biological products that include a wide range of products such as vaccines, blood
and blood components, allergenics, somatic cells, gene therapy, tissues, and
recombinant therapeutic proteins.
Biologics

A product that is highly similar to, or is interchangeable with, a biologic that has
already been approved by the FDA.
Biosimilar

Interactive software systems designed to help clinicians with decision‐making tasks,
such as determining a diagnosis or recommending a treatment for a patient.
Clinical decision support systems

Systems that involve the organized processing, storage, and retrieval of information
to support patient care processes.
Clinical information systems

A research study, generally based on random assignments, designed to study the
effectiveness of a new drug, device, or treatment.
Clinical trial

Evaluation of overall usefulness of medical technology, including evaluation of the
safety and efficacy of a technology in relation to its cost. See cost‐efficiency.
Cost‐effectiveness

Computer‐based information and analytical tools to support managerial decision
making in health care organizations.

Decision support systems

The health benefit to be derived from the use of technology or how effective a
given technology is in diagnosing or treating a condition.
Efficacy

Any type of professional therapeutic interaction that makes use of the Internet to
connect qualified mental health professionals and their clients.
E‐therapy

The application of information science to improve the efficiency, accuracy, and
reliability of health care services. It requires the use of information technology (IT)
but goes beyond IT by emphasizing the improvement of health care delivery.
Health informatics

Any process of examining and reporting properties of a medical technology used in
health care, such as safety, effectiveness, feasibility, and indications for use, and
cost‐effectiveness.
Health technology assessment

Technology used for the transformation of data into useful information. IT involves
determining data needs, gathering appropriate data, storing and analyzing the data,
and reporting the information generated in a user‐friendly format.
Information technology

The ability to share and access patient information by various users.
Interoperability

Specific criteria in quality, safety, efficiency, etc. that providers are required to
meet to comply with the Health Information Technology for Economic and Clinical
Health Act of 2009.
Meaningful use

Practical application of the scientific body of knowledge for the purpose of
improving health and creating efficiencies in the delivery of health care.
Medical technology

A developing area of medicine in which materials are manipulated on the atomic
and molecular level (one nanometer is one‐billionth of a meter).
Nanomedicine

Certain new drug therapies for conditions that affect fewer than 200,000 people in
the United States.
Orphan drugs

Protection against unnecessary harm from the use of technology.
Safety

Use of technology without cost considerations, especially when the benefits to be
derived from the use of technology are small compared to the costs.
Technological imperative

Any process of examining and reporting properties of a medical technology used in
health care, such as safety, effectiveness, feasibility, and indications for use, and
cost‐effectiveness.
Technology assessment

The proliferation of technology once it is developed.
Technology diffusion

Greater benefits or higher quality at the same or lower price levels (costs).
Value

Online consultations between physicians and patients.
Virtual visits

Billing of the leftover sum by the provider to the patient after insurance has
partially paid the charge initially billed.
Balance bill

Anyone covered under a particular health insurance plan.
Beneficiary

Under Medicare rules, benefits for an inpatient stay are based on this, which is
determined by a spell of illness beginning with hospitalization and ending when the
beneficiary has not been an inpatient in a hospital or a skilled nursing facility for 60
consecutive days.
Benefit period

Payment scheme in which a number of related services are included in one price.
Bundled payments

An aggregate of the severity of conditions requiring medical intervention. Case‐mix
categories are mutually exclusive and differentiate patients according to the extent
of resource use.
Case mix

Public health care programs designed to benefit only a certain category of people.
Categorical programs

Cost sharing in the form of a percent amount. A plan with an 80-20, for example,
pays 80% of all covered medical expenses after the deductible requirement has been
met until the maximum out‐of‐pocket liability in a given year has been met.
Coinsurance

A measure of inflation in the general economy.
Consumer price index

A high‐deductible health plan that carries a savings option to pay for routine health
care expenses.
Consumer‐driven health plan

A portion of health care charges that the insured has to pay under the terms of his
or her health insurance policy. See deductible.
Copayment (coinsurance)

Sharing in the cost of health insurance premiums by those enrolled and/or payment
of certain medical costs out of pocket, such as copayments and deductibles.
Cost sharing

The portion of health care costs that the insured must first pay (generally up to an
annual limit) before insurance payments kick in. Insurance payments may be further
subject to copayment.
Deductible

The contractual arrangement between the MCO and the enrollee, including the
collective array of covered health services that the enrollee is entitled to.
Health plan

The individual who is covered for risk by insurance.
Insured

A program in which eligibility depends on income.
Means‐tested program

Commercial health insurance policies purchased by individuals covered by Medicare
to insure the expenses not covered by Medicare.
Medigap

An enrollee in a private health insurance plan.
Member

Consumer behavior that leads to a higher utilization of health care services because
people are covered by insurance.
Moral hazard

A type of reimbursement that pays a flat rate for each day of inpatient stay.
Per diem


The insurer's charge for insurance coverage; the price for an insurance plan.
Premium


A method of payment in which certain preestablished criteria are used to determine
in advance the amount of reimbursement.
Prospective reimbursement

The amount insurers pay to a provider. The payment may only be a portion of the
actual charge.
Reimbursement

Stop‐loss coverage that self‐insured employers purchase to protect themselves
against any potential risk of high losses.
Reinsurance

Reimbursement rates based on costs actually incurred.
Retrospective reimbursement


The possibility of a substantial financial loss from an event of which the probability
of occurrence is relatively small.
Risk

Health insurance provided by large employers who can afford to assume the risk by
budgeting funds to pay medical claims incurred by their employees.
Self‐insurance

An insurance provision in which an insured has a maximum out‐of‐pocket liability in
a given year.
Stop‐loss

In a multipayer system, the payers for covered services, for example, insurance
companies, managed care organizations, and the government. They are called third
parties because they are neither the providers nor the recipients of medical
services.
Third‐party payers

A systematic technique used by an insurer for evaluating, selecting (or rejecting),
classifying, and rating risks.
Underwriting

A community‐based, long‐term care service that provides a wide range of health,
social, and recreational services to elderly adults who require supervision and care
while members of the family or other informal caregivers are away at work.
Adult day care

Also called alternative and complementary medicine. Nontraditional remedies, for
example, acupuncture, homeopathy, naturopathy, biofeedback, yoga exercises,
chiropractic, and herbal therapy.
Alternative medicine

Related to walking, typically used as the opposite of inpatient.
Ambulatory

Also referred to as outpatient services. This includes (1) care rendered to patients
who come to physicians' offices, outpatient departments of hospitals, and health
centers (2) outpatient services intended to serve the surrounding community
(community medicine); and (3) certain services that are transported to the patient.
Ambulatory care

Incorporates the elements of good primary care delivery and adds to this a
population‐based approach to identifying and addressing community health
problems.
Community‐oriented primary care

Care that embodies the concepts of comprehensive, coordinated, and continuous
services that provide a seamless process of care.
Integrated care

Primary care delivery based on a partnership between the patient and the provider
with a focus on chronic care.
Medical home

In contrast to inpatient, see Ambulatory.
Outpatient

Pain and symptom management; it is a primary area of emphasis in hospice care.
Palliative care

A type of proprietary, community‐based, freestanding medical facility found across
the country in retail establishments such as Walmart, Walgreens, and CVS
pharmacies.
Retail clinic

Routine hospitalization, routine surgery, and specialized outpatient care, such as
consultation with specialists and rehabilitation.
Secondary care

A freestanding, ambulatory surgery center that performs various types of surgical
procedures on an outpatient basis.
Surgicenter

The most complex level of care. Typically, it is institution based, highly specialized,
and highly technological. Examples include burn treatment, transplantation, and
coronary artery bypass surgery.

Tertiary care

A walk‐in clinic generally open to see patients after normal business hours in the
evenings and weekends without having to make an appointment.
Urgent care center

A freestanding, ambulatory clinic in which patients are seen without appointments
on a first‐come, first‐served basis.
Walk‐in clinic

As opposed to inpatient services, these include any health care services that are not
provided based on an overnight stay in which room and board costs are incurred.
See ambulatory care.
Outpatient services

An organization in which there is active collaboration among a university, medical
school, hospital/health system, and health care professionals.
Academic medical center

A patient's wishes regarding continuation or withdrawal of treatment when the
patient lacks decision‐making capacity.
Advance directives

Average number of hospital beds occupied daily over a given period of time. This
measure provides an estimate of the number of inpatients receiving care each day
at a hospital.
Average daily census

The average number of days each patient stays in the hospital. For individual or
specific categories of patients, this measure indicates severity of illness and
resource use.
Average length of stay


The ethical obligation of a health services organization to do all it can to alleviate
suffering caused by ill health and injury.
Beneficence

The number of beds set up, staffed, and made available by a hospital for inpatient
use.
Capacity

The number of patients in a hospital on a given day or the number of beds occupied
on a given day.
Census

Conferred by the U.S. Department of Health and Human Services, it entitles an
organization to participate in Medicare and Medicaid. The organization must comply
with the conditions of participation.
Certification

Nonfederal (i.e., VA and military hospitals are excluded), short‐term, general or
special hospital whose services are available to the public.
Community hospital

Standards developed by the Department of Health and Human Services (DHHS) that
a facility must comply with in order to participate in the Medicare and Medicaid
programs.
Conditions of participation


Medicare designation for small rural hospitals with 25 beds or fewer that provide
emergency medical services besides short‐term hospitalization for patients with
noncomplex health care needs. CAHs receive cost‐plus reimbursement.
Critical access hospital


Cumulative number of patient days over a given period of time.
Days of care


A designation used when a hospital, by virtue of its accreditation by the Joint
Commission or the American Osteopathic Association, does not require separate
certification from the DHHS to participate in the Medicare and Medicaid programs.
Deemed status


Release of a patient who has received inpatient services. Total number of these
indicates access to hospital inpatient services as well as the extent of utilization.
Discharge

An interdisciplinary committee responsible for developing guidelines and standards
for ethical decision‐making in the provision of health care and for resolving issues
related to medical ethics.
Ethics committee

A hospital that provides general and specialty medical services for a variety of
medical needs.
General hospital

A fundamental patient right to make an informed choice regarding medical
treatment based on full disclosure of medical information by the providers.
Informed consent

Services delivered on the basis of an overnight stay in a health care institution.
Inpatient

A night spent in the hospital by a person admitted as an inpatient. It is also called a
patient day or a hospital day.
Inpatient day

Permission granted by the state for an organization to legally operate.
License

A hospital with a high level of specialization and a wide scope of services.
Medical center

Large organizations that may include more than one hospital to serve a large
geographical area.
Medical system

The moral obligation of health services personnel not to harm the patients. This
principle requires physicians to use their best professional judgment in choosing
interventions that maximize the potential health benefits at minimum risk.
Nonmaleficence

The percentage of a hospital's total inpatient capacity that is actually utilized.
Occupancy rate

The cumulative census over a given period of time. See days of care and inpatient
day.
Patient day


A for‐profit hospital owned by individuals, a partnership, or a corporation. Also
referred to as investor‐owned hospital.
Proprietary hospital

A hospital owned by the federal, state, or local government.
Public hospital

A hospital located in a county that is not part of a metropolitan statistical area.
Rural hospital

A hospital that admits only certain types of patients or those with specified illnesses
or conditions. Examples include rehabilitation hospitals, tuberculosis hospitals,
children's hospitals, cardiac hospitals, orthopedic hospitals, etc.
Specialty hospital

A hospital with an approved residency program for physicians.
Teaching hospital

A nonprofit hospital.
Voluntary hospital

An integrated group of providers—including hospitals, physicians, and post‐discharge
care delivery organizations—who work together to deliver coordinated care and take
responsibility for quality and efficiency of services delivered.
Accountable care organization

Purchase of one organization by another.
Acquisition

A joint agreement between two organizations to share their resources without joint
ownership of assets.
Alliance

The assignment through contractual arrangements of specialized services to an
outside organization because these services are not included in the contracts
managed care organizations (MCOs) have with their providers or the MCO does not
provide the services.
Carve‐out


Part of the overall treatment plan designed to facilitate discharge from an inpatient
setting. It includes, for example, an estimate of how long the patient will be in the
hospital, what the expected outcome is likely to be, whether any special
requirements will be needed at discharge, and what needs to be facilitated for
postacute continuity of care.
Discharge planning

Any mechanism that gives people the ability to pay for health care services.
Financing

The use of primary care physicians to coordinate health care services needed by an
enrollee in a managed care plan.
Gatekeeping

A growth strategy in which an organization extends its core product or service. See
vertical integration.
Horizontal integration

A network of organizations that provides or arranges to provide a coordinated
continuum of services to a defined population and is willing to be held clinically and
fiscally accountable for the outcomes and health status of the population serviced.
Integrated delivery system

Creation of a new organization in which two or more institutions share resources to
pursue a common purpose.
Joint venture

The percentage of premium revenue spent on medical expenses.
Medical loss ratio

Unification of two or more organizations into a single entity through mutual
agreement.
Merger

Utilization of medical services, the cost of which exceeds the benefit to consumers
or the risks of which outweigh potential benefits.
Overutilization

A legal entity formed between a hospital and a physician group to achieve shared
market objectives and other mutual interests.
Physician–hospital organization

Requirement by some insurance plans that the enrollee or the provider call the plan
administrators for approval before certain services are provided.
Precertification

Occurs when medically needed health care services are withheld. This is especially
true when potential benefits are likely to exceed the cost or risks.
Underutilization

A process by which an insurer reviews decisions by physicians and other providers on
how much care to provide.
Utilization review

Linking of services that are at different stages in the production process of health
care. For example, a hospital system that launches hospice, long‐term care, or
ambulatory care services. See horizontal integration.
Vertical integration

The formation of networks based on contractual arrangements.
Virtual integration

New organization that is formed by contractual arrangements between two or more
organizations; it is an organization without walls.
Virtual organization
a person enrolled in a health plan, especially in a managed care plan
Enrollee

the cost of ancillary servies that often accompany major procedures such as surgery
Item-based pricing
The most commonly used measure of disability. ADLs determine whether an
individual needs assistance to perform basic activities, such as eating, bathing,
dressing, toileting, and getting into or out of a bed or chair. See instrumental
activities of daily living (IADLs).

Activities of daily living

Care that improves function despite deficits that remain.

Adaptive rehabilitation

LTC services provided in small, family‐operated homes, located in residential
communities, which provide room, board, and varying levels of supervision,
oversight, and personal care to nonrelated adults.

Adult foster care

An organized approach to evaluating and coordinating care, particularly for patients
who have complex, potentially costly problems that require a variety of services
from multiple providers over an extended period.

Case management

A long‐lasting medical condition that can be controlled but not cured.

Chronic condition (chronic disease)

A mental disorder that is indicated by a person having difficulty remembering,
learning new things, concentrating, or making decisions that affect the individual's
everyday life.

Cognitive impairment

Presence of more than one health problem in an individual.

Comorbidity

Nonmedical care provided to support and maintain the patient's condition, generally
requiring no active medical or nursing treatments.

Custodial care

A physical incapacity that generally accompanies mental retardation and often
arises at birth or in early childhood.

Developmental disability

A cluster of special services for the dying, which blends medical, spiritual, legal,
financial, and family‐support services. The venue can vary from a specialized
facility to a nursing home to the patient's own home.

Hospice

A person's ability to perform household and social tasks, such as home maintenance,
cooking, shopping, and managing money. See activities of daily living (ADLs).

Instrumental activities of daily living

Care that aims to preserve the present level of function and prevent further
decline.

Maintenance rehabilitation

Serving to relieve or alleviate, such as pharmacologic pain management and nausea
relief.

Palliation

A service that provides temporary relief to informal caregivers, such as family
members.

Respite care

Short‐term therapy treatments to help a person regain or improve physical function.

Restorative care

Local community centers for older adults that provide opportunities to congregate
and socialize, and in some cases have a midday meal.

Senior center

Medically oriented long‐term care provided mainly by a licensed nurse under the
overall direction of a physician.

Skilled nursing care

Clinically complex services that are beyond traditional skilled nursing care.

Subacute care

The ability of persons needing health services to obtain appropriate care in a timely
manner.

Access

Costs associated with health insurance marketing and enrollment, contracting with
providers, claims processing, utilization monitoring, and handling of denials and
appeals.

Administrative costs

Standardized guidelines in the form of scientifically established protocols,
representing preferred processes in medical practice.

Clinical practice guidelines (medical practice guidelines)

In general, shifting of costs from one entity to another as a way of making up losses
in one area by charging more in other areas. For example, when care is provided to
the uninsured, the provider makes up the cost for those services by charging more
to the insured.

Cost shifting (cross‐subsidizing)

A service is cost efficient when the benefit received is greater than the cost
incurred to provide the service.

Cost‐efficiency

Outcome‐based, patient‐centered case management tools that are interdisciplinary,
facilitating coordination of care among multiple clinical departments and
caregivers. A critical pathway identifies planned medical interventions in a given
case, along with expected outcomes.

Critical pathways

Excessive medical tests and procedures performed as a protection against
malpractice lawsuits, otherwise regarded as unnecessary.

Defensive medicine

Cost‐sharing mechanism that places a larger cost burden on consumers, thereby
encouraging consumers to be more cost conscious in selecting the insurance plan
that best serves their needs and more judicious in their utilization of services.

Demand‐side incentive

Decisions made by governments to limit health care resources, such as hospital beds
and diffusion of costly technology.

Health planning

Delivery of health care that places its primary emphasis on the treatment of disease
and relief of symptoms instead of prevention of disease and promotion of optimum
health.

Medical model

See clinical practice guidelines.

Medical practice guidelines

The end result of health care delivery; often viewed as the bottom‐line measure of
the effectiveness of the health care delivery system.

Outcome

The general process of medical review of utilization and quality when it is carried
out directly or under the supervision of physicians.

Peer review

The specific way in which care is provided. Examples of this include correct
diagnostic tests, correct prescriptions, accurate drug administration,
pharmaceutical care, waiting time to see a physician, and interpersonal aspects of
care delivery.

Process

The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge.

Quality

A payment method instituted by Medicare for determining physicians' fees. Each
treatment or encounter by the physician is assigned a relative value based on the
time, skill, and training required to treat the condition.

Resource‐based relative value scale

Limiting risks against lawsuits or unexpected events.

Risk management

A national health care program in which the financing and insurance functions are
taken over by the federal government.

Single‐payer system

Unexplained variations in the treatment patterns for similar patients and medical
conditions.

Small area variations

The relatively stable characteristics of the providers of care, of the tools and
resources they have at their disposal, and of the physical and organizational settings
in which they work (Donabedian, 1980, p. 81).

Structure

The antitrust laws passed in the United States, which prohibit business practices
that stifle competition among providers, such as price fixing, price discrimination,
exclusive contracting arrangements, and mergers deemed anticompetitive by the
Department of Justice.

Supply‐side regulation

Limiting utilization of medical services to only those deemed appropriate and
necessary.

Utilization control

Competitive strategy used by employers who shop for the best value in terms of the
cost of premiums and the benefits package (competition among insurers), and when
MCOs shop for the best value from providers of health services (competition among
providers).

Payer‐driven competition