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206 Cards in this Set

  • Front
  • Back
Alternative health therapy
nontraditional sources of health care, such as use of herbal and nutritional supplements, acupuncture, support groups, meditation, and massage therapy, among others.
Blue Cross and Blue Shield
originally a nonprofit health insurance established in 1929 offering comprehensive plans. Most Blue Cross and Blue Shield plans switched to for-profit status in the 1990s.
Chronic diseases
illnesses that last a longtime, affecting patients either continuously or episodically. Chronic illnesses such as heart disease and cancer begin to appear with greater frequency in the early 20th century.
Comprehensive
characteristics whereby essential health care benefits are covered.
Dispensary
separate, freestanding institutions in urban neighborhoods designed to provide medical care for the poor, usually employing a physician and/or pharmacist.
Employer mandate
a proposal that would require employers to provide health insurance for all their workers or pay a tax that would create an insurance pool for the uninsured.
Flexner report
a report on the state of medical education in the United States sponsored by Carnegie Foundation and prepared by Abraham Flexner in 1910, The report examined such factors as entrance requirements, teaching, labs, financing, and clinical status. Recommendations of the report resulted in closure of inadequate medical schools and new emphasis on scientific, lab-based medical education.
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
a law enacted by Congress that limits the amount of time a preexisting condition may be excluded from coverage to one year, requires insurance companies to sell health insurance policies to small employers and individuals who lose coverage without regard to their health history, requires insurance companies to renew policies they sell to groups and individuals, and outlines standards for patient confidentiality.
Health Maintenance Organization Act of 1973
a federal law that set standards and provided start-up funds for health maintenance organizations - specialized insurance plans that involve restrictive provider networks and primary-care gatekeepers that are responsible for referrals to other health care services and risk sharing with providers. This act also required employers with more than 25 employees to offer a HMO plan.
Health Security Act
A Clinton administration proposal that would have imposed an employer mandate and established managed competition in which health providers would compete for patients based on cost and value.
Heroic medical therapy
an aggressive type of patient care that used depletive and strengthening measures to return the patient's diseased body to equilibrium. Methods used included leeches, tonics, medical instruments, and medicines to bleed, purge puke, or sweat patients.
Hospital Survey and Construction Act of 1946 (Hill-Burton Act)
A federal law that established hospitals in rural, town, and city areas that were previously underserved and provided renovations and extensions to already-existing hospitals. This act contributed to the growth of major medical centers, which are now widespread in the United States.
Humoralism
Galen's second-century concept that saw the human body as interrelated and in natural balance. Health equalized a human body in balance; disease meant the body's system was in disequilibrium.
Incremental health reform
step-by-step, slow passage of individual pieces of health legislation.
Infant mortality rate
the number of children younger than one year of age who die during a particular year divided by the number of live births during the same year.
Medicare Part D
a provision that created a new voluntary outpatient prescription drug benefit for Medicare recipients; it became available in 2006.
Orthodox (allopathic, regular, or mainstream) physicians
physicians who possessed some didactic medical education and underwent apprenticeship to develop their clinical skills. They practiced heroic medicine.
Patent medicines
cheap concoctions in tonic or pill form that were widely advertised in newspapers and popular magazines and sold in pharmacies or by traveling tradesmen.
Quackery
pretending to have medical knowledge or credentials so as to defraud the public; manufacturing or selling nontherapeutic nostrums or medical devices that generally cause harm.
Sectarians (irregular physicians)
rivals to orthodox physicians who sought education or training outside the orthodox medical, educational system. They represented various beliefs, therapies, or medical systems that competed with the orthodox practice of medicine and included homeopaths and eclectics.
Single-payer plan
a plan in which the government is the primary financer in one, all-inclusive health care system.
Social healers
usually female healers who treated friends and neighbors in rural and small-town communities in the 18th and 19th centuries. Patients sought simple medicines and treatments for boils or wounds as well as advice. Social healers were often also midwives.
Activity-passivity model of care
as described by Szasz and Hollender, practitioner-patient communication in which the patient is passive. This interaction can be compared to a parent-infant relationship.
Biopsychosocial model of care
a model of care in which the social, emotional, and psychological aspects of the patient are taken into account, as well as the patient’s physical status, in understanding his or her health or illness.
Consumer model of care
a practitioner-patient model of care in which patients have greater autonomy in decision making and are somewhat skeptical “buyers” of medial care
Direct-to-consumer advertising (DTCA)
the act of advertising prescription medications to the general public through a variety of media.
Effectiveness
the ability of a product to produce an effect in real-world practice, typically outside of the well-controlled setting of clinical trials.
Efficacy
the ability of a product to produce an effect, typically demonstrated in randomized controlled clinical trials.
Guidance cooperation model of care
as described by Szasz and Hollender; practitioner-patient communication in which the patient is active in the interaction, but defers to medical expertise. This interaction can be compared to a parent-adolescent relationship
Health belief model
a health behavior theory that describes the likelihood and individual will take action to change a behavior. Components of this theory include susceptibility and severity of disease, perceived benefits and barriers, cues to action, self-efficacy, and demographic, socio-psychological, and structural variables.
Health insurance
a situation in which individuals or employers "buy" a plan from a company to assist them in paying for health care costs incurred. Insurance coverage varies, but often includes physician visits, hospitalizations, laboratory tests, and other medical expenses.
Locus of control
a health behavior theory that refers to whether an individual feels the attainment of a particular outcome is within his or her control (e.g., internal locus of control) or outside of it (e.g., external locus of control).
Medication assistance programs (MAPs)
programs that provide lower-income patients with access to brand-name prescription drugs in community and institutional settings that ensures medications are used safely and effectively.
Mutual participation model of care
as described by Szasz and Hollender, a practitioner-patient communication in which the patient assumes an active role and is equally powerful to the practitioner. This model is most commonly seen with patients who have chronic diseases and can be compared to a parent-adult child relationship.
Patient-centered model of care
a model in which the focus of the practitioner shifts from disease orientations (the body) to the person as w hole. Practitioners are encouraged to view the illness from the patient's eyes.
Preventive health care
performance of activities or behaviors for the purpose of avoiding or deterring disease and maintaining health.
Social cognitive theory
a health behavior theory that describes an individual's expectations in relation to changing behavior. The model includes two main components: (1) outcome expectations, or the individual's belief that a behavior leads to a specific outcome, and (2) efficacy expectations, or the individual's belief that he or she has the ability to perform this behavior.
Theory of planned behavior (TPB)
a health behavior theory that is an extension of the theory of reasoned action. It includes an additional component relating to the theory of reasoned action. It includes an additional component related to the degree an individual has control over the behavior, such as knowledge, time, money, and opportunity.
Theory of reasoned action (TRA)
a health behavior theory that hypothesizes an individual's behavior is related to his or her behavioral intentions or the likelihood that the person will perform a behavior. According to the model, two main factors contribute to this intention: (1) attitude toward performing the behavior (beliefs and outcome), and (2) the subjective norm (what "important" individuals think of the behavior and the motivation to comply) associate with the behavior.
Transtheoretical model
often referred to as stages of change or readiness to change model. This health behavior theory theorizes that a patient progresses through five stages before a change in behavior occurs: (1) pre-contemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance.
Changes in demand
a shift in an entire demand curve such that the quantity demanded changes even though price remains constant. An increase in demand is represented by a rightward shift of the demand curve; a decrease in demand is illustrated by a leftward shift of the demand curve.
Changes in quantity demanded
a movement along a given demand curve caused by a change in price. The demand schedule shows that as the price charged increases, the quantity demanded decreases. Therefore, a chance in quantity demanded in caused solely by a change in the price charged to customers.
Changes in quantity supplied
a movement along a given supply curve caused by a change in price. The supply schedule shows that, as the price that customers are willing to pay increases, the quantity supplied increases. Therefore, a change in quantity supplied is caused solely by a chance in the price charged to customer.
Changes in supply
a shift in an entire supply curve such that the quantity supplied changes even though price customers are willing to pay remains constant. An increase in supply is represented by a rightward shift of the supply curve; a decrease in supply is illustrated by a leftward shift of the supply curve.
Demand
the ability and willingness of a consumer to pay for a good or service
Demand schedule
a table or chart that shows the amounts of a commodity consumers are willing and able to purchase at each specific price charged in a set of possible prices during some specified period of time. Two variables exist: (1) the price charged by the supplier (independent variable) and (2) the quantity demanded by the consumer at each given price (dependent variable). It is assumed, for the sake of simplicity, that all other variables are held constant.
Economic resources
(1) land, including all natural resources, (2) labor, and (3) capital, including physical resources produced by labor. Economists refer to these three basic economic resources as factors of production because they are used to produce those things that people desire (commodities)
Economics
the study of how individuals and societies allocate their limited resources in attempts to satisfy their unlimited wants.
Elastic demand
a situation in which consumers are relatively sensitive to price changes, such that an increase in price will result in a decrease in total revenue.
Elasticity
economic concept that measures the responsiveness of consumer demands to a chance in price.
Equilibrium price
the price corresponding to the point where the demand curve and the supply curve intersect; the price where the market can rest without a natural tendency to increase or decrease price.
Equilibrium quantity
the quantity corresponding to the point where the demand curve and the supply curve intersect; the price where the market can rest without a natural tendency to increase or decrease the quantity supplied or demanded.
Induced demand
the increased demand for health care services that is created by the availability of insurance payment. Health care providers, especially physicians, can increase utilization of health services by creating more demand for the services they provide.
Inelastic demand
a situation in which consumers are relatively insensitive to price changes, such that an increase in price will not result in a decrease in demand.
Law of demand
an economic principle that states that, as the price charged for a product or service falls, the corresponding quantity demand rises; alternatively, as the price charged increases, the corresponding quantity demanded falls. In short, an inverse relationship exists between the price charged and the quantity demanded.
Law of diminishing marginal utility
an economic principle states that the value of any additional goods declines as one consumes more of it. In other words, the more we have of a good, the less we desire it.
Law of supply
an economic principle that states that, as the price customers are willing to pay falls, the corresponding quantity supplied falls; alternatively, as the price customers are willing to pay increases, the corresponding quantity supplied increases. In short, a direct relationship exists between the price customers are willing to pay and the quantity supplied.
Marginal utility
the additional utility received from consuming one additional unit of a particular good or service.
Shortage
a situation that occurs when the market price is below the equilibrium price, resulting in a quantity supplied that is less than the quantity demanded.
Supply
the ability and willingness of a supplier to provide a good or service.
Supply curve
a graphic representation of a supply schedule
Supply schedule
a table or chart that shows the amounts of a commodity suppliers are willing and able to supply at each specific price that consumers are willing to pay in a set of possible prices during a specified period of time.
Surplus
a situation in which the market price exceeds the equilibrium price, resulting in a quantity supplied that is greater than the quantity demanded.
Ambulatory patient groups (APGs)
a type of prospective payment for outpatient services that is based on diagnosis.
Discounted fee-for-service
a retrospective reimbursement rate in which health care providers are paid a negotiated fee each time a service is provided. The agreed-upon rate is lower than the providers’ usual and customary charges to cash-paying patients.
Duration of treatment
a measure of how long patients continue receiving treatment. For hospitals, this means length of stay; for physicians, the episode of care; and for pharmacies, the number of prescription refills.
Flat of the curve
a point where additional health care expenditures produce relatively little incremental benefit to the patient.
Intensity of services
a measure of the types and numbers of services provided. It include the service mix (types of service), the quantity (per capita use), and the quality of services.
Market structure
the categorization of firms based on attributes such as the numbers of buyers and sellers, product differentiation, pricing behavior, and so on. The four types of market structures are perfect competition, monopolistic competition, monopoly, and oligopoly.
Monopolistic competition
a market structure similar to perfect competition except that it does not have standardized and interchangeable products.
Monopoly
a market structure that has only one seller of a product that has no close substitutes.
Monopsony
a market structure that has only one buyer, but several competing suppliers.
Oligopoly
a market structure that consists of a few sellers and many buyers. Firms in oligopolies are often interdependent, and a dominant firm can exert influence through price leadership.
Oligopsony
a market structure that consists of only a few buyers, but several competing suppliers.
Patient-induced demand
an increase in the quantity of services demanded resulting from insurance coverage that lowers patients' out-of-pocket expenses. By isolating patients from the true cost of health care services, health insurance has encouraged patients to consume more health care services than they would if they were bearing the full cost of the product or service themselves.
Per diem
a type of prospective reimbursement in which hospitals are paid a flat rate for each day of hospital care provided to covered individuals without regard to the actual costs incurred.
Perfect competition
a market structure characterized by (1) many buyers and sellers, (2) freedom of entry and exit, (3) standardized products, (4) full and free information, and (5) no collusion.
Population effects
a measure of the number of patients and the mix of various demographic factors within the group (e.g., gender, age, socioeconomic status and other factors) that affect utilization. For hospitals, this means the number of hospital admissions; for physicians, the number of new patients; and for pharmacies, the number of new prescriptions.
Roemer's law
"A built bed is a filled bed." This statement reflects the historical tendency for health care providers to increase hospital admissions and the use of health care technology when excess capacity exists.
Substitutes
related products that may be interchanged by consumers. When the price of one good increases, the quantity demanded for that good decreases and the demand for its substitute increases.
Supplier-induced demand
an increase in demand created by the service provider. Physicians may induce demand for their own services by ordering follow-up care or referring patients to physician-owned laboratory, pharmacy, radiology, or other diagnostic or treatment services.
Actual acquisition cost (AAC)
the price that pharmacists pay for drug products after subtracting all discounts.
Actuary
an insurance company employee who conducts a statistical analysis of an insured population to estimate the income (premiums) that must be earned to cover the estimated expenses, usually expressed as cost per member per month (PMPM).
Adjudication
the process of reviewing or screening claims to determine payment.
Adverse selection
a situation in which individuals or companies purchase insurance only when they expect a loss.
Average manufacturer’s price (AMP)
a proposed method for estimating pharmacy acquisition costs that is based on actual costs charged by manufacturers rather than the wholesale list price.
Average wholesale price (AWP)
the list price established by the manufacturer. AWP is higher than the actual acquisition cost (AAC) that pharmacies pay for drug products and is discontinued by the payer to arrive at the estimated acquisition cost (EAC).
Catastrophic hazard
a situation in which an insurance company incurs excessive losses due to widespread and catastrophic events such as hurricanes, acts of war, and earthquakes. Companies that provide casualty insurance limit their exposure for catastrophic events by trying to avoid insuring large numbers of policyholders in the same geographic area.
Co-insurance
a form of patient cost sharing that requires patients to pay a specified percentage (usually 20%) of the cost of covered services; the plan pays the remainder.
Co-payment
a form of patient cost sharing that requires patients to pay a specified dollar amount every time a service is received (e.g., $50 per hospital admission or $5 per prescription).
Community rating
a method of setting insurance premiums based on the insurance company’s overall expenses for a specific geographic area during the previous year.
Coordination of benefits
a provision in insurance contracts that is designed to prevent duplicate payment by more than one insurance plan for the same medical care by limiting total reimbursement from all insurance plans for the same event to the amount of the actual loss. Health insurance policies usually pay after automobile, homeowners’, or workers’ compensation insurance policies have paid their portion.
Deductible
a form of patient cost sharing that requires patients to pay their own health care expenses until a specified dollar amount has been paid out-of-pocket during a given period of time, usually a year.
Dispense as written (DAW)
a provision in the participating pharmacy agreement that allows full reimbursement for the higher-cost multiple-source drug product if the pharmacy indicates on the prescription claim that the prescriber demanded a brand-name product instead of its generic equivalent.
Elimination period
a restriction found in group insurance policies that is aimed at reducing adverse selection by restricting coverage for preexisting health problems until after the policyholder has been covered for a given period of time. Expenses related to pregnancy and childbirth, for example, may not be covered for the first 9 months of a new policy. Elimination periods are often waived when new employees are hired and during open enrollment periods.
Estimated acquisition cost (EAC)
the amount paid by a pharmacy benefit manager (PBM) for drug ingredient costs, calculated as a percentage of the average wholesale price.
Experience rating
a method of setting insurance premiums based on the insurance company’s overall expenses for a specific subset of insured individuals ‘ usually an employer group’ based on the group’s experience for the previous year.
First dollar coverage
a reimbursement mechanism in which there is no provision for patient cost sharing.
Fiscal intermediary
an organization that facilitates exchanges between health care payers and health care providers by underwriting and/or administering health care benefit programs.
Gross margin (GM)
the difference between the selling price and the cost to the pharmacy for the product that was sold.
Group policies
insurance plans sponsored by employer groups for employees and their dependents. Group policies are usually less expensive than individual policies because they are less subject to adverse selection and because they are less expensive to sell and administer.
Indemnity
a form of insurance that traditionally required patients to submit claims for reimbursement. Today the term is often used to refer to any health insurance plan with fee-for-service reimbursement and few cost controls.
Insurable hazard
a type of pure risk that can lead to specific, measurable, and substantial losses that are unanticipated for an individual, but that are anticipated and relatively predictable for the group as a whole.
Insurable interest
a situation in which the individual who will receive payment for an insurance claim actually experiences a loss when an insurable hazard occurs.
Law of large numbers
an insurance principle that states that the larger the number of insured persons, the more accurate the predictions regarding losses. With losses being more predictable, the risk of this loss actually decreases.
Major medical insurance
a type of insurance policy designed to help offset expenses incurred by catastrophic illness or injury. These policies usually have high deductibles and are not designed to cover minor expenses.
Maximum allowable cost (MAC)
the amount paid by a pharmacy benefit manager (PBM) for the drug ingredient costs for a multiple-source drug. The MAC is usually set at the price of a low-cost generic product without regard as to whether a brand-name or generic product was actually dispensed.
Moral hazard
a situation in which patients, with insurance coverage, overconsume health care services to the extent that the additional health benefit achieved from consuming additional health services are not really worth their full costs. Nevertheless, because the enrollees are paying only a fraction of the costs, they still want to use the services. Overconsumption of health services owing to moral hazard increases total health expenditures and insurance premiums.
Patient cost sharing
a provision in health insurance plans that provide financial incentives for patients to avoid using unnecessary health care services by making them pay a portion of the cost of the service. Patient cost-sharing methods include co-payments, co-insurance, deductibles, out-of-pocket limits, and maximum benefit limits.
Pure risk
a type of risk in which there is a possibility of a loss but no possibility of a gain. This type of risk is insurable.
Reinsurance
a type of insurance that protects insurance companies from extraordinary, unexpected losses. Insurance companies are willing to accept some risk of having claims exceed income, but obtain reinsurance to protect them from catastrophic losses. The reinsurance company pools the risks faced by many insurance companies together.
Risk pool
an arrangement in which an HMO places a portion of payments in a pool as a source for any subsequent claims that exceed projections, with the provider and the HMO sharing the surplus (or loss) from the risk pool at the end of the year.
Service benefit
a form of health insurance plan in which health care providers submit claims and are paid directly by the insurance plan
Speculative risk
a type of risk in which there is the possibility of either a gain or a loss. Business ventures and gambling are examples of activities in which there is speculative risk. This type of risk is not insurable.
Subrogation
the process in which an insurance company enforces a coordination of benefits provision by determining which insurance company is required to pay first if a particular patient has duplicate coverage.
Underwriting
the process of insuring. Underwriters attempt to calculate the amount of financial risk they assume for insurable events, estimate losses and administrative expenses (with the aid of actuaries), and set the level of premiums needed to cover expenditures and provide for a reasonable profit.
Academic Detailing
a tool used by managed care organizations (MCOs) in which a health plan representative (or the contracting pharmacy benefit manager [PBM]) visits targeted physicians to provide information regarding the most cost-effective use of selected drugs and to encourage physicians to prescribe in ways that will reduce overall costs while maintaining program quality. The targeted physicians are usually identified by the practice profiling program as ones with higher than average costs or unusual prescribing patterns.
Counterdetailing
a tool used by managed care organizations (MCOs) in which a health plan representative (or the contracting pharmacy benefit manager [PBM]) visits targeted physicians to provide information regarding the most cost-effective use of selected drugs and to encourage physicians to prescribe in ways that will reduce overall costs while maintaining program quality. The targeted physicians are usually identified by the practice profiling program as ones with higher than average costs or unusual prescribing patterns.
Drug use evaluation (DUE)
an evaluation of the use of one or more drugs prescribed for one or more diseases or conditions within the context of quality assurance and risk management procedures.
Drug utilization review (DUR)
the review of physician prescribing, pharmacist dispensing, and patient use of drugs with the goal of ensuring that drugs are used appropriately, safely, and effectively. A DUR may be conducted prospectively or retrospectively.
Exclusive provider organization (EPO)
a form of PPO in which no coverage is provided for care received outside the provider network.
Formulary
a list of medications compiled by a hospital or pharmacy benefit manager (PBM) that contain either those drugs approved for use within the hospital or for reimbursement by the PBM. Medications are included based on the relative clinical benefit and cost of the medication as compared to other agents within a similar therapeutic class.
Group-model HMO
a type of HMO characterized by contracts with large, multispecialty medical groups offering services exclusively to the HMO on a capitated basis.
Health maintenance organization (HMO)
a type of managed care organization that shares risk with a network of health care providers by requiring that the providers assume some risk, either directly or indirectly, and that generally does not provide coverage for medical care that is received outside the network. The risk arrangement can take many forms, such as capitation or risk pools. The gatekeeper is a central component of most HMOs. The four basic types of HMO models are staff models, group models, network models, and independent practice associations.
Health Plan Employer Data and Information Set (HEDIS)
a group of performance measures developed by NCQA, which gives plan sponsors objective information that they can use to evaluate MCOs.
Managed care
the application of cost and quality controls to health care by controlling patient demand and provider supply. The defining feature of managed care is the use of provider networks through a contractual arrangement specifying the types of services to be provided and the reimbursement to be received in return.
Managed care organization (MCO)
an organization designed to manage the cost and quality of a health insurance program. The differentiating feature of managed care plans versus fee-for-service plans is the use of a provider network. MCOs are categorized according to their degrees of (1) risk sharing, (2) provider exclusivity, (3) out-of-network coverage, and (4) physician autonomy and organization.
Network
a defined group of providers, typically linked through contractual arrangements, who supply a full range of primary and acute health care services. Managed care enrollees who use providers outside the network may receive reduced coverage or even no coverage.
Network-model HMO
a type of HMO characterized by nonexclusive contracts with large medical groups. While networks typically bear risk, the nonexclusivity of the arrangement reduces the influence of the risk on the physician's behavior.
Pharmacy benefit manager (PBM)
a specialized company that adjudicates prescription drug claims and manages the prescription drug coverage for a third-party payer by containing costs and influencing the quality of services provided.
Physician profiling
a tool used by managed care organizations to analyze the practice patterns of physicians on cost and quality dimensions. Measures are generally expressed as a rate over a specified period of time within the physician's patient population (e.g., the average dollars spent per patient per month).
Prospective drug utilization review (DUR)
the review of physician prescribing, pharmacist dispensing, and patient use of drugs with the goal of ensuring that drugs are used appropriately, safely, and effectively. A DUR may be conducted prospectively or retrospectively.
Quality
originally applied to manufacturing, meaning the state of zero defects and reliable engineering process. It now applies to health care, meaning the reduction of preventable errors and reduced variability in evidence-based best practices (Kerzner, 1995). Quality is considered on of three major facets of the "iron triangle" of health care - cost, access, and quality.
Quality assurance
quality of care considerations that typically include both assessment of care and a feedback loop to the health care organization that recommends either a continuation or a change in care.
Quality-adjusted life-years (QALYs)
an outcome measured as life-years gained adjusted for patient preference or another means of weighting/adjusted gains in life-years.
Rebate
payment received by a pharmacy benefit manager (PBM) from a pharmaceutical manufacturer for putting a specific drug on the PBM's formulary or giving the drug preferred status. The amount of a rebate may be based on performance (i.e., a certain level of prescribing) or market share (i.e., the percentage of all prescriptions within a given therapeutic class that are dispensed for the company's product).
Retrospective drug utilization review (DUR)
the review of physician prescribing, pharmacist dispensing, and patient use of drugs with the goal of ensuring that drugs are used appropriately, safely, and effectively. A DUR may be conducted prospectively or retrospectively.
Risk-bearing
the amount of risk borne by the providers, which can range from full risk to no risk. Physicians typically accept risk in the form of capitation and risk pools; hospitals accept capitation as well as per diem and DRG reimbursement.
Staff-model HMO
a type of HMO characterized by direct ownership of health care facilities and direct employment physicians. Physicians in a staff-model HMO typically bear no direct risk, but the HMO can influence the physician through utilization review (the review of the necessity and efficiency of patients' utilization patterns).
Tiered co-payments
a type of patient cost sharing that specifies multiple co-payment levels that are designed to encourage the use of preferred drug products, such as generics and lower-cost brand-name drugs.
Utilization review
a tool used by managed care organizations (MCOs) to review the necessity and efficiency of health care services, with the aim of decreasing costs and enhancing the safety and quality of services. See also drug utilization review.
Developed nation
any country with a high standard of living that is characterized by high per capita incomes, strong health infrastructures, and positive health care outcomes. Also known as an industrialized country.
Developing nation
any country with a low standard of living that is characterized by low per capita incomes, weak health infrastructures, and poor health care outcomes.
Factors explaining changes in mortality rates and life expectancy
improvements in public health measures (e.g., garbage collection, pure water, clean air, sewerage disposal), improvements in lifestyle (e.g., domestic sanitary practices, diet), and therapeutic interventions (e.g., anesthetics, antibiotics, surgical procedures).
Life expectancy
average number of years remaining for a person of a given age to live.
Portability
a characteristic whereby health care benefits are readily transportable when individuals changes their jobs or place of residence.
Sickness funds
the common name for the quasi-public, third-party payers characterizing Germany's health care system.
Social partnership
characteristic whereby both the employer and the employee contribute funds to the health care system.
Social solidarity
a characteristic whereby some members of a country subsidize other members' health care costs.
Socialized medicine
a type of health care system where the government participates in or enforces participation in the country's health care system, employs health care practitioners, owns health care facilities, and administers the health care system.
Universality
characteristic whereby all heath care benefits are provided for all citizens of a given country.
Off-label drug use
use of drugs for an indication for which they do not have formal approval from the FDA.
U.S. drug approval process
the process identified by the FDA, and which pharmaceutical manufacturers must abide by, for products to be approved for use in the United States.
U.S. Food and Drug Administration (FDA)
the federal agency that is responsible for assuring the safety and effectiveness of many food and drug products.
Balanced Budget Act of 1997
law the required the implementation of a prospective payment system (PPS) for home health services, reductions in reimbursement rate for home medical equipment, and implementation of competitive bidding processes. Under a PPS, a home health agency is paid a flat rate to care for a Medicare recipient.
Cost sharing
a provision in managed care plans requiring patients to share in the cost of services received. Cost sharing attempts to optimize utilization of health services by making patients more cost-conscious. It can take many forms, including co-payments, co-insurance, deductibles, out-of-pocket limits, or maximum benefits.
Medicaid
Title XIX of the Social Security Act; a joint program between the federal and state governments that pays for medical care for individuals who receive case assistance through the Supplemental Security Income (SSI) program and certain low-income pregnant women, children, and other vulnerable groups.
Medicaid waiver
a provision established by the Omnibus Budget Reconciliation Act (OBRA) of 1981 that allows states to apply for exceptions to federal Medicaid guidelines for the purpose of either establishing Medicaid managed care plans or creating new initiatives to curb costs or improve delivery of Medicaid services.
Medicare
Title XVIII if the Social Security Act; a federal social health insurance program for individuals 65 years of age and older, individuals who receive disability benefits from Social Security or the Railroad Retirement Board, or individuals with end-stage renal disease requiring dialysis or kidney transplantation.
Skilled nursing facility (SNF)
a facility that provides basic medical and nursing care, as well as additional services or therapies, that can include restorative, physical, and occupational therapies.
Social Security
a program created by the Social Security Act if 1935 that provides a minimum level of income for qualified individuals who are 65 years of age or older or who are disabled.
Trust fund
a fund that accounts for the moneys collected as Social Security and Medicare taxes.
Cost containment
concept considered to either decrease health care spending or restrain the growth of health care spending. It has become the focus of much of health care reform since the 1970s.
Employee mandate
a requirement usually set by a state law requiring all employees to purchase health insurance.
Gross domestic product (GDP)
the market value of all final goods and services produced within a country within a given period of time.
Health savings account (HSA)
a provision of the Medicare Prescription Drug Improvement and Modernization Act that established tax-free savings accounts to be used for out-of-pocket medical expenses for those individuals who select a high-deductible health insurance plan.
Kerr-Mills Act of 1960
an amendment to the Social Security Act that provided health care coverage to poor elderly individuals.
Managed competition
a provision of the Health Security Act that would have organized health care providers into health alliances that would compete with one another for patients based on cost and value.
Medicare Catastrophic Coverage Act
A 1988 proposal to expand Medicare Part B coverage to include outpatient prescription drug coverage.
Oregon Health Plan
The Oregon Basic Health Services Act of 1989 expanded the state's Medicaid program to include previously uninsured citizens. To determine what was covered, the program evaluated treatment options based on their effectiveness and their cost.
Sin tax
a tax applied to nonessential items, such as alcohol and tobacco products.
TennCare
Tennessee's program to extend Medicaid coverage to include previously uninsured citizens in managed care plans.
Uncompensated care pool
an account financed by a tax on hospital bills or general tax revenue that establishes a pool of money used to reimburse hospitals for a portion of the cost of providing medical care to underinsured and uninsured patients.
Clinical testing of new drugs
the phase of testing required by the FDA in which the drug entity is first used in human subjects to determine its safety and efficacy.
Community chain pharmacy
a retail pharmacy that serves the general public and that is owned by a larger corporation (e.g., Walgreens, CVS, Rite-Aid).
Community independent pharmacy
a retail pharmacy that serves the general public and that is independently owned, usually by a pharmacist.
Counterfeiting
creating fraudulent medical products and passing them off as the real thing.
Dispenser
points of distribution for medications through the pharmaceutical supply chain (e.g., manufacturer, wholesaler, pharmacy).
Internet pharmacy
a retail entity in which consumers can purchase pharmaceuticals via an Internet Web site. Also known as a cyberpharmacy.
Investigational new drug (IND)
a chemical entity that shows promise as a potential new drug and has been approved by the FDA for clinical testing.
Mail-order pharmacy
the practice of pharmacy in which consumers mail in their prescriptions to a pharmacy to be filled and mailed back.
Medicalization
redefining or relabeling of a personal or social problem as a medical condition, thus necessitating treatment for it in the health care system.
Medication therapy management services (MTMS)
a broad range of activities within the scope of practice of pharmacists and other qualified health care providers intended to ensure that patients with multiple diseases and on many medications get the greatest benefit possible from their medication regimen.
New drug application (NDA)
the application submitted by a pharmaceutical manufacturer to the FDA for approval of a drug product that has completed the FDA's clinical testing requirements.
Nonprescription (over-the-counter [OTC], nonlegend) products
pharmaceutical products that can be purchased without a prescription.
Pharmakon
the Greek term for "drug," meaning remedy, poison, or magical charm
Self-care
the act of consumers selecting and using products or processes to treat health ailments without the supervision of a health care professional.
Substance abuse disorders
disorder related to the use and abuse of various substances, both legal and illegal. Also referred to as addictive disorders and chemical disorders.
Activities of Daily Living (ADLs)
activities that are performed during the course of a normal day, such as bathing, toileting, dressing, and eating.
Continuing care retirement community
a retirement community that provides a continuum of independent living, assisted living, and skilled nursing care on a single campus.
Hospice
care provided for individuals who are terminally ill or close to death
Long-term care services
a set of services - whether health, personal, or social - that is provided over a period of time to individuals who have lost some aspect of functioning.
Capitation
a type of prospective payment in which providers are paid a fixed amount each month for each enrolled patient, regardless of the amount of health care services actually provided.
Employee Retirement Income Security Act (ERISA)
a federal law designed to protect employees’ benefits, including health insurance and retirement plans. Self-insured plans are exempt from state employer mandates under ERISA.
Managed behavioral health care
specialty managed care organizations that attempt to reduce the costs of health care by carving out mental health services and using mental health practitioners at discounted fees thus reducing the length of mental health treatment, decreasing the use of hospital treatment, and increasing the use of ambulatory mental health care treatment.
Medication adherence
successfully following a specified medication treatment regimen
Mental health
functioning at a satisfactory level of physical, mental, and social well-being; a harmonious balance between the individual, his or her social group, and the larger environment context.
Psychopharmacology
treatment of mental disorders with the use of prescription drugs.
Psychotherapy
a variety of treatment modalities for treating and evaluating individuals with mental and/or emotional disorders.
Accrediting agencies
independent organizations that develop standards for entities such as hospitals, home care providers, and colleges and universities, among others. Accrediting organizations are not federal or state agencies.
Home care
provision of health care services in a patient's home that are intended to restore and maintain the patient's optimal level of well-being in a familiar environment.
Home care standards for pharmacists
standards established by the American Society of Health-System Pharmacists that apply to activities pertaining to home care pharmacy practice. These standards establish a minimum level of pharmacy services within this component of pharmacy practice.
Home health services
services usually associated with nursing care provided through a home health agency. They may also include speech and physical therapy or other types of rehabilitation therapies, homemaker services, social services, and hospice care.
Home infusion therapy
the parenteral administration of drugs, solutions, and nutrition to patients in their homes.
Instrumental activities of daily living (IADLs)
activities that are required for independent living, but are not necessarily performed on a daily basis, such as meal preparation, housework, balancing a checkbook, driving, and using a telephone.
Regulatory agencies
federal and state agencies that regulate components of the health care industry, such as the Department of Public Health (DPH), the Drug Enforcement Administration (DEA), and the Food and Drug Administration (FDA).