Health Policy Terms - Final Exam
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The ability of persons needing health services to obtain appropriate care in a timely manner. Can you get medical care when you need it? If yes, you have access to medical care. Access is not the same as health insurance coverage, although insurance coverage is a strong predictor of access for primary care services.
Refers to the respective responsibility by clinicians and patients for the provision and receipt of efficient and quality health care services
Accountable Care Organization
- An integrated group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and satisfaction with care for a defined population
Activities of Daily Living
- 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.
Adjusted community rating
Also called modified community rating, it is a method of determining health insurance premiums that takes into account demographic factors such as age, gender, geography, and family composition, while ignoring other risk factors.
Adult Day Care
- 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 Foster Care
- 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.
Affordable Care Act
- Shortened name for the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010, and also nicknamed Obamacare.
Assisted Living Facility
A residential setting that provides personal care services, 24-hour supervision, scheduled and unscheduled assistance, social activities, and some health care services.
Use of store-and-forward technology that allows the users to review the information at a later time.
A reimbursement mechanism under which the provider is paid a set monthly fee per enrollee (sometimes referred to as a 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.
An organized approach to evaluating and coordinating care, particularly for patients who have complex, potentially costly problems that require an variety of services from multiple providers over an extended period.
Centers for Medicare & Medicaid Services
- Federal agency that administers the Medicare and Medicaid programs
Certificate of Need
- Control exercised by a government planning agency over expansion of medical facilities, for example, determination of whether a new facility should be opened in a certain location, whether an existing facility should be expanded, or whether a hospital should be allowed to purchase major equipment.
Conferred by the US Department of Health and Human Services, it entitles a hospital to participate in Medicare and Medicaid. A necessary condition is for the hospital to comply with the conditions of participation.
Children’s Health Insurance Program
- A joint federal-state program established as Title XXI of the Social Security Act under the 1997 Balanced Budget Act. CHIP provides health insurance for children from low-income families who do not qualify for Medicaid.
- AKA closed network, in network, closed access
- A health plan that pays for services only when provided by physicians and hospitals on the plan’s panel.
Community health assessment
A method used for conduction broad assessments of populations at a local or state level
Community health center
- Local, nonprofit, community-owned health care providers serving low-income and medically underserved communities.
Same insurance for everyone, as opposed to experience rating
Continuing care retirement home
- A CCRC integrates and coordinates independent living and institutional components of the LTC continuum. As a convenience factor, different levels of services are all located on one campus. Secondly, CCRCs guarantee delivery of higher-level services as future need arises.
Department of Health and Human Services
- The principle US federal agency responsible for protecting the health of all Americans and providing essential human services
- A physical incapacity that generally accompanies mental retardation and often arises at birth or in early childhood.
- A diagnostic category associated with a fixed payment to an acute care hospital under the prospective payment system
Both SNF and NF certifications. Dual certification allows a facility to admit both Medicaid and Medicare patients.
Health care information and services offered over the internet by professionals and nonprofessionals alike
Any type of professional therapeutic interaction that makes use of the internet to connect qualified mental health professionals and their clients.
Electronic Health Records
- Information technology applications that enable the processing of any electronically stored information pertaining to individual patients for the purpose of delivering health care services.
Setting of insurance rates based on a group’s actual health care expenses in a prior period. This allows healthier groups to pay less.
Medical care that produces relatively little or no benefit for the patient because of diminishing marginal returns
Health Information organization
- An independent organization that brings together health care stakeholders within a defined geographic area and governs electronic information exchange among these stakeholders with the objective of improving the delivery of health care in the community.
Health Maintenance organization
- A type of managed care organization that provides comprehensive medical care for a predetermined annual fee per enrollee
Healthcare Effectiveness Data and Information Set
- The standard for reporting quality information on managed care plans. The standards are developed by National Committee for Quality Assurance, a private nonprofit organization
Home Health Care
Services such as nursing, therapy, and health-related homemaker or social services brought to patients in their own home because such patients are generally unable to leave their homes safely to get the care they need.
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.
- AKA fee-for-service health insurance
- An indemnity plan allows the insured to obtain health care services anywhere and from any physician or hospital. Indemnity insurance and fee-for-service reimbursement to providers are closely intertwined.
Independent practice association
- A legal entity that physicians in private practice can join so that the organization can represent them in the negotiation of managed care contracts.
An organizational arrangement in which an HMO contracts with an independent practice association for the delivery of physician services.
Instrumental Activities of Daily Living
- A person’s ability to perform household and social tasks, such as home maintenance, cooking, shopping, and managing money.
Previously called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), it is a private, nonprofit organization that sets the standards and accredits most of the nation’s general hospitals and many of the long term facilities, psychiatric hospitals, substance abuse programs, outpatient surgery centers, urgent care clinics, group practices, community health centers, hospices, and home health agencies.
Long term care
- 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 and extended period to meet the patients’ physical, mental, social, and spiritual needs, while maximizing quality of life.
Long term care hospital
- A special type of long-stay hospital described in section 1886(d)(l)(B)(iv) of the Social Security Act. LTCHs must meet Medicare’s conditions of participation for acute (short-stay) hospitals and must have an average length of stay greater than 25 days. LTCHs serve patients who have complex medical needs and may suffer from multiple chronic problems requiring long term hospitalization.
Management Services Organization
- An MSO is an organization that brings management expertise and, in some instances, capital for expansion to physician group practices.
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 the price at which the services are purchased and, consequently, how much the providers get paid.
Refers to the quality features of primary health care delivery in the primary care settings such as physician office or community health center.
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 optimal health.
Medical records committee
A medical committee that is responsible for certifying complete and clinically accurate documentation of the care given to each patient
Practical application of the scientific body of knowledge for the purpose of improving health and creating efficiencies in the delivery of health care.
Mobile health, which is the use of wireless communication devices to support public health and clinical practice
National Committee on Quality Assurance
- A private organization that accredits managed care organizations and establishes standards for reporting quality.
National health insurance
- A tax-supported national health care program in which services are financed by the government but are rendered by private providers (e.g. Canada)
National health system
- A tax-supported national health care program in which the government finances and also controls the service infrastructure (e.g. Great Britain)
- A nursing home (or part of a nursing home) certified to provide services to Medicare beneficiaries.
- AKA open access
- A plan that allows access to providers outside the panel, but some conditions apply, such as higher out-of-pocket costs.
Providers selected to render services to the members of a managed care plan constitute its panel. The plan generally refers to them as “preferred providers”
Pay for performance
A reimbursement plan that links payment to quality and efficiency as an incentive to improve the quality of health care and to reduce costs.
Physician hospital organization
- A legal entity formed between a hospital and a physician group to achieve shared market objectives and other mutual interests.
Preadmission Screening and Resident Review
- An evaluation required under federal regulations before a patient can be admitted to a Medicaid-certified nursing facility to determine whether a nursing facility is the best alternative for individuals with serious mental illness or intellectual disability or whether their needs can be adequately met in community-based settings.
Preferred provider organization
- A type of managed care organization that has a panel of preferred providers who are paid according to a discounted fee schedule. The enrollees do have the option to go to out-of-network providers at a higher level of cost sharing.
Primary care case management
- A managed care arrangement in which a state contracts directly with primary care providers, who agree to be responsible for the provision and/or coordination of medical services for Medicare recipients under their care.
Prospective payment system
- Criteria for how much will be paid for a particular service is predetermined, as opposed to “retrospective payment” in which the amount of reimbursement is determined on the basis of costs actually incurred.
Provider induced demand
Artificial creation of demand by providers that enables them to deliver unneeded service to boost their incomes.
Provider Sponsored Organization
- AKA provider service organization
- A quasi-managed care organization that is a risk-bearing entity sponsored by physicians, hospitals, or jointly by physicians and hospitals to compete with regular MCOs.4
- The four key functions necessary for health care delivery:
Quality adjusted life year
- The value of 1 year of high-quality life, used as a measure of health benefit
Resource-based relative value scale
- A system 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.
Programs, generally government financed, that enable people to receive health care services when they lack private resources to pay for them. Without these programs, many people would have to forgo the services. For example, Medicaid becomes the safety net for long term care services once a patient has exhausted private funds. Community health centers are safety net providers for many uninsured and vulnerable populations
Local community centers for older adults that provide opportunities to congregate and socialize. Many centers offer subsidized meals, wellness programs, health education, counseling, and referral services.
Skilled nursing care
Medically oriented care provide mainly by a licensed nurse under the overall direction of a physician
Skilled nursing facility
- A nursing home (or part of a nursing home) certified to provide series under Medicare.
A credit card-like device with an embedded computer chip and memory to hold personal medical information that can be accessed and updated at a hospital or physician’s office
Socialized health insurance
- Health care is financed through government-mandated contributions by employers and employees. Health care is delivered by private providers (e.g. Germany, Israel, Japan)
Supplemental Security Income
- A federal program of income support for the disabled, including mental illness and some infectious diseases.
Technology in which telecommunications occur in real time
Implies the use of technology without cost considerations, especially when the benefits to be derived from the use of technology are small compared to the costs.
Although in general the terms telemedicine and telehealth can be used interchangeably, in a stricter sense, telehealth encompasses educational, research, and administrative uses, as well as clinical applications that involve nurses, psychologists, administrators, and other non-physicians.
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