abuse
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access
the ability of persons needing health services to obtain appropriate care in a timely manner
accountability
the responsibility of clinicians and patients, respectively, for the provision and receipt of efficient and quality heath care services
activities of daily living (ADLs)
the most commonly used measure of disability, which includes 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
acute condition
short-term, intense medical care for an illness or injury, usually requiring hospitalization
agent
one of the factors of the epidemiology triangle, which must be present for an infectious disease to occur
alliance
a joint agreement between two organizations to share their resources without having joint ownership of assets
average daily census
average number of hospital beds occupied daily over a given period of time (est. number of inpatients receiving care each day at hospital)
average length of stay
the average number of days each patient stays in the hospital
balance bill
the practice in which the provider bills the patient for the leftover sum after insurance has only partially paid the charge initially billed
beneficiary
anyone covered under a particular insurance plan
bundled payment
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capitation
a reimbursement mechanism under which the provider is paid a set monthly fee per enrollee regardless of whether the enrollee sees the provider and how often the enrollee sees the provider
capacity
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case management
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
charge
the amount a provider bills for rendering a service
chronic
refers to diseases or health conditions that last for a significant amount of time (3 months+) and often with no complete cure or recovery
claim
a demand for payment of covered medical expenses sent to an insurance company
community health assessment
a method used for conducting broad assessments of populations a local or state level.
comoribidity
the presence of more than one health problem in an individual
concurrent utilization review
a process that determines, on a daily basis, the length of stay necessary and the ancillary services used in a hospital
cost-plus reimbursement
a payment scheme in which reimbursement to a provider is based on cost plus a factor to cover the value of capital
cost-shifting
shifting of costs from one entity to another as a way of making up losses in one area by charging more in other areas (also called cross-subsidization)
critical pathways
outcome-based, patient-centered, interdisciplinary case management tools designed to facilitate coordination of care among multiple clinical departments and caregivers; identifies planned medical interventions in a given case, along with expected outcomes
days of care
cumulative number of patient days over a given period of time
dependency
1. a person's reliance on another for assistance with common daily functions, such as bathing and grooming; 2. children's reliance on adults, such as parents or school officials, to recognize and respond to their health needs
defensive medicine
excessive medical tests and procedures performed as a protection against malpractice lawsuits, and otherwise regarded as unnecessary
disability
physical or mental handicap (partial or total) resulting from sickness or injury
discharge
a patient who has received inpatient services; the total number of discharges indicate access to hospital inpatient services as well as the extent of utilization
diagnostic related groups (DRGs)
a diagnostic category associated with a fixed payment to an acute care hospital under the prospective payment system
enabling services
services that enable people to receive medical care that otherwise would not be received despite insurance coverage (i.e. transportation and translation services)
enrollee
a person enrolled in a health plan, especially a managed care plan
environment
one of the factors of the epidemiology triangle, which is external to the host; it includes the physical, social, cultural, and economic aspects of the environment
fee-for-service
payment of separate fees to providers for each separate service, such as examination, administering a test, and hospitalization
fee schedule
a list of fees charged for various health care services
fraud
intentional filing of false billing claims or cost reports and provision of services that are not medically necessary
gatekeeping
the use of primary care physicians to coordinate health care services needed by enrollees in a managed care plan
health plan
the contractual arrangement between a managed care organization and an enrollee, including the collective array of covered health services to which the enrollee is entitled
health professional shortage areas (HPSAs)
a federal designation indicating an area has shortages of primary medical care, dental, or mental health providers (urban or rural, medical or public facilities)
host
one of the factors of the epidemiology triangle; an organism, generally a human, who receives the agent and becomes sick
incidence
the number of new cases of a disease in a defined population within a specified period
integration
various strategies that health care organizations employ to achieve economies of operation, diversify existing operations by offering new products or services, or gain market share
life expectancy
actuarial determination of how long, on average, a person of a given age is likely to live
long term care (LTC)
a variety of individualized, well-coordinated services that are designed to promote the maximum possible independence for people with functional limitations, provided over an extended period to meet the patients' physical, mental, social, and spiritual ne
maldistribution
an imbalance of the distribution of health professionals needed to maintain the health status of a given population at an optimal level (geographic and specialty)
managed 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 the price at which the servic
Medicaid
a joint federal-state program of health insurance for the poor
medically underserved area (MUA)
a federal designation for a geographic area that has a shortage of personal health services for its residents
Medicare
a federal program of health insurance for the elderly, certain disabled individuals, and people with end-stage renal disease
merger
unification of two or more organizations into a single entity through mutual agreement
money follows the person (MFP)
a demonstration program codified in the Deficit Reduction Act of 2005 to provide adequate federal funding to states for the sole purpose of moving qualified people whose care is funded by Medicaid from nursing homes back into community-based settings
moral hazard
consumer behavior that leads to a higher utilization of health care services because people are covered by insurance
morbidity
sickness
mortality
death
non-profit (organization)
a private organization, such as a hospital, that operates under Internal Revenue Code, Section 501 (c)(3), meaning they are tax exempt and in exchange they must provide some defined public good, such a service, education, or community welfare, and not dis
occupancy rate
the percentage of a hospital's total inpatient capacity that is actually utilized
outcomes
the end results of health care delivery; often viewed as the bottom-line measure of the effectiveness of the health care delivery system
palliation
serving to relieve or alleviate, such as pharmacologic pain management and nausea relief
patient day
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point of service (POS) plan
a managed care plan that allows its members to decide at the time they need medical care (at the point of service) whether to go to a provider on the panel or to pay more to receive services out of network
predisposing factors
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preferred provider organization (PPO)
a type of managed care organization that has a panel of preferred providers who are paid according to a discounted fee schedule (penalized for going to out of network providers)
premium cost sharing
employers' requirement that their employees pay a portion of the health insurance cost
prevalence
the number of cases of a given disease in a given population at a certain point in time
primary care
basic and routine health care provided in an office or clinic by a provider who takes responsibility for coordinating all aspects of a patient's health care needs (first contact with health care delivery system0
prospective reimbursement
a method of payment in which certain pre-established criteria are used to determine in advance the amount of reimbursement
prospective utilization review
a process that determines the appropriateness of utilization before the care is actually delivered
provider
any entity that delivers health care services and can either independently bill for those services or is tax supported (i.e. physicians, dentists, optometrists, therapists in private clinics; hospitals; diagnostic and imaging clinics; suppliers of medical
quality
the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
rate
the price for a health care service set by a third-party payer
reimbursement
the amount insurers pay to a provider (may just be a portion of the actual charge)
resource-based relative value scale (RBRVS)
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 teh condition
retrospective reimbursement
a payment scheme in which reimbursement rates are based on costs actually incurred
retrospective utilization review
a review of utilization after services have been delivered
risk management
limiting risks against lawsuits or unexpected events
quality of life
(1) factors considered important by patients, such as environmental comfort, security, interpersonal relations, personal preferences, and autonomy in making decisions when institutionalized; (2) overall satisfaction with life during and following a person
standards of participation
minimum quality standards established by government regulatory agencies to certify providers for delivery of services to patients covered by Medicare and Medicaid
surge capacity
the ability of a health care facility or system to expand its operations to safely treat an abnormally large influx of patients
third-party payers
in a multipayer system, the payers for covered services (i.e. the insurance company)
upcoding
a fraudulent practice in which a higher-priced service is billed when a lower-priced service is actually delivered
utilization
the extent to which health care services are actually used
vulnerability needs
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