Glossary/FAQ's

The following are terms likely to be useful as health care reform continues.

A B C D E F G H I J K L M N O P Q U-Z

Academic Medical Center: A group of related institutions including a teaching hospital or hospitals, a medical school and its affiliated faculty practice plan, and other health professional schools. (PPRC, 1997)
Access: The ability to obtain needed health care services. (PPRC, 1997)
Accountable Health Plan (AHP): A plan that would offer a nationally defined package of specified benefits and provide consumers with a report card on the quality and services offered by the plan.
Accountable Health Partnership: An organization of doctors and hospitals which provides care for people organized into large groups of purchasers.
Accounting Perspectives (Evaluation): Perspectives underlying decisions on which categories of goods and services to include as costs or benefits in an analysis. (Rossi and Freeman, 1993)
Activities of Daily Living (ADL): An index or scale that measures an individual's degree of independence in bathing, dressing, using the toilet, eating, and moving across a small room. (MedPAC, 1998)
Activity-based Costing (ABC): Activity-based costing defines costs in terms of an organization's processes or activities and determines costs associated with significant activities or events. ABC relies on the following three step process: Activity mapping, which involves mapping activities in an illustrated sequence; Activity analysis, which involves defining and assigning a time value to activities; and Bill of activities, which involves generating a cost for each main activity. (Canby, 1995)
Activity-based Management (ABM): Activity-based Management...supports operations by focusing on the causes of costs and how costs can be reduced. It assesses cost drivers that directly affect the cost of a product or service, and uses performance measures to evaluate the financial or nonfinancial benefit an activity provides. By identifying each cost driver and assessing the value the element adds to the healthcare enterprise, ABM provides a basis for selecting areas that can be changed to reduce costs. (Player, 1998)
Adjusted Admissions: A measure of all patient care activity undertaken in a hospital, both inpatient and outpatient. Adjusted admissions are equivalent to the sum of inpatient admissions and an estimate of the volume of outpatient services. This estimate is calculated by multiplying outpatient visits by the ratio of outpatient charges per visit to inpatient charges per admission. (AHA and ProPAC, 1996)
Adjusted Average Per Capita Cost (AAPCC): (1) Actuarial projections of per capita Medicare spending for enrollees in fee-for-service Medicare. Separate AAPCCs are calculated - usually at the county level - for Part A services and Part B services for the aged, disabled, and people with ESRD. Medicare pays risk plans by applying adjustment factors to 95 percent of the Part A and Part B AAPCCs. The adjustment factors reflect differences in Medicare per capita fee-for-service spending related to age, sex, institutional status, Medicaid status, and employment status. (ProPAC, 1996)
Adjusted Community Rate (ACR): Estimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use. Health plans estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. See Adjusted Average Per Capita Cost, Medicare Risk Contract. (PPRC, 1996)
Adjusted Community Rate (ACR) Proposal: A process by which a health plan contracting with Medicare estimates the cost of providing services to its Medicare enrolles based on costs and revenues from its commercial business. Health plans estimate their ACRs annually and adjust the subsequent year's supplemental benefits or premiums offered so that they do not receive a higher rate of return on Medicare enrollees than they do on their commercial business. (MedPAC, 1998)
Adjusted Payment Rate (APR): The Medicare capitated payment to risk-contract HMOs. For a given plan, the APR is determined by adjusting county-level AAPCCs to reflect the relative risks of the plan's enrollees. See Adjusted Average Per Capita Cost. (PPRC, 1996)
Adjusted Community Rate (ACR) Proposal: A process by which a health plan with a Medicare risk contract estimates the cost of providing services to its Medicare enrollees based on costs and revenues from its commercial business. Health plans estimate their ACRs annually and adjust the subse quent year's supplemental benefits or premiums offered so that they do not receive a higher rate of return on Medicare enrollees than they do on their commercial business. See Adjusted Average Per Capita Cost, Medicare Risk Contract. (PCRP, 1997)
Administrative Costs: Costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance activities, medical libraries and risk management. (AMA, 1993)
Adverse Selection: Adverse selection occurs when a larger proportion of persons with poorer health status enroll in specific plans or insurance options, while a larger proportion of persons with better health status enroll in other plans or insurance options. Plans with a subpopulation with higher than average costs are adversely selected. Plans with a subpopulation with lower than average costs are favorably selected.(MedPAC, 1998)
Age-at-Issuance Rating: A method for establishing health insurance premiums whereby an insurer's premium is based on the age of individuals when they first purchased health insurance coverage. (PPRC, 1996)
Age-Attained Rating: A method for establishing health insurance premiums whereby an insurer's premium is based on the current age of the beneficiary. Age-attained-rated premiums increase as the purchaser grows older.(PPRC, 1996)
Aggregate Margin: A margin that compares revenues to expenses for a group of hospitals, rather than a single hospital. It is computed by subtracting the sum of expenses for all hospitals in the group from the sum of revenues and dividing by the sum of revenues. (See also PPS Inpatient Margin, PPS Operating, Margin, and Total Margin.) (MedPAC, 1998)
Aggregate PPS Operating Margin/Aggregate Total Margin: A PPS operating margin or total margin that compare revenue to expenses for a group of hospitals, rather than a single hospital. It is computed by subtracting the sum of expenses for all hospitals in the group from the sum of revenues and dividing by the sum of revenues. (See also PPS Operating Margin and Total Margin.) (ProPAC)
Aid to Families with Dependent Children (AFDC) program: A program established by the Social Security Act of 1935 and eliminated by welfare reform legislation in 1996. AFDC provided cash payments to needy children (and their caretakers) who lacked support because at least one parent was unavailable. Families had to meet income and resource criteria specified by the state to be eligible. AFDC has been replaced by a new block grant program, but AFDC standards are retained for use in Medicaid. See Temporary Assistance for Needy Families. (PPRC, 1997)
Alliances (a/k/a Health Insurance Purchasing Cooperatives): Organizations consisting of large groups of purchasers of health care. The buying power of Alliances is expected to force competitive marketing among providers.
Allowed Charge: The amount Medicare approves for payment to a physician. Typically, Medicare pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. The allowed charge for a nonparticipating physician is 95 percent of that for a participating physician. Nonparticipating physicians may bill beneficiaries for an additional amount above the allowed charge. See Balance Billing, Participating Physician and Supplier Program. (MedPAC, 1998)
All-Payer System: A system by which all payers of health care bills - the government, private insurers, big companies and individuals - pay the same rates, set by the government, for the same medical service. This system does not allow for cost-shifting.
Alternative Delivery System: Provision of health services in settings that are more cost-effective than an inpatient, acute-care hospital, such as skilled and intermediary nursing facilities, hospice programs, and in-home services. (Source, 1994)
Ambulatory Care: Medical services provided on an outpatient (non-hospitalized) basis. Services may include diagnosis, treatment, surgery, and rehabilitation. (Source, 1994)
Ambulatory Patient Classifications (APC): A system for classifying outpatient services and procedures for purposes of payment. The APC system classifies some 7,000 services and procedures into about 300 procedure groups. (MedPac, 1998)
Ambulatory Surgical Center (ASC): A free-standing facility certified by Medicare that performs certain types of types of procedures on an outpatient basis. (MedPAC, 1998)
ASC-Approved Procedure: A procedure that has been approved by Medicare for payment in the ASC. A procedure is approved if it can be performed safely in the outpatient setting, if it was performed in the inpatient setting at least 20 percent of the time when it was approved, and if it is performed in physicians' offices no more than 50 percent of the time. (HCFA)
Assessment: The regular collection, analysis and sharing of information about health conditions, risks, and resources in a community. The assessment function is needed to identify trends in illness, injury, and death, the factors which may cause these events, available health resources and their application, unmet needs, and community perceptions about health issues. (PHIP, 1996)
Assignment: A process under which Medicare pays its share of the allowed charge directly to the physician or supplier. Medicare will do this only if the physician accepts Medicare's allowed charge as payment in full (guarantees not to balance bill). Medicare provides other incentives to physicians who accept assignment for all patients under the Participating Physician and Supplier Program. See Balance Billing, Nonparticipating Physicians, Participating Physician, Participating Physician and Supplier Program. (MedPAC, 1998)
Assurance: Making sure that needed health services and functions are available. (PHIP, 1996)
Balance Billing: (1) Physician charges in excess of Medicare-allowed amounts, for which Medicare patients are responsible, subject to a limit. (ProPAC). (2) In Medicare and private fee-for-service health insurance, the practice of billing patients in excess of the amount approved by the health plan. In Medicare, a balance bill cannot exceed 15 percent of the allowed charge for nonparticipating physicians. See Allowed Charge, Nonparticipating Physicians. (MedPAC, 1998)
Basic DRG Payment Rate: The payment rate a hospital will receive for a Medicare patient in a particular diagnosis-related group. The payment rate is calculated by adjusting the standardized amount to reflect wage rates in the hospital's geographic area (and cost of living differences unrelated to wages) and the costliness of the DRG. see also Standardized Amount, Diagnosis-Related Groups (MedPAC, 1998)
Basic Health Plan: Washington's state-sponsored health insurance plan for children and adults not eligible for the standard Medicaid program or who do not otherwise receive employment-based coverage. The plan pays all costs for children in families with incomes up to 200% of the federal poverty level, and part of insurance costs for adults up to 200% of the federal poverty level. Individuals or families above the income cutoff can purchase BHP coverage at unsubsidized rates. (Vital Signs, 1999)
Before-and-After Design (Evaluation): A reflexive design in which only a few before-intervention and after-intervention measures are taken. (Rossi and Freeman, 1993)
Behavioral Offset see Volume Offset.
Beneficiary: Someone who is eligible for or receiving benefits under an insurance policy or plan. The term is commonly applied to people receiving benefits under the Medicare or Medicaid programs. (MedPAC, 1998)
Beneficiary Liability: The amount beneficiaries must pay providers for Medicare-covered services. Liabilities include copayments, and coinsurance amounts, deductibles, and balance billing amounts. (MedPAC, 1998)
Benefit Package: Services covered by a health insurance plan and the financial terms of such coverage, including cost sharing and limitations on amounts of services. See Cost Sharing. (MedPAC, 1998)
Benefits (Evaluation): Net project outcomes, usually translated into monetary terms. Benefits may include both direct and indirect effects. (Rossi and Freeman, 1993)
Benefits-to-Costs Ratio (Evaluation): The total discounted benefits divided by the total discounted costs. (Rossi and Freeman, 1993)
Board of Health: The State Board of Health (for Washington State) has ten members, nine of whom are appointed by the Governor. The tenth member is the Secretary of the State Department of Health, or designee. The membership includes people who are experienced in matters of health and sanitation, an elected city official who is a member of a local board of health, a local health officer, and two people representing consumers of health care.
Bonus Payment: An additional amount paid by Medicare for services provided by physicians in Health Professional Shortage Areas. Currently, the bonus payment is 10 percent of Medicare's share of allowed charges. See Allowed Charge, Health Professional Shortage Area. (PPRC, 1997)
BRFSS: Behavioral Risk Factor Surveillance System. Annual telephone survey of state residents aged 18 and over that measures a variety of behaviors that affect health, such as diet, smoking, and use of preventive health services. (Vital Signs, 1999)
Broadbanding: Is the grouping of jobs and roles into fewer but wider pay ranges to encourage incentives such as management development, career ladders, and skill- and competency-based pay. (Pierson and Williams, 1994)
Budget Neutrality: For the Medicare program, adjustment of payment rates when policies change so that total spending under the new rules is expected to be the same as it would have been under the previous payment rules. (MedPAC, 1998)
Bundled Payment: A single comprehensive payment for a group of related services. (PPRC, 1997)
Bundled Service: A "bundled service" combines closely-related specialty and ancillary services for an enrolled group or insured population by a group of associated providers. (Queisser, 1995)
Bundling: The use of a single payment for a group of related services. (MedPAC, 1998)
Buy-In: Refers to the arrangments states make for paying Medicare premiums on behalf of those they are required or choose to cover. See Qualified Medicare Beneficiary, Specified Low-income Beneficiary. (PPRC, 1997)
Capacity: The ability to perform the core public health functions of assessment, policy development, and assurance on a continuous, consistent basis, made possible by maintenance of the basic infrastructure of the public health system, including human, capital, and technology resources. (PHIP, 1996)
Capacity standards: Statements of what public health agencies and other state and local partners must do as a part of ongoing, daily operations to adequately protect and promote health, and prevent disease and injury. (PHIP, 1996)
Capital Costs: Depreciation, interest, leases and rentals, and taxes and insurance on tangible assets like physical plant and equipment. (MedPAC, 1998)
Capitation: (1) Method of payment for health services in which a physician or hospital is paid a fixed amount for each person served regardless of the actual number of nature of services provided. (Source, 1994)
Carrier: (1) An organization, typically an insurance company, that has a contract with the Health Care Financing Administration to administer claims processing and make Medicare payments to health care providers for most Medicare Part B benefits. (See also Fiscal Intermediary and Part B.) (HCFA)
Carve-Out Coverage: Carve-out refers to an arrangement where some benefits (e.g., mental health) are removed from coverage provided by an insurance plan, but are provided through a contract with a separate set of providers. Also, carve-out may refer to a population subgroup for whom separate health care arrangements are made. (PPRC, 1997)
Carve-Out Service: A "carve-out" is typically a service provided within a standard benefit package but delivered exclusively by a designated provider or group. (Queisser, 1995)
Case Management: A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. (CMSA)
Case Mix: The mix of patients treated within a particular institutional setting, such as the hospital. Patient classification systems like DRGs can be used to measure hospital case mix. See also DRGs and Case-Mix Index. (MedPAC, 1998)
Case-Mix Index (CMI): The average DRG weight for all cases paid under PPS. The CMI is a measure of the relative costliness of the patients treated in each hospital or group of hospitals. See also DRG. (MedPAC, 1998)
Certified health plan: A managed health care plan, certified by the Health Services Commission and the Office of the Insurance Commissioner to provide coverage for the Uniform Benefits Package to state residents. (PHIP, 1996)
Charges: The posted prices of provider services. (MedPAC, 1998)
Charity Care: Free or reduced fee care provided due to financial situation of patients. (AMA, 1993)
CHIP: Children's Health Insurance Program. Federal program initiated in 1998, and jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs. In Washington state, the plan covers children in families with an ncome between 200 and 250% of the federal poverty level. (Vital Signs, 1999)
Clinical personal health services: Health services generally provided one-on-one in a medical clinical setting. (PHIP, 1996)
Clinical preventive services: Health care services delivered to individuals in clinical settings for the purpose of preventing the onset or progression of a health condition or illness. (PHIP, 1996)
Coding: A mechanism for identifying and defining physicians' services. See Current Procedural Terminology (CPT) (PPRC, 1996)
Coinsurance: A type of cost sharing where the insured party and insurer share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians' services, the beneficiary pays coinsurance of 20 percent of allowed charges. See Allowed Charge, Copayment, Cost Sharing, Deductible. (MedPAC, 1998)
Community Rating: (1) A system of setting health insurance premiums based on the average cost of providing medical services to all people in a geographic area, without adjusting for an individual's medical history.
Competency-Based Pay: Is compensation based on the development of those attributes that distinguish exceptional performers, such as customer orientation, team commitment and conflict resolution. (Pierson and Williams, 1994)
Competitive Bidding: A pricing method that elicits information on costs through a bidding process to establish payment rates that reflect the costs of an efficient health plan or health care provider. (MedPAC, 1998)
Competitive Medical Plan (CMP): A health plan that is eligible for a Medicare risk contract (although it is not a federally qualified HMO) because it meets specified requirements for service provision, payment, and financial solvency. See Federally Qualified HMO. (PPRC, 1996)
Composite Rate: Payment by Medicare that covers the bundle of services, tests, drugs, and supplies routinely required for dialysis treatment. (MedPAC, 1998)
Conceptual Utilization (Evaluation): Long-term, indirect utilization of the ideas and findings of an evaluation. (Rossi and Freeman, 1993)
Conversion Factor: The multiplicative factor used to translate relative value units into dollar amounts for physician payments under a fee schedule. (MedPAC, 1998)
Conversion Factor Update: Annual percentage change to the conversion factor. For Medicare, the update is set by a formula to reflect medical inflation, changes in enrollment, growth in the economy, and changes in spending due to other changes in law. See Conversion Factor, Sustainable Growth Rate, Sustainable Growth Rate System, Volume Performance Standard System. (MedPAC, 1998)
Coordinated Coverage: Method of integrating benefits payable under more than one health insurance plan (for example, Medicare and retiree health benefits). Coordinated coverage is typically orchestrated so that the insured's benefits from all sources do not exceed 100 percent of allowable medical expenses. Coordinated coverage may require beneficiaries to pay some deductibles or coinsurance. (PPRC, 1996)
Copayment: (1) A fixed dollar amount paid for a covered service by a health insurance enrollee. See Coinsurance and Deductible. (MedPAC, 1998)
(2) Amount that a member of a health plan has to pay for specific health services, such as visits to a physician.(Vital Signs, 1999)
Core functions: Three basic functions of the public health system: assessment, policy development, and assurance. State and local public health agencies must perform these functions in order to protect and promote health, and prevent disease and injury. (PHIP, 1996)
Cost Containment: Control or reduction of inefficiencies in the consumption, allocation, or production of health care services that contribute to higher than necessary costs. (Inefficiencies in consumption can occur when health services are inappropriately utilized; inefficiencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and, inefficiencies in production exist when the costs of producing health services could be reduced by using a different combination of resources.) (Source, 1994)
Cost Contract: An arrangement between a managed health care plan and HCFA under Section 1876 or 1833 of the Social Security Act, under which the health plan provides health services and is reimbursed its costs. The beneficiary can use providers outside the plan's provider network. (See also Health Care Prepayment Plan, Medicare Cost Contract, and Risk Contract.) (ProPAC)
Cost-Benefit Analysis (Evaluation): Analytical procedure for determining the economic efficiency of a program, expressed as the relationship between costs and outcomes, usually measured in monetary terms. (Rossi and Freeman, 1993)
Cost Effectiveness (Evaluation): The efficacy of a program in achieving given intervention outcomes in relation to the program costs. (Rossi and Freeman, 1993)
Cost Sharing: A general term referring to payments made by health insurance enrollees for convered services. Examples of cost sharing include deductibles, coinsurance, and copayments. See Balance Billing, Coinsurance, Copayment, Deductible. (MedPAC, 1998)
Cost Shifting: (1) When the cost of uncompensated care provided to the uninsured is passed onto the insured.
Costs (Evaluation): Inputs, buth direct and indirect, required to produce an intervention. (Rossi and Freeman, 1993)
Coverage Decision: A decision by a health plan whether to pay for or provide a medical service or technology for particular clinical indications. (PPRC, 1996)
Critical Paths: Focus on a patient and document essential steps in the diagnosis and treatment of a condition or the performance of a condition. They document a standard pattern of care to be followed for each patient and are developed primarily as a nursing tool specific to a healthcare organization and its unique system (Meyer and Feingold, 1995). Synonyms for Care Paths: critical paths, practice guidelines/parameters, clinical guidelines/protocols/algorithms, care tracks, care maps, care process models, case care coordination, collaborative case management plans, collaborative care tracks, collaborative paths, coordinated care, minimum standards, patient pathways, quality assurance triggers, reference guidelines, service strategies, recovery routes, target tracks, standards of care, standard treatment guidelines, total quality management, key processes, anticipated recovery paths (Lumsdon and Hagland, 1993)
Current Population Survey: U.S. Census Bureau survey conducted nationally to measure employment, health insurance status, income, and other variables.(Vital Signs, 1999)
Current Procedural Terminology (CPT): The coding system for physicians' services developed by the CPT Editorial Panel of the American Medical Association; basis of the HCFA Common Procedure Coding System. (MedPAC, 1998)
Customary Charge: One of the screens previously used to determine a physician's payment for a service under Medicare's customary, prevailing, and reasonable payment system. Customary charges were calculated as the physician's median charge for a given service over a prior 12-month period. See Customary, Prevailing, and Reasonable. (PPRC, 1996)
Customary, Prevailing, and Reasonable (CPR): The method of paying physicians under Medicare from 1965 until implementation of the Medicare Fee Schedule in January 1992. Payment for a service was limited to the lowest of (1) the physician's billed charge for the service, (2) the physician's customary charge for the service, or (3) the prevailing charge for that service in the community. Similar to the usual, customary, and reasonable system used by private insurers. See Medicare Fee Schedule, Usual, Customary, and Reasonable. (MedPAC, 1998)
Deductible: (1) The amount paid by the patient for medical care prior to insurance covering the balance.
Defensive Medicine: Physician practices just to reduce risk of a liability claim, e.g., performing diagnostic tests of marginal value. Defensive medicine totals an estimated $20.7 billion. (AMA, 1993)
Defined Contribution Coverage: A funding mechanism for health benefits whereby employers make a specific dollar contribution toward the cost of insurance coverage for employees, but make no promises about specific benefits to be covered. (PPRC, 1996)
Diagnosis-Related Groups (DRGs): (1) A system of classifying patients on the basis of diagnoses for purposes of payment to hospitals. (PPRC, 1996)
Direct Contracting: Direct contracting usually refers to a service (e.g. substance abuse treatment) that an employer contracts directly to save money on its employees' health plan, leaving employees free to choose among other eligible providers for their primary, obstetric, pediatric and other medical care needs. (Queisser, 1995)
Direct Utilization (Evaluation): Explicit utilization of specific ideas and findings of an evaluation by decision makers and other stakeholders. (Rossi and Freeman, 1993)
Discounting (Evaluation): The treatment of time in valuing costs and benefits, that is, the adjustment of costs and benefits to their present values, requiring a choice of discount rate and time frame. (Rossi and Freeman, 1993)
Disproportionate Share (DSH) Adjustment: A payment adjustment under Medicare's PPS or under Medicaid for hospitals that serve a relatively large volume of low-income patients. (MedPAC, 1998)
Distributional Effects (Evaluation): Effects of programs that result in a redistribution of resources in the general population. (Rossi and Freeman, 1993)
Dually Eligible: A Medicare beneficiary who also receives the full range of Medicaid benefits offered in his or her state. (MedPAC, 1998)
Economic Credentialing: [T]he use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff membership or privileges. (Council, 1991)
Effectiveness: The net health benefits provided by a medical service or technology for typical patients in community practice settings. (PPRC, 1994)
Efficacy: The net health benefits achievable under ideal conditions for carefully selected patients. (PPRC, 1996)
Employee Benefit Survey: Survey of employers administered by the U.S. Bureau of Labor Statistics to measure the number of employees receiving particular benefits such as health insurance, paid sick leave, and paid vacations. (Vital Signs, 1999)
Encounter Data: Description of the diagnosis made and services provided when a patient visits a health care provider under a managed-care plan. Encounter data provide much of the same information abailable on the bills submitted by fee-for-service providers. (MedPAC, 1998)
Enrollee: A person who is covered by health insurance. See also Beneficiary. (ProPAC, 1996)
ERISA: Employee Retirement Income Security Act. Federal law that regulates various employee benefits, and also exempts from state regulation those companies that manage their own health care benefit plans.(Vital Signs, 1999)
Evaluation and Management (EM) Service: A nonprocedural service, such as a visit or consultation, provided by physicians to diagnose and treat diseases and counsel patients. (MedPAC, 1998)
Environmental health: An organized community effort to minimize the public's exposure to environmental hazards by identifying the disease or injury agent, preventing the agent's transmission through the environment, and protecting people from the exposure to contaminated and hazardous environments. (PHIP, 1996)
ERISA: The Employee Retirement Income Security Act. ERISA exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination, and other state health reforms. (AMA, 1993)
Essential Community Providers: Providers such as community health centers that have traditionally served low-income populations. (PPRC, 1994)
Evaluation, see Formative Evaluation, Process Evaluation, Outcome Evaluation or Impact Evaluation
Evaluation and Management (EM) Service: A nontechnical service, such as a visit or consultation, provided by most physicians to diagnose and treat diseases and counsel patients. (PPRC, 1996)
Ex Ante Efficiency Analysis (Evaluation): An efficiency analysis undertaken prior to program implementation, usually as part of program planning, to estimate net outcome in relation to costs. (Rossi and Freeman, 1993)
Ex Post Efficiency Analysis (Evaluation): An efficiency analysis undertaken subsequent to knowing a program's net outcome effects. (Rossi and Freeman, 1993)
Excluded Hospitals and Distinct-Part Units: Specialty hospitals, rehabilitation, psychiatric, long-term care, children's, and cancer) that are excluded from Medicare's hospital inpatient PPS. Hospitals located in U.S. territories, Federal hospitals, and Christian Science Sanatoria are also excluded from PPS. Excluded facilities are paid under cost-reimbursement, subject to rate of increas limits. Rehabilitation facilities are slated to move into a prospective payment system in October 2000. Congress has also directed HCFA to develop a legislative proposal for a prospective payment system for long-term care facilities. (MedPAC, 1998)
Exclusion Coverage: Method of integrating payment for health benefits provided by Medicare and an employer. Medicare payments are subtracted from actual claims and the employer-sponsored plan's benefits are applied to the balance. Such coverage generally leaves the beneficiary responsible for the employer's plan's cost sharing and deductibles. (PPRC,1996)
Exclusions: Populations or services can be ecxluded from a mainstream managed care plan, and reimbursed on a fee-for-service basis. An exclusion generally employed if mainstream plans are unwilling to enroll high cost individuals or if a system of care does not exist to serve this population, because either their disease is rare or their rural or remote location prohibits the formation of a managed care network. (State. 1997)
Exclusive Provider Organization (EPO): (1) Consists of a group of hospitals, physicians and other providers who have a contractual agreement with an insurance company, employer or other third party to provide health care services to covered patients. Members are permitted to seek care outside of the network, but in such cases the benefits may be significantly reduced, or costs to the patient are higher. An EPO offers coverage only to contracted providers.
Experience Rating: A system used by insurers to set premium levels based on the insured's past loss experience. For example, rating may be based on service utilization for health insurance or on liability experience for professional liability insurance. See Community Rating. (PPRC, 1994)
Extended Care Facility: Is a skilled nursing facility that provides post-hospital services to be reimbursable by Medicare. (Schulz and Johnson, 1990 p.31)
Externalities (Evaluation): Effects of a program that impose costs on persons or groups who are not targets. (Rossi and Freeman, 1993)
Favorable Selection: The result of enrolling in a health plan a disproportionate share of healthy individuals compared with the population from which the share is drawn. See Adverse Selection, Risk Adjustment, Risk Selection.
Failsafe Budget Mechanism: An overall limit on Medicare spending proposed in a conference agreement (H.R. 2491) passed by the Congress in November 1995. The mechanism would obtain scored savings of $270 billion by the year 2002 based on economic assumptions of the Congressional Budget Office, and would provide a safeguard against unrestrained growth in Medicare spending. See Scored Savings. (PPRC, 1996)
Federal Deficit: Federal government spending in excess of revenues. (AMA, 1993)
Federal Poverty Level (FPL): The amount of income determined by the federal Department of Health and Human Services to provide a bare minimun for food, clothing, transportation, shelter, and other necessities. The level varies according to family size; for a family of three in 1999, the FPL is $13,880, or $1,157 per month. (Vital Signs, 1999)
Federally Qualified Health Center (FQHC): A health center in a medically underserved area that is eligible to receive cost-based Medicare and Medicaid reimbursement. (MedPAC, 1998)
Federally Qualified HMO: An HMO that has satisfied certain federal qualifications pertaining to organizational structure, provider contracts, health service delivery information, utilization review/quality assurance, grievance procedures, financial status, and marketing information as specified in Title XIII of the Public Health Service Act. See Health Maintenance Organization. (MedPAC, 1998)
Fee Disclosure: Physicians discuss, or have posted, charges for services rendered.
Fee-For-Service: (1) Is the most prevalent payment mechanism for physicians. It is reimbursing the provider whatever fee he or she charges on completion of a specific service. (Schulz and Johnson, 1990 p.38)
Fee Schedule: A list of predetermined payment rates for medical services. See Medicare Fee Schedule. (MedPAC, 1998)
Fee Schedule Payment Area: A geographic area within which payment for a given service under the Medicare Fee Schedule does not vary. See Geographic Adjustment Factor. (MedPAC, 1998)
Finance: The sources, timing, and channels of public health funds, and the authority to raise and distribute those funds. (PHIP, 1996)
Fiscal Intermediary: An entity, usually an insurance company, that has a contract with HCFA to determine and make Medicare payments for Part A and certain Part B benefits to hospitals and other providers of services and to perform related functions. (See also Part A and Part B.) (MedPAC, 1998)
Fiscal Year: A 12-month period for which an organization plans the use of its funds, such as the Federal government's fiscal year (October 1 to September 30). Fiscal years are referred to by the calendar year in which they end; for example, the Federal fiscal year 1998 began October 1, 1997. Hospitals can designate their own fiscal years, and this is reflected in differences in time periods covered by the Medicare Cost Reports. See also PPS year. (MedPAC 1998)
Five-Year Review: A review of the accuracy of Medicare's relative value scale that the Health Care Financing Administration is required to conduct every five years. (MedPAC, 1998)
Foodborne illness: Illness caused by the transfer of disease organisms or toxins from food to humans. (PHIP, 1996)
Formative Evaluation: Formative evaluation, including pretesting, is designed to assess the strengths and weakensses of materials or campaigning strategies before implementation. It permits necessary revisions before the full effort goes forward. Its basic purpose is to maximize the chance for program success before the communication activity starts. (Making, 1992)
Functional Independence Measure - Function Related Group: A Patient classification system developed for medical rehabilitation patients. (MedPAC, 1998)
Gaming: Gaining advantage by using improper means to evade the letter or intent of a rule or system. (PPRC, 1996)
Gainsharing: Is an incentive program focused on improving operating results, typically implemented at the group or organizational level. (Pierson and Williams, 1994)
Gatekeeper: The person in a managed care organization who decides whether or not a patient will be referred to a specialist for further care. Physicians, nurses and physician assistants all function as gatekeepers.
Generalists: Physicians who are distinguished by their training as not limiting their practice by health condition or organ system, who provide comprehensive and continuous services, and who make decisions about treatment for patients presenting with undifferentiated symptoms. Typically include family practitioners, general internists, and general pediatricians. (PPRC, 1996)
Geographic Adjustment Factor (GAF): The GAF for each service in a particular payment area is the average of the area's three geographic practice cost indexes weighted by the share of the service's total RVUs accounted for by the work, practice expense, and malpractice expense components of the Medicare Fee Schedule. See Geographic Practice Cost Index, Relative Value Units. (PPRC, 1996)
Geographic Practice Cost Index (GPCI): An index summarizing the prices of resources required to provide physicians' services in each payment area relative to national average prices. There is a GPCI for each component of the Medicare Fee Schedule: physician work, practice expense, and malpractice expense. The indexes are used to adjust relative value units to determine the correct payment in each fee schedule payment area. See Fee Schedule Payment Area, Medicare Fee Schedule. (MedPAC, 1998)
Governance: The legal authority and responsibility for the public health system. (PHIP, 1996)
Graduate Medical Education (GME): The period of medical training that follows graduation from medical school; commonly referred to as internship, residency, and fellowship training. See Undergraduate Medical Education. (MedPAC, 1998)
Gross Domestic Product (GDP): The total current market value of all goods and services produced domestically during a given period; differs from the gross national product by excluding net income that residents earn abroad. (MedPAC, 1998)
Group-Model HMO: An HMO that pays a medical group a negotiated, per capita rate, which the group distributes among its physicians, often under a salaried arrangement. See Health Maintenance Organization, Independent Practice Association, Network-Model HMO, Staff-Model HMO. (MedPAC, 1998)
Guaranteed Issue: The requirement that each insurer and health plan accept everyone who applies for coverage and guarantee the renewal of that coverage as long as the applicant pays the premium. (PPRC, 1996)
Guaranteed Renewable: The requirement that each insurer and health plan continue to renew health policies purchased by individuals as long as the person continues to pay the premium for the policy. (PPRC, 1996)
HCFA Common Procedure Coding System (HCPCS): A Medicare coding system based on the American Medical Association's Current Procedural Terminology (CPT), expanded to accommodate additional services covered by Medicare. See Coding, Current Procedural Terminology. (MedPAC, 1998)
Health Care Authorithy (HCA): Washington state agency that manage variuos state-sponsored health plans, including the Basic Health Plan and programs for public employees and retirees. HCA also provides funding for community clinics in various areas of the state. (Vital Signs, 1999)
Health Care Commission: A 17-member commission appointed by Governor Booth Gardner in May 1990 to study and develop comprehensive recommendations on fundamental reform of the health system in Washington State. Its goals were to recommend changes to Washington's health care system that would control costs, ensure universal access, implement incentives for the use of appropriate and effective health services, improve the health care liability system, and improve the state's purchasing of health services. The Commission's final report was submitted to the Governor and Legislature on November 30, 1992. The Commission sunset in December 1992. (PHIP, 1996)
Health Care Prepayment Plan (HCPP): Plans that receive payment for their reasonable costs of providing Medicare Part B services to Medicare enrollees. (See also Cost Contract and Risk Contract.) (AMCRA)
Health Care Provider: An individual or institution that provides medical services (e.g., a physician, hospital, laboratory). This term should not be confused with an insurance company which "provides" insurance. (OTA, 1993)
Health Impact Assessment: Health impact assessment is any combination of procedures or methods by which a proposed policy or program may be judged as to the effect(s) it may have on the health of a population. (Ratner, et al, 1997)
Health Insurance: Coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment. (Source, 1994)
Health Insurance Purchasing Cooperative (HIPC): A local board created under managed competition to enroll individuals, collect and distribute premiums, and enforce the rules that manage the competition. (PPRC, 1993) [Note: MeSH uses the term: INSURANCE POOLS]
Health IRAs: Proposed tax-preferred plans to encourage saving for future medical expenses. Funds in health IRAs could be later cashed out for medical expenses. (AMA, 1993)
Health Maintenance Organization (HMO): A managed care plan that integrates financing and delivery of a comprehensive set of health care services to an enrolled population. HMOs may contract with, directly employ, or own participating health care providers. Enrollees are usually required to choose from among these providers and in return have limited copayments. Providers may be paid through capitation, salary, per diem, or prenegotiated fee-for-service rates. (See also Capitation, Fee for Service, Managed Care, Managed Care Plan, Per Diem, and Preferred Provider Organization.) (ProPAC)
Health Plan: An organization that acts as insurer for an enrolled population. See Fee-for-Service, Managed Care, Medical Savings Account. (MedPAC, 1998)
Health Plan Employer Data and Information Set (HEDIS): A set of standardized measures of health plan performance. HEDIS allows comparisons between plans on quality, access and patient satisfaction, membership and utilization, financial information, and health plan management. HEDIS was developed by employers, HMOs, and the National Committee for Quality Assurance. (MedPAC, 1998)
Health Plan Purchasing Cooperative (HPPC): A health insurance purchasing entity advanced by some health system reform proposals to enroll individuals, collect premiums, purchase enrollees' insurance from participating health plans, and enforce the rules that manage health plan competition. (PPRC, 1994) [Note: MeSH term is INSURANCE POOLS]
Health Professional Shortage Area (HPSA): (1)An urban or rural geographic area, a population group, or a public or nonprofit private medical facility that the Secretary of Health and Human Services determines to be served by too few health professionals. Physicians who provide services in HPSAs qualify for the Medicare bonus payment. Replaces Health Manpower Shortage Area. (MedPAC, 1998) [Note: MeSH term is MEDICALLY UNDERSERVED AREA]

(2) Federally-Designated areas within a state that have fewer than a specified number of physicians per unit of population (currently 1 per 3,500) (Vital Signs, 1999)
Health Promotion: Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. (AJHP, 1989)
Health Risk Behaviors: Behaviors, such as smoking, lack of exercise, and overeating, that increase the potential for an individual to experience disease, or injury. (Vital Signs, 1999)
Health Risk Factors: In addition to "health risks behaviors" defined above,risk factors include genetic factor such as a family history of heart disease, or environmental factors such as living in a polluted area.(Vital Signs, 1999)
Health Services Act of 1993: A Washington State law enacted in May 1993 that sets forth early implementation measures and a process for overall reform of the health services system. The intent is to stabilize health services costs, assure access to essential services for all residents, actively address the health care needs of persons of color, improve the public's health, and reduce unwarranted health services costs. (PHIP, 1996)
Health Services Commission: A Governor-appointed state regulatory commission created by the Health Services Act of 1993. The Commission has five voting members, and the Insurance Commissioner is a non-voting member. Responsibilities include defining the Uniform Benefits Package (UBP) and supplemental benefits package, setting a maximum premium for the UBP, and establishing a system of accountability for systems reform and cost control. (PHIP, 1996)
Health Services Information System: A state-wide health care data system which will track health care costs, quality, utilization, and outcomes of care. The development, implementation, and custody of the system is the responsibility of the Department of Health, with policy direction and oversight provided by the Health Services Commission. (PHIP, 1996)
Health Services Research: Health services research is the study of the scientific basis and management of health services and their effect on access, quality, and cost of health care. (NLM)
HEDIS: Health Employer Data and Information Set. A set of performance measures for health plans developed for the National Committee for Quality Assurance (NCQA) that provides purchasers with information on effectiveness of care, plan finances and costs, and other measures of plan performance and quality.(Vital Signs, 1999)
Hierarchical Coexisting Conditions Model (HCC): A risk-adjustment model that groups beneficiaries based on their diagnoses. (MedPAC, 1998)
HMO: Health Maintenance Organization. A state-licensed health plan that offers prepaid, comprehensive coverage for both hospital and physician services, and also manages care and restricts members to using only healthcare providers affiliated with the plan. (Vital Signs, 1999)
Hospital Inpatient Prospective Payment System (PPS): Medicare's method of paying acute care hospitals for inpatient care. Prospective per case payment rates are set at a level intended to cover operating costs for treating a typical inpatient in a given DRG. Payments for each hsopital are adjusted for differences in area wages, teaching activity, care to the poor, and other factors. Hospitals may also receive additional payments to cover extra costs associated with atypical patients (outliers) in each DRG. Capital costs, originally excluded from PPS, are being phased into the system. By 2001, capital payments will be made on a fully prospective, per case basis. Prospective payment systems are also being developed for Medicare payments for home health services, outpatient hospital services, skilled nursing facilities, and rehabilitation facilities. See Capital Costs, Diagnosis-Related Groups, Outliers, Prospective Payment. (MedPAC, 1998)
Hospital Insurance (HI): The part of the Medicare program that covers the cost of hospital and related post-hospital services. Eligibility is normally based on prior payment of payroll taxes. Beneficiaries are responsible for an initial deductible per spell of illness and copayments for some services. Also called Part A coverage or benefits. (MedPAC, 1998)
Hospital Outshopping: The bypassing of local hospitals by patients in favor of other hospitals (usually because the patients believe the quality of care is better in the other hospital). (Gooding, 1994)
Impact Evaluation: Impact evaluation is the most comprehensive of the four evaluation types. it is desirable because it focuses on the long-range results of the program and changes or improvements in health status as a result. Impact evaluations are rarely possible beca use they are frequently costly, involve extended commitment and may depend upon other strategies in addition to communication. Also, the results often cannot be directly related to the effects of an activity or program because of other (external) Influences on the target audience which will occur over time. (Making, 1992)
Incidence: The number of new cases of a particular problem or condition that are identified or arise in a specified area during a specified period of time. (Rossi and Freeman, 1993)
Indemnity Plan: Insurance plan in which the insured person receives payment for covered expenses and then must reimburse the provider of services. (Vital Signs, 1999)
Independent Practice Association (IPA): An HMO that contracts with individual physicians or small physician groups to provide services to HMO enrollees at a negotiated per capita or fee-for-service rate. Physicians maintain their own offices and can contract with other HMOs and see other fee-for-service patients. See Group-Model HMO, Health Maintenance Organization, Network-Model HMO, Staff-Model HMO. (PPRC, 1996)
Indicator: A measure of a specific compononet of a health improvement strategy. An indicator can reflect an activity implemented to address a particular health issue-such as the number of children age two who have received all appropriate immunizations, or it might reflect outcomes from activities already implemented-such as a decline in the number of cases of childhood German Measles in any given year. (Vital Signs, 1999).
Indirect Medical Education (IME) Adjustment: A payment adjustment applied to DRG and outlier payments under PPS for hospitals that operate an approved graduate medical education program. For operating costs, the adjustment is based on the hospitals's ratio of the number of interns and residents to the number of beds. For capital costs, it is based on the hospital's ratio of interns and residents to average daily occupancy. (HCFA) (MedPAC, 1998)
Individual Insurance: Policies purchased by individuals directly from an insurance company, not through the auspices of another organization such as an employer or association (Vital Signs, 1999).
Infectious: Capable of causing infection or disease by entrance of organisms (e.g. bacteria, viruses, protozoans, fungi) into the body, when then grow and multiply. Often used synonymously with "communicable". (PHIP, 1996)
Input: The labor. capital, and other resources hospitals use to produce goods and services. (ProPAC, 1996)
Instrumental Activities of Daily Living (IADL): An index or scale that measures a patient's degree of independence in aspects of cognitive and social functioning, including shopping, cooking, doing housework, managing money, and using the telephone. (MedPAC, 1998)
Integrated Delivery System (IDS): An entity that usually includes a hospital, a large medical group, and an insurance vehicle such as an HMO or PPO. Typically, all provider revenues flow through the organization. (MedPAC, 1998)
Integrated Service Networks (ISNs): Integrated Service Networks are organizations that are accountable for the costs and outcomes associated with delivering a full continuum of health care services to a defined population. (Laws 1993) Under an ISN arrangement, a network of hospitals, physicians, and other health care providers furnish all needed health services for a fixed payment. (Kralewski, et al, 1995)
Intensity of Services: The number and complexity of resources used in producing a patient care service, such as a hospital admission or home health visit. Intensity of services reflects, for example, the amount of nursing care, diagnostic procedures, and supplies. (MedPAC, 1998) See also Volume and Intensity of Services
Intermediate Care Facility: Provides mainly maintenance services in such facilities such as homes for the aged and rest homes. (Schulz and Johnson, 1990 p.31)
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM): A diagnosis and procedure classification system designed to facilitate collection of uniform and comparable health information. This system is used to group patients into DRGs. (HCFA) (MedPAC, 1998)
Internal Rate of Return (Evaluation): The calculated value for the discount rate necessary for total discounted program benefits to equal total discounted program costs. (Rossi and Freeman, 1993)
Job-Lock: The inability of individuals to change jobs because they would lose crucial health benefits. (AMA, 1993)
A Key Contributor Plan: Is a performance-based incentive program created for the sole purpose of attracting, motivating and retaining key individuals or small groups. (Pierson and Williams, 1994)
Large Urban Area: A metropolitan statistical area with a population of one million or more, or a New England County Metropolitan Area with a population of 970,000 or more. (See also Metropolitan Statistical Area and Other Urban Area.) (ProPAC, 1996)
Life Expectancy: Average expected length of life for a group of people, of a particular age, chosen at a particular time (for example, for White infants born in 1960). (Vital Signs, 1999).
Limiting Charge: The maximum amount that a nonparticipating physician is permitted to charge a Medicare beneficiary for a service; in effect, a limit on balance billing. Starting in 1993 the limiting charge has been set at 115 percent of the Medicare-allowed charge. See Allowed Charge, Balance Billing, Nonparticipating Physician. (MedPAC, 1998)
Locality See Fee Schedule Payment Area.
Long-Term Care: Ongoing health and social services provided for individuals who need assistance on a continuing basis because of physical or mental disability. Services can be provided in an institution, the home, or the community, and include informal services provided by family or friends as well as formal services provided by professionals or agencies. (IOM)
Loss Ratio: The ratio of benefits paid out to premiums collected for a particular type of insurance policy. Low loss ratios indicate that a small proportion of premium dollars were paid out in benefits, while high loss ratios indicate that a high percentage of the premium dollars were paid out as benefits. (PPRC, 1996)
Major Teaching Hospitals: Hospitals with an approved graduate medical education program and a ratio of interns and residents to beds of 0.25 or greater. See also Indirect Medical Education Adjustment; Other Teaching Hospitals. (HCFA) (MedPAC, 1998)
Malpractice Expense: The cost of professional liability insurance incurred by physicians. A component of the Medicare relative value scale. See Relative Value Scale. (MedPAC, 1998)
Managed care: (1) An integrated system of health insurance, financing, and service delivery functions involving risk sharing for the delivery of health services and defined networks of providers. (PHIP, 1996)
Managed Care Plan: A health plan that uses managed care arrangements and has a defined system of selected providers that contract with the plan. Enrollees have a financial incentive to use participating providers that agree to furnish a broad range of services to them. Providers may be paid on a prenegotiated basis. (See also Health Maintenance Organization, Point-of-Service Plan, and Preferred Provider Organization.) (ProPAC)
Managed Competition: An approach to health system reform in which health plans compete to provide health insurance coverage for enrollees. Typically, enrollees would sign up with a health plan purchasing entity and would be offered a choice of health plans during an open season. (PPRC, 1994)
Mandated Employer Insurance: Employers are required to provide health benefit coverage for their employees. (AMA, 1993)
Mandated Insurance Benefits: Minimum health insurance coverage requirements specified by government statute. (OTA, 1993)
Market Basket Index: An index of the annual change in the prices of goods and services providers used to produce health services. There are separate market baskets for PPS hospital operating inputs and capital inputs; and SNF, home health agency and renal dialysis facility operating and capital inputs. (MedPAC, 1998) [refer to recent Health Care Financing Review issues for examples of Market Basket Index tables and figures.]
Medicaid: (1) A state/federal health benefit program for the poor who are aged, blind, disabled, or members of families with dependent children. Each stats sets its own eligibility standards. Only 40% of individuals with income below the poverty level currently are covered. (AMA, 1993)
(2) Insurance program, funded jointly by the federal and state governments and managed by the states, that provides medical coverage for low-income families and individual. (Vital Signs, 1999)
Medical Assistance Administration: Division within the Washington State Department of Social and HEalth Services that administers the Medicaid and other medical assistance programs. (Vital Signs, 1999)
Medical Savings Account (MSA): A health insurance option consisting of a high-deductible insurance policy and a tax-advantaged savings account. Individuals would pay for their own health care up to the annual deductible by withdrawing from the savings account or paying out of pocket. The insurance policy would pay for most or all costs of covered services once the deductible is met. (PPRC, 1996)
Medical Technology: Includes drugs, devices, techniques, and procedures used in delivering medical care and the support systems for that care. (AMA, 1993)
Medical Underwriting, see Underwriting
Medicare: (1) The federal health benefit program for the elderly and disabled that covers 35 million Americans or about 14% of the population for an annual cost of over $120 billion. Medicare pays for 25% of all hospital care and 23% of all physician services. (AMA, 1993)
Medicare Assignment: An agreement in advance by a physician to accept Medicare's Allowed charge as payment in full (guarantees not to balance bill). Medicare pays its share of the allowed charge directly to physicians who accept assignment and provides other incentives under the Participating Physician and Supplier Program. (PPRC, 1994)
Medicare+Choice: A program created by the Balenced Budget Act of 1997 to replace the existing system of Medicare risk and cost contracts. Beneficiaries will have the choice during an open season each year to enroll in a Medicare+Choice plan or to remain in traditional Medicare. Medicare+Choice plans may include coordinated care plans (HMOs, PPOs, or plans offered by provider -sponsored organizations); private fee-for-service plans; or plans with medical savings accounts. (MedPAC, 1998)
Medicare Choices Demonstration: A demonstration project designed to offer flexibility in contracting requirements and payment methods for Medicare's managed-care program. Participating plans include PSOs and PPOs. Plans are required to submit encounter data to HCFA, and most will test new risk-adjustment methods. (MedPAC, 1998)
Medicare Cost Contract: A contract between Medicare and a health plan under which the plan is paid on the basis of reasonable costs to provide some or all of Medicare-covered services for enrollees. See Health Care Prepayment Plan, Medicare Risk Contract. (MedPac, 1998)
Medicare Cost Report (MCR): An annual report required of all institutions participating in the Medicare program. The MCR records each institution's total costs and charges associated with providing services to all patients, the portion of those costs and charges allocated to Medicare patients, and the Medicare payments received. (See also PPS year.) (MedPAC, 1998)
Medicare Current Beneficiary Survey (MCBS): A longitudinal survey administered by HCFA that provides information on specific aspects of beneficiary access, utilization of services, expenditures, health insurance coverage, satisfaction with care, health status and physical functioning, and demographic information. (MedPAC, 1998)
Medicare Economic Index (MEI): An index that tracks changes over time in physician practice costs. From 1975 through 1991, increases in prevailing charge screens were limited to increases in the MEI. See Prevailing Charge, Volume Performance Standard System. (MedPAC, 1998)
Medicare Fee Schedule: The resource-based fee schedule Medicare uses to pay for physicians' services. See Resource-Based Relative Value Scale; Conversion Factor, Geographic Practice Cost Index. (MedPAC, 1998)
Medicare Provider Analysis and Review (MedPAR) File: A HCFA data file that contains charge data and clinical characteristics, such as diagnoses and procedures, for every hospital inpatient bill submitted to Medicare for payment. (ProPAC, 1996)
Medicare Risk Contract: A contract between Medicare and a health plan under which the plan receives monthly capitated payments to provide Medicare-covered services for enrollees, and thereby assumes insurance risk for those enrollees. A plan is eligible for a risk contract if it is a federally qualified HMO or a competitive medical plan. See Adjusted Average Per Capita Cost, Competitive Medical Plan, Medicare Cost Contract. (MedPAC, 1998)
Medicare SELECT: A form of Medigap insurance that allows insurers to experiment with the provision of supplemental benefits through a network of providers. Coverage of supplemental benefits is often limited to those services furnished by participating network providers and emergency, out-of-area care. (PPRC, 1996)
MedicarePlus: Program to offer private health plans to Medicare beneficiaries, as proposed under the conference agreement passed by the Congress in November 1995 (H.R. 2491 ). (PPRC, 1996)
Medigap Insurance: Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, coinsurance and balance bills, as well as payment for services not covered by Medicare. Medigap insurance must conform to one of ten federally standardized benefit packages. (MedPAC, 1998)
Medigap Plan: Plan purchased by Medicare enrollees to cover co-payments, deductibles, and health care goods or services not paid for by Medicare. Also known as a Medicare supplemental policy. (Vital Signs, 1999)
Medigap Policy: A privately purchased insurance policy that supplements Medicare coverage and meets specified requirements set by Federal statute and the National Association of Insurance Commissioners. (ProPAC)
Meta-Analysis: A systematic, typically quantitative method for combining information from multiple studies. (OTA, 1993)
Metropolitan Statistical Area (MSA): A geographic area that includes as least one city with 50,000 or more inhabitants, or a Census Bureau-defined urbanized area of at least 50,000 inhabitants and a total MSA population of at least 100,000 (75,000) in New England). (OMB)
Morbidity: A measure of disease incidence or prevalence in a given population, location, or other grouping of interest. (PHIP, 1996)
Mortality: A measure of deaths in a given population, location, or other grouping of interest. (PHIP, 1996)
National Claims History (NCH) System: A HCFA data reporting system that combines both Part A and Part B claims in a common file. The National Claims History system became fully operational in 1991. (MedPAC, 1994)
National Health Expenditures: Total spending on health services, prescription and over-the-counter drugs and products, nursing home care, insurance costs, public health spend, and health research and construction. In 1993, U.S. health expenditures are projected at $903 billion. (AMA, 1993)
National Health Insurance: The government as the single payor of medical bills. Key features often include: federal financing from general tax revenues; beneficiary contributions and/or payroll taxes; government fee controls; and prospective budgets. (AMA, 1993)
National Practitioner Data Bank: A computerized data bank maintained by the federal government that contains information on physicians against whom malpractice claims have been paid or certain disciplinary actions have been taken. (PPRC, 1994)
Needs Assessment (Evaluation): Systematic appraisal of the type, depth, and scope of a problem. (Rossi and Freeman, 1993)
Net Benefits: The total discounted benefits minus the total discounted costs (also called net rate of return). (Rossi and Freeman, 1993)
Network-Model HMO: An HMO that contracts with several different medical groups, often at a capitated rate. Groups may use different methods to pay their physicians. See Group-Model HMO, Health Maintenance Organization, Independent Practice Association, Staff-Model HMO. (MedPAC, 1998)
Nominal Value: Measurement of an economic amount in terms of current prices. See Real Value. (MedPAC, 1998)
Non-infectious: Not spread by infectious agents. Used to describe diseases such a heart disease, most cancers, and cirrhosis. Often used synonymously with "noncommunicable." (PHIP, 1996)
Nonparticipating Physician: A physician who does not sign a participation agreement and, therefore, is not obligated to accept assignment on all Medicare claims. See Assignment, Participating Physician, Participating Physician and Supplier Program. (MedPAC, 1998)
Nonphysician Practitioner: A health care professional who is not a physician. Examples include advanced practice nurses and physician assistants. (PPRC, 1996)
NCQA: National Committee for Quality Assurance. A private, not-for-profit organization that assesses and reports on the quality of managed care plans, with the goal of enabling purchasers and consumers of managed health care to distinguish among plans based on quality. (Vital Signs, 1999)
Nursing Facility: An institution that provides skilled nursing care and rehabilitation services to injured, functionally disabled, or sick persons. Formerly, distinctions were made between intermediate care facilities (ICFs) and skilled nursing facilities (SNFs). The Omnibus Budget Reconciliation Act of 1987 eliminated this distinction effective October 1, 1990, by requiring all nursing facilities to meet SNF certification requirements. See Skilled Nursing Facility. (MedPAC, 1998)
Occupational health: Activities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices and environments to reduce injury, and reducing or eliminating other health threats. (PHIP, 1996)
Opportunity Costs (Evaluation: The value of opportunities foregone because of an intervention project. (Rossi and Freeman, 1993)
Optimal Health: Optimal health...[is] a balance of physical, emotional, social, spiritual and intellectual health. (O'Donnell, 1989)
Other Teaching Hospitals: Hospitals with an approved graduate medical education program and a ratio of interns and residents to beds of less than 0.25. See Indirect Medical Education Adjustment and Major Teaching Hospitals. (MedPAC, 1998)
Other Urban Area: A metropolitan statistical area with a population of less than one million, or a New En-land County Metropolitan Area with fewer than 970,000 people. (See also Large Urban Area and Metropolitan Statistical Area.) (ProPAC, 1996)
Outcome standards: Long-term objectives that define optimal, measurable future levels of health status, maximum acceptable levels of disease, injury, or dysfunction, or prevalence of risk factors. (PHIP, 1996)
Out-of Pocket Costs: Total costs paid directly by consumers for insurance co-payment and deductibles, prescription or over-the-counter drugs, and other services.(Vital Signs, 1999)
Out-of-Pocket Expense: Payments made by an individual for medical services. These may include direct payments to providers as well as payments for deductibles and coinsurance for covered services, for services not covered by the plan, for provider charges in excess of the plan's limits, and for enrollee premium payments. (OTA, 1993)
Outcome: The consequence of a medical intervention on a patient. (PPRC, 1996)
Outcome Evaluation: Outcome evaluation is used to obtain descriptive data on a project and to document short-term results. Task-focused results are those that describe the output of the activity (e.g., the number of public inquiries received as a result of a public servi ce announcement). Short-term results describe the immediate effects of the project on the target audience (e.g., percent of the target audience showing increased awareness of the subject). Information that can result from an outcome evaluation includes: k nowledge and attitude changes; expressed intentions of the target audience; short-term or intermediate behavior shifts; and policies initiated or other institutional changes made. (Making, 1992)
Outcomes and Effectiveness Research (sometimes called Outcomes Research): Medical or health services research that attempts to identify the clinical outcomes (including mortality, morbidity, and functional status) of the delivery of health care. (PPRC, 1993)
Outliers: Cases with extremely long lengths of stay (day outliers) or extraordinarily high costs (cost outliers) compared with others classified in the same diagnosis-related group. Hospitals receive additional PPS payment for these cases. (ProPAC, 1996)
Paid Amount: The portion of a submitted charge that is actually paid by both third-party payers and the insured, including copayments and balance bills. For Medicare this amount may be less than the allowed charge if the submitted charge is less. or it may be more because of balance billing. See Allowed Charge. Balance Billing, Payment Rate, Submitted Charge. (PPRC, 1996)
Part A Medicare: Medical Hospital Insurance (HI) under Part A of Title XVIII of the Social Security Act, which covers beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and copayments. Part A services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments. (See also Fiscal Intermediary and Part B.) (ProPAC, 1996)
Part B Medicare: Medicare Supplementary Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act, which covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, copayments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues. (See also Carrier and Part A.) (ProPAC, 1996)
Partial Capitation: An insurance arrangement where the payment made to a health plan is a combination of a capitated premium and payment based on actual use of services; the proportions specified for these components determine the insurance risk faced by the plan. (PPRC, 1996)
Partial Risk Contract: A contract between a purchaser and a health plan, in which only part of the financial risk is transferred from the purchaser to the plan. See Self-Insured Health Plan. (PPRC, 1996)
Participating Physician: A physician who signs a participation agreement to accept assignment on all Medicare claims for one year. See Assignment. (PPRC, 1996)
Participating Physician and Supplier Program (PAR): A program that provides financial and administrative incentives for physicians and suppliers to agree in advance to accept assignment on all Medicare claims for a one-year period. See Assignment. (PPRC, 1996)
Pay for Skills: Is compensation that rewards individuals for developing the various skills necessary for certain roles or jobs. (Pierson and Williams, 1994)
Payment Rate: The total amount paid for each unit of service rendered by a health care provider, including both the amount covered by the insurer and the consumer's cost sharing: sometimes referred to as payment level. Also used to refer to capitation payments to health plans. For Medicare payments to physicians, this is the same as the allowed charge. See Allowed Charge. (PPRC, 1996)
PEBB: Public Employees Benefits Boards. Oversees insurance for Washington state employees and teachers and is managed by the state Health Care Authority. (Vital Signs, 1999)
Peer Review Organization (PRO): (1) An organization contracting with HCFA (Health Care Financing Administration) to review the medical necessity and the quality of care provided to Medicare beneficiaries; formerly called Utilization and Quality Control Peer Review Organization. (PPRC 1993)
Per Capita Health Care Spending: Annual spending on health care per person. (AMA, 1993)
Per Diem Payments: Fixed daily payments that do not vary with the level of services used by the patient. This method generally is used to pay institutional providers, such as hospitals and nursing facilities. (See also Capitation.) (ProPAC, 1996)
Performance Measure: A specific measure of how well a health plan does in providing health services to its enrolled population. Can be used as a measure of quality. Examples include percentage of diabetics receiving annual referrals for eye care, mammography rate, or percentage of enrollees indicating satisfaction with care. (PPRC, 1996)
Performance Standard: The target rate of expenditure growth set by the Volume Performance Standard system. See Volume Performance Standard System. (PPRC, 1996)
Personal Health Care Expenditures: (1) These are outlays for good and services relating directly to patient care. (Health, United States, 1993)
Physician/Hospital Organization (PHO): (1) A structure in which a hospital and physicians - both in individual and group practices - negotiate as an entity directly with insurers.
Physician Income: Net income after expenses and before taxes. Median net income for physicians in 1991 was $139,000. Physician net income in 1991 was 13% of U.S. health expenditures. (AMA, 1993)
Physician Services: One portion of national health care expenditures. Includes physicians' overhead, administrative expenses, and income. Total expenditures for physician services in 1991 were $142 billion or 19% or total health spending. (AMA, 1993)
Physician Work: A measure of the physician's time, physical effort and skill, mental effort and judgment, and stress from iatrogenic risk associated with providing a medical service. A component of the Medicare relative value scale. See Relative Value Scale. (PPRC, 1996)
Play or Pay: Employers would be required to provide health insurance to their employees or to pay a special government program tax. (AMA, 1993)
Point-of-Service (POS) Plan: (1) A managed-care plan that combines features of both prepaid and fee-for-service insurance. Health plan enrollees decide whether to use network or non-network providers at the time care is needed and usually are charged sizable copayments for selecting the latter. See Health Plan, Health Maintenance Organization, Preferred Provider Organization. (PPRC, 1996)
(2) A helath plan in which enrollees select providers either within or outside of a preferred network, with co-payment or deductibles higher for out-of-network providers. (Vital Signs, 1999)
Policy Development: The process whereby public health agencies evaluate and determine health needs and the best ways to address them. (PHIP, 1996)
Policy Significance (Evaluation): The significance of an evaluation's findings for policy and program development (as opposed to their statistical significance). (Rossi and Freeman, 1993)
Policy Space (Evaluation): The set of policy alternatives that are within the bounds of acceptability to policymakers at a given point in time. (Rossi and Freeman, 1993)
Population at Need (Evaluation): Units of potential targets that currently manifest a particular condition. (Rossi and Freeman, 1993)
Population at Risk: Segment of population with significant probability of having or developing a particular condition. (Rossi and Freeman, 1993)
Population Carve-outs: A population carve-out provides health care to a designated population, targeted or defined by a specific health condition. (State, 1997)
Portability: (1) An individual changing jobs would be guaranteed coverage with the new employer, without a waiting period or having to meet additional deductible requirements. (AMA, 1993)
Potentially Avoidable Hospitalizations (PAHs): Admissions to a hospital that could have been avoided if adequate and timely health care had been available. (Vital Signs, 1999)
PPS Inpatient Margin: -A measure that compares PPS operating and capital payments with Medicare-allowable inpatient operating and capital costs. It is calculated by subtracting total Medicare-allowable inpatient operating and capital costs from total PPS operating and capital payments and dividing by total PPS operating and capital payments. See also PPS Operating Margin.) (ProPAC, 1996)
PPS Operating Margin: A measure that compares PPS operating payments with Medicare-allowable inpatient operating costs. This measure excludes Medicare costs and payments for capital, direct medical education, organ acquisition, and other categories not included among Medicare-allowable inpatient operating costs. It is calculated by subtracting total Medicare-allowable inpatient operating costs from total PPS operating payments and dividing by total PPS operating payments. (ProPAC, 1996)
PPS Year: A designation referring to hospital cost reporting periods that begin during a given Federal fiscal year, reflecting the number of years since the initial implementation of PPS. For example, PPS1 refers to hospital fiscal years beginning during Federal fiscal year 1984, which was the first year of PPS. For a hospital with a fiscal year beginning July 1, PPS 1 covers the period from July 1, 1984, through June 30, 1985. (See also Fiscal Year) (ProPAC, 1996)
Practice Expense: The cost of nonphysician resources incurred by the physician to provide services. Examples are salaries and fringe benefits received by the physician's employees, and the expenses associated with the purchase and use of medical equipment and supplies in the physician's office. A component of the Medicare relative value scale. See Relative Value Scale. (PPRC, 1996)
Practice Expense Relative Value: A value that reflects the average amount of practice expenses incurred in performing a particular service. All values are expressed relative to the practice expenses for a reference service whose value equals one practice expense unit. See Relative Value Scale. (PPRC, 1996)
Practice Guideline: An explicit statement of what is known and believed about the benefits, risks, and costs of particular courses of medical action. intended to assist decisions by practitioners, patients, and others about appropriate health care for specific clinical conditions. (PPRC, 1994)
Practice Parameters: Strategies for patient management, developed to assist physicians in clinical decisionmaking. Parameters improve quality and assure appropriate utilization of health services. (AMA, 1993)
Prevalence: Number of existing cases with a particular condition in a specified area at a specified time. (Rossi and Freeman, 1993)
Prevention: Actions taken to reduce susceptibility or exposure to health problems (primary Prevention), detect and treat disease in early stages (secondary prevention), or alleviate the effects of disease and injury (tertiary prevention). (PHIP, 1996)
Preexisting Condition Exclusion: A practice of some health insurers to deny coverage to individuals for a certain period, for example, six months, for health conditions that already exist when coverage is initiated. See Portability. (PPRC, 1996)
Preexisting Condition Limitations: A provision in insurance policies that excludes health conditions existing prior to coverage sign up. These limitations exclude specified conditions entirely or for a specified period. When an individual changes jobs and enrolls in a new insurance plan, these limitations can cause a critical gap in health benefits. (AMA, 1993)
Preferred Provider Organizations (PPO): (1) Are somewhat similar to IPAs and HMOs in that the PPO is a corporation that receives health insurance premiums from enrolled members and contracts with independent doctors or group practices to provide care. However, it differs in that doctors are not prepaid, but they offer a discount from normal FFS charges. (Schulz and Johnson, 1990 p.40)
Premium: (1) An amount paid periodically to purchase health insurance benefits. (PPRC, 1996)
(2) The amount paid or payable in advance, often in monthly installments, for an insurance policy.(Vital Signs, 1999)
Prepaid Group Practice Plan: A plan which specified health services are rendered by participating physicians to an enrolled group of persons, with a fixed periodic payment made in advance by (or on behalf of) each person or family. If a health insurance carrier is involved, a contract to pay in advance for the full range of health services to which the insured is entitled under the terms of the health insurance contract. A Health Maintenance Organization (HMO) is an example of a prepaid group practice plan. (Source, 1994)
Preventive Services: Services intended to prevent the occurrence of a disease or its consequences. (OTA, 1993)
Prevailing Charge: One of the screens that determined a physician's payment for a service under the Medicare CPR payment system. In Medicare, it was the 75th percentile of customary charges, with annual updates limited by the MEI. See Customary Charge; Customary, Prevailing, and Reasonable; Medicare Fee Schedule; Medicare Economic Index. (PPRC, 1996)
Prevention Measures: Actions taken to reduce susceptibility or exposure to health problems, to detect and treat disease in early stages, or to alleviate the effects of disease and injury. (Vital Signs, 1999)
Primary Care: A basic level of health care provided by the physician from whom an individual has an ongoing relationship and who knows the patient's medical history. Primary care services emphasize a patient's general health needs such as preventive services, treatment of minor illnesses and injuries, or identification of problems that require referral to specialists. Traditionally, primary care physicians are family physicians, internists, gynecologists and pediatricians.
Primary Care Case Management (PCCM): A Medicaid managed care program in which an eligible individual may use services only with authorization from his or her assigned primary care provider. That provider is responsible for locating, coordinating, and monitoring all primary and other medical services for enrollees. See also Prepaid Health Plan. (HCFA) (ProPAC, 1996)
Primary Care Provider: Health care professional capable of providing a wide variety of basic health services. Primary care providers include practitioners of family, general, or internal medicine; pediatricians and obstetricians; nurse practitioners; midwives; and physician's assistant in general or family practice. (Vital Signs, 1999)
Primary Dissemination (Evaluation): Dissemination of the detailed findings of an evaluation to sponsors and technical audiences. (Rossi and Freeman, 1993)
Private Expenditures: These are outlays for services provided or paid for by nongovernmental sources - consumers, insurance companies, private industry, and philanthropic and other nonpatient care sources. (Health, United States, 1993)
Process Evaluation: Process evaluation examines the procedures and tasks involved in implementing a program. This type of evaluation also can look at the administrative and organizational aspects of the program. (Making, 1992)
Productivity: The ratio of outputs (goods and services produced) to inputs (resources used in production). Increased productivity implies that the hospital or health care organization is either producing more output with the same resources or the same output with fewer resources. (ProPAC, 1996)
Professional Liability Insurance: The insurance physicians purchase to help protect themselves from the financial risks associated with medical liability claims. (PPRC, 1996)
Professional Standards Review Organization (PSRO): Organization responsible for determining whether care and services provided were medically necessary and meet professional standards regarding eligibility for reimbursement under the Medicare and Medicaid programs. (Source, 1994)
Profiling: Expressing a pattern of practice as a rate - some measure of utilization (costs or services) or outcome (functional status, morbidity, or mortality) aggregated over time for a defined population of patients - to compare with other practice patterns. May be done for physician practices, health plans, or geographic areas. (PPRC, 1996)
Prospective Payment: A method of paying health care providers in which rates are established in advance. Providers are paid these rates regardless of the costs they actually incur. (ProPAC, 1996)
Promotion: Health education and the fostering of healthy living conditions and lifestyles. (PHIP, 1996)
Prospective Payment System (PPS): (1) The Medicare system used to pay hospitals for inpatient hospital services; based on the DRG classification system.
Protection: Elimination or reduction of exposure to injuries and occupational or environmental hazards. (PHIP, 1996)
Public Health: Activities that society does collectively to assure the conditions in which people can be healthy. This includes organized community efforts to prevent, identify, preempt, and counter threats to the public's health. (PHIP, 1996)
In Washington state, the Department of Health and local health departments have primary responsibility for protecting the health of the public. The State Board of Health and local boards of health also provide forums for developing health policy and can make rules and regulations to protect and promote the health of the publci. (Vital Signs, 1999)
Public Health Department/District: Local (county or multi- county) health agency, operated by local government, with oversight and direction from a local board of health, which provides public health services throughout a defined geographic area. (PHIP, 1996)
Quality Assurance: A formal, systematic process to improve quality of care that includes monitoring quality, identifying inadequacies in delivery of care, and correcting those inadequacies. (PPRC, 1996)
Quality Assurance: Monitoring and maintaining the quality of public health services through licensing and discipline of health professionals, licensing of health facilities, and the enforcement of standards and regulations. (PHIP, 1996)
Rate: Occurrence or existance of a particular condition expressed as a proportion of units in the population (e.g., deaths per 1,000 adults. (Rossi and Freeman, 1993)
Rate Setting: A method of paying health care providers in which the Federal or state government establishes payment rates for all payers for various categories of health services. (PPRC and ProPAC, 1996)
Real Value: Measurement of an economic amount corrected for change in price over time (inflation), thus expressing a value in terms of constant prices. See Nominal Value. (PPRC, 1996)
Refinement: The correction of relative values in Medicare's relative value scale that were initially set incorrectly. (PPRC, 1996)
Reflexive Controls (Evaluation): Outcome measures taken on participating targets before interventions and used as control observations. (Rossi and Freeman, 1993)
Reinsurance: An insurance arrangement where an insurer pays a premium into a pool, and any claims paid by the insurer above a predefined dollar level are covered in whole or in part by the pool. (PPRC, 1996)
Relative Value: A value that reflects a comparison with a standard. See Relative Value Scale. (PPRC, 1996)
Relative Value Scale (RVS): An index that assigns weights to each medical service: the weights represent the relative amount to be paid for each service. The RVS used in the development of the Medicare Fee Schedule consists of three cost components: physician work, practice expense, and malpractice expense. See Malpractice Expense, Medicare Fee Schedule. Physician Work, Practice Expense, Resource-Based Relative Value Scale. (PPRC, 1996)
Relative Value Unit (RVU): The unit of measure for a relative value scale. RVUs must be multiplied by a dollar conversion factor to become payment amounts. See Conversion Factor, Relative Value, Relative Value Scale. (PPRC, 1996)
Replacement Insurance: Insurance that substitutes coverage under one policy for coverage under another policy. (PPRC, 1996)
Resource-Based Relative Value Scale (RBRVS): A relative value scale that is based on the resources involved in providing a service. See Relative Value Scale. (PPRC, 1996)
Revenue Share: The proportion of a practice's total revenue devoted to a particular type of expense. For example, the practice expense revenue share is that proportion of revenue used to pay for practice expense. (PPRC, 1996)
Risk: The probable amount of loss foreseen by an insurer in issuing a contract. The term sometime also applies to the person insured or to the hazard insured against. (Source, 1994)
Risk-Adjusted Capitation: A method of payment to either an organization or individual provider which takes the form of a fixed amount per person per period and which is varied to reflect the health characteristics of individuals or groups of individuals. (Conrad, 1995)
Risk Adjuster: A measure used to adjust payments made to a health plan on behalf of a group of enrollees in order to compensate for spending, that is expected to be lower or higher than average, based on the health status or demographic characteristics of the enrollees. (PPRC, 1996)
Risk Adjustment: Risk Adjustment uses the results of risk assessment in order to fairly compensate plans that, by design or accident, end up with a larger-than-average share of high-cost enrollees. (Kent, 1995)
Risk Assessment: (1) Is the means by which plans and policymakers estimate the anticipated claims costs of enrollees. (Kent, 1995)
(2) Identifying and measuring the presence of direct causes and risk factors which, based on scientific evidence or theory, are thought to directly influence the level of a specific health problem. (PHIP, 1996)
Risk communication: The production and dissemination of information regarding health risks and methods of avoiding them. (PHIP, 1996)
Risk Contract: An arrangement between a managed health care plan and HCFA under section 1876 of the Social Security Act. Under this contract, enrolled Medicare beneficiaries generally must use the plans' provider network. Capitation payments to plans are set at 95 percent of the AAPCC. (See also Adjusted Average Per Capita Cost, Capitation, Cost Contract, and Health Care Prepayment Plan, Medicare Risk Contract.) (ProPAC, 1996)
Risk Factor: Behavior or condition which, based on scientific evidence or theory, is thought to directly influence susceptibility to a specific health problem. (PHIP, 1996)
Risk Measure: Measure of the expected per capita costs of efficiently provided health care services to a defined group for a specified future period. (PPRC, 1993)
Risk Pools: Legislatively created programs that group together individuals who cannot get insurance in the private market. Funding for the pool is subsidized through assessments on insurers or through government revenues. Maximum rates are tied to the rest of the market. (AMA, 1993)
Risk Selection: (1)The process by which health plans seek to enroll healthy, low-cost subscribers. (Kent, 1995)
(2) Enrollment choices made by health plans or enrollees on the basis of perceived risk relative to the premium to be paid. (See also Risk Adjustment.) (PPRC and ProPAC, 1996)
(3) Any situation in which health plans differ in the health risk associated with their enrollees because of enrollment choices made by the plans or enrollees, that is, where one health plan's expected costs differ from another's due to underlying differences in their enrolled populations. (PPRC, 1996)
Scored Savings: Amount of savings expected to be obtained from enacting new legislation. Estimated by the Congressional Budget Office by calculating the difference in spending projected under current law and under the proposed legislation. (PPRC, 1996)
Secondary Dissemination (Evaluation): Dissemination of summarized, often simplified findings to audiences composed of stakeholders. (Rossi and Freeman, 1993)
Secondary Insurance: Any insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans, and Medicaid. (PPRC, 1996)
Self-Insured Health Plan: Employer-provided health insurance in which the employer, rather than an insurer, is at risk for its employees' medical expenses. (PPRC, 1996)
Sensitivity: Extent to which the criteria used to identify the target population results in the inclusion of persons, groups, or objects at risk. (Rossi and Freeman, 1993)
Sentinel Event: An adverse health event that could have been avoided through appropriate care. An example would be hospitalization for uncontrolled hypertension that might have been avoided. (PPRC, 1993)
Service Carve-outs: A service carve-out provides a set of specific services outside a mainstream plan; these services might be administered separately and reimbursed on either a capitated or a fee-for-service basis. (State, 1997)
Shadow Controls (Evaluation): Expert and participant judgments used to estimate net impact. (Rossi and Freeman, 1993)
Shadow Prices (Evaluation): Imputed or estimated costs of goods and services not valued accurately in the marketplace. Shadow prices also are used when market prices are inappropriate due to regulation or externalities. (Rossi and Freeman, 1993)
Short Stay Hospitals: Those hospitals in which the average length of stay is less than 30 days. The American Hospital Association and National Master Facility Inventory (a NCHS dataset) define short-term hospitals as hospitals in which more than half the patients are admi tted to units with an average length of stay of less than 30 days. (Health, United States, 1993)
Single Payer: In an attempt to provide universal coverage to all residents of a state or country, the state (or country) becomes the single payer for all health care bills.
Single Payer System: (May be known as the Canadian System) A single, government fund pays for everyone's health care using tax revenue. (AMA, 1993)
Single-Specialty Group Practice: Physicians in the same specialty pool their expenses, income, and offices. (Schulz and Johnson, 1990 p.29)
Site-of-Service Differential: The difference in the amount paid when the same service is performed in different practice setting, for example, an outpatient visit in a physician's office or a hospital clinic. (PPRC, 1996)
Skilled Nursing Facility (SNF): (1) Provides registered nursing services around the clock. (Schulz and Johnson, 1990 p.31)
Small Market Insurance Reform: Changes in the marketing of insurance to small businesses that increase the availability and affordability of coverage. (AMA, 1993)
Social Indicator: Periodic measurements designed to track the course of a social problem over time. (Rossi and Freeman, 1993)
Sole Community Hospital: A hospital Medicare designates as the only provider of hospital care in its market area. Under PPS, sole community hospitals benefit form payment provisions intended to ensure their financial viability and access to hospital services for Medicare beneficiaries. (ProPAC, 1996)
Solo Practice: A physician who practices alone or with others but does not pool income or expenses. (Schulz and Johnson, 1990 p.28)
Specificity: Extent to which the criteria used to identify the target population results in the exclusion of persons, groups, or objects not at risk. (Rossi and Freeman, 1993)
Spider Graphs/Charts: A technique or tool developed by Ernst & Young, to combine analyses of a market's level of managed care evolution with an internal readiness review. It involves three steps: Market Assessment, Internal Analysis and Gap Analysis. Components of the graph include: Network formation, Managed care penetration, Utilization levels, Reimbursement, Excess inpatient capacity, Geographic distribution, Commercial premium, Physician integration, Managed care characteristics, Employer and purchaser base, Outcomes management, Strategic alignment, Organization and Governance, Access to markets, Delivery systems, Medical management, Finance, Performance management, and Information technology. (Insider, 1997)
Staff Model HMO: (1) Physicians are employed and salaried by consumer owners and services are provided exclusively to HMO plan enrollees. Group Health Cooperative of Puget Sound in Seattle is an example. (Schulz and Johnson, 1990 p.28 and 39)
Standards: Accepted measures of comparison having quantitative or qualitative value. (PHIP, 1996)
Standard Benefits Package: (1) A core set of health benefits that everyone in the country should have - either through their employer, a government program, or a risk pool. (AMA, 1993)
Standardized Amount: An amount used as the basis for payment under PPS. It is intended to represent the national average operating cost of inpatient treatment for a typical Medicare patient in a reasonably efficient hospital in a large urban or other area. Standardized amount are based on Medicare costs reported by hospitals for cost reporting periods ending in 1982, adjusted for geographic location and certain hospital characteristics, such as teaching activity. The adjusted amounts are updated to the year of payment by an annual update factor. (See also Update Factors.) (CRS) (ProPAC, 1996)
State Population Survey: Survey conducted by the State of Washington to provide more accurate information than the U.S. Census Current Population Survey. Last conducted in 1998 and scheduled again for the year 2000. (Vital Signs, 1999)
Subacute Care: Is usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury or disease, but who don't require intensive hospital services. ... The range of services considered subacute can include infusion therapy, respiratory care, cardiac services, wound care, rehabilitation services, postoperative recovery programs for knee and hip replacements, and cancer, stroke, and AIDS care. (Tokarski, 1995)
Submitted Charge: The charge submitted by a provider to the patient or a payer. See Paid Amounts. (PPRC, 1996)
Supplemental Insurance: Any private health insurance plan held by a Medicare beneficiary, including medigap policies and post-retirement health benefits. (ProPAC, 1996)
Supplemental Security Income (SSI): A federal income support pro-ram for low-income disabled, aged, and blind persons. Eligibility for the monthly cash payments is based on the individual's current status without regard to previous work or contributions. (PPRC, 1996)
Supplemental Medical Insurance (SMI): The part of the Medicare program that covers the costs of physicians' services, outpatient laboratory and X-ray tests, durable medical equipment, outpatient hospital care, and certain other services. This voluntary program requires payment of a monthly premium, which covers 25 percent of pro-ram costs. Beneficiaries are responsible for a deductible and coinsurance payments for most covered services. Also called Part B coverage or benefits. (PPRC, 1996)
Supplier: A provider of health care services, other than a practitioner, that is permitted to bill under Medicare Part B. Suppliers include independent laboratories, durable medical equipment providers, ambulance services, orthotist, prosthetist, and portable X-ray providers. (PPRC, 1996)
Sustainable Growth Rate: The target rate of expenditure growth set by the Sustainable Growth Rate system. Similar to the performance standard under the Volume Performance Standard system, except that the target depends on growth of gross domestic product instead of historical trends. See Sustainable Growth Rate System, Volume Performance Standard System, Performance Standard. (PPRC, 1996)
Sustainable Growth Rate System: A revision to the Volume Performance Standard system, proposed by the Congress and the Administration. This system would provide an alternative mechanism for adjusting fee updates for the Medicare Fee Schedule. The mechanism would use a single conversion factor, base target rates of growth on growth of gross domestic product, and change the method for calculating the conversion factor update to eliminate the two-year delay. See Volume Performance Standard System, Conversion Factor Update. (PPRC, 1996)
Survey: Systematic collection of information from a defined population, usually by means of interviews or questionnaires administered to a sample of units in the population. (Rossi and Freeman, 1993)
Swing-Bed Hospital: A hospital participating in the Medicare swing-bed program. This program allows rural hospitals with fewer than 100 beds to provide skilled post-acute care services in acute care beds. (HCFA) (ProPAC, 1996)
TANF: Temporary Assistance for Needy Families. Federally-sponsored public assistance program that replaced Aid to Families with Dependant Chlidren (AFDC) in 1996. (Vital Signs, 1999)
Target (Evaluation): The unit (individual, family, community, etc.) to which a program intervention is directed. (Rossi and Freeman, 1993)
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA): Legislation that established target rate of increase limits on reimbursements for inpatient operating costs per Medicare discharge. A facility's target amount is derived from costs in a base year updated to the current year by the annual allowable rate of increase. Medicare payments for operating costs generally may not exceed the facility's target amount. These provisions still apply to hospitals and units excluded from PPS. (See also Excluded Hospitals and Units.) (ProPAC, 1996)
Team-Based Pay: Is a base or variable program that recognizes group efforts and results. (Pierson, 1994)
Technology Assessment: In health policy, a synthesis of infirmation on the safety, effectiveness, and cost of a service or technology to predict how providing it would affect patients and the health care system. (PPRC, 1996)
Tertiary Center: A large medical care institution, usually a teaching hospital, that provides highly specialized care.
Third-Party Payer: An organization (private or public) that pays for or insures at least some f the health care expenses of its beneficiaries. Third-party payers include Blue Cross/Blue Shield, commercial health insurers, Medicare, and Medicaid. The individual receiving the health care services is the first party, and the individual or institution providing the service is the second party. (OTA, 1993)
Threshold standards: Rate or level of illness or injury in a community or population which, if exceeded, should signal alarms for renewed or redoubled action. (PHIP, 1996)
Time-series Analysis (Evaluation): Reflexive designs that rely on relatively long series of repeated outcome measurements taken before and after an intervention. (Rossi and Freeman, 1993)
Tri-Association: The Association of Washington Cities, the Washington State Association of Counties, and the Washington Association of County Officials are, collectively, the Tri- Association. Responsibilities of the Tri-Association under the Health Services Act of 1993 include analyzing the membership of local public health department/district governing bodies and developing recommendations regarding the appropriateness of Motor Vehicle Excise Tax financing of local public health. (PHIP, 1996)
TRICARE (formerly CHAMPUS): Insurance program for Veterans and civilian dependents of members of the military. (Vital Signs, 1999)
Tort Reform: Changes in the legal rules governing medical malpractice lawsuits. (PPRC, 1994)
Total Margin: A measure that compares total hospital revenue and expenses for inpatient, outpatient, and non-patient care activities. The total margin is calculated by subtracting total expenses from total revenue and dividing by total revenue. (ProPAC, 1996)
Uncompensated Care: Care rendered by hospitals or other providers without payment from the patient or a government-sponsored or private insurance program. It includes both charity care, which is provided without the expectation of payment, and bad debts, for which the provider has made an unsuccessful effort to collect payment due from the patient. (ProPAC, 1996)
Undergraduate Medical Education: The medical training provided to students in medical school. See Graduate Medical Education. (PPRC, 1996)
Underwriting: The process by which an insurer determines whether and on what basis it will accept an application for insurance. Some insurers use medical underwriting to exclude individuals, groups, or coverage for certain health conditions that are expected to incur high costs. (PPRC, 1996)
Unified Insurance: Health insurance coverage that is provided through a single insurance policy. (PPRC, 1996)
Uniform Benefits Package: The subset of the "Uniform Set of Health Services" (see below) that is guaranteed to all Washington State residents through an insurance mechanism. This package will be defined by the Health Services Commission by December 1, 1994. (PHIP, 1996)
Uniform Claim Form: All insurers and self-insurers would be required to use a single claim form and standardized format for electronic claims. (AMA, 1993)
Uniform Set of Health Services: A broad range of health services including: (1) a comprehensive and affordable "Uniform Benefits Package" (see above) of personal health services delivered by competing certified health plans; (2) a variety of services provided through the public health system; and (3) health system support, such as clinical research and health personnel education. (PHIP, 1996)
Uninsured Population: An estimated 35-37 million Americans. 56% are workers. 28% are children. 16.5% are nonworking adults. 83% of workers have private insurance. (AMA, 1993)
Universal Access: Access to health insurance coverage for everyone. (AMA, 1993)
Universal access: The right and ability to receive a comprehensive, uniform, and affordable set of confidential, appropriate, and effective health services. (PHIP, 1996)
Update Factor: The year-to-year increase in base payment amounts for PPS and excluded hospitals and dialysis facilities. The update factors generally are legislated by the Congress after considering annual recommendations provided by ProPAC and the Secretary of HHS. ProPAC's update factors are intended to reflect changes in the prices of inputs used to provide patient care services, as well as changes in productivity, technological advances, quality of care, and long-term cost-effectiveness of services. ProPAC recommends separate update factors for PPS hospital operating payments, PPS hospital capital payments, the TEFRA target amounts for PPS-excluded hospitals and distinct-part units, and composite rate payments to dialysis facilities. (See also Market Basket Index.) (ProPAC, 1996)
Urgent needs: Urgent public health problems and unmet needs in Washington communities. The Health Services Act of 1993 allocated $20 million to enable the public health system to respond to these urgent health needs. (PHIP, 1996)
U.S. Per Capita Cost (USPCC): The national average cost per Medicare beneficiary, calculated annually by HCFA's Office of the Actuary. See Adjusted Average Per Capita Cost, Adjusted Payment Rate, Medicare Risk Contract. (PPRC, 1996)
Usual, Customary, and Reasonable (UCR): A method used by private insurers for paying physicians based on charges commonly used by physicians in a local community. Sometimes called customary, prevailing, and reasonable charges. See Customary, Prevailing, and Reasonable. (PPRC, 1996)
Utilization Review (UR): The review of services delivered by a health care provider or supplier to determine whether those services were medically necessary; may be performed on a concurrent or retrospective basis. (PPRC, 1996)
Volume and Intensity of Services: The quantity of health care services per enrollee, taking into account both the number and the complexity of the services provided. (PPRC, 1996)
Volume Offset See Behavioral Offset. (PPRC, 1996)
Volume Performance Standard (VPS) System: The VPS system provides a mechanism to adjust fee updates for the Medicare Fee Schedule based on how annual increases in actual expenditures compare with previously determined performance standard rates of increase. (PPRC, 1996)
Volume Performance Standards (VPS): A mechanism to adjust updates to fee-for-service payment rates based on how actual aggregate