Glossary of Terms as Commonly Used in Health Care
Alpha Center: Health Policy and Planning

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Acronyms: A| B| C| D| E| F| G| H| I| L| M| N| O| S

Definitions

A

acronyms
acceptability
access
accreditation
active intervention
Activities of Daily Living (ADL)
actual charge
acute care
acute disease
adjusted average per capital cost (AAPCC)
adverse selection
affiliation
Agency for Health Care Policy and Research (AHCPR)
alcoholism
allied health personnel
allowable costs
alternatives to long term institutional care
ambulatory care
ambulatory setting
amortization
ancillary services
antitrust
appropriateness
Area Health Education Center (AHEC)
association


acceptability
The level of satisfaction expressed by consumers with the availability, accessibility, cost, quality, continuity, and degree of courtesy and consideration afforded them by the health care system
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access
Often defined as the potential and actual entry of a population into the health care system and features such as private or public insurance coverage. The probability of entry is also dependent upon the wants, resources, and needs that patients may bring to the care-seeking process. Actual entry into the system is described by utilization rates and subjective evaluations of care. Ability to obtain wanted or needed services may also be influenced by the distance one has to travel, waiting time, total income, and whether one has a regular source of care.
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accreditation
A process whereby a program of study or an institution is recognized by an external body as meeting certain predetermined standards. For facilities, accreditation standards are usually defined in terms of physical plant, governing body, administration, and medical and other staff. Accreditation is often carried out by organizations created for the purpose of assuring the public of the quality of the accredited institution or program. The State or Federal Governments can recognize accreditation in lieu of, or as the basis for licensure or other mandatory approvals. Public or private payment programs often require accreditation as a condition of payment for covered services. Accreditation may either be permanent or may be given for a specified period of time.
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active intervention
An active intervention is a prevention strategy which requires direct participation of the individual him/herself to be effective (e.g, weight loss programs)
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Activities of Daily Living (ADL)
An index or scale which measures a patient's degree of independence in bathing, dressing, using the toilet, eating, and moving around the house.
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actual charge
One of the factors determining a physician's payment for a service under Medicare; equivalent to the billed or submitted charge.
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acute care
Medical treatment rendered to individuals whose illness or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.
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acute disease
A disease which is characterized by a single episode of a relatively short duration from which the patient returns to his normal or previous state of level of activity. While acute diseases are frequently distinguished from chronic diseases, there is no standard definition or distinction. It is worth noting that an acute episode of a chronic disease (for example, an episode of diabetic coma in a patient with diabetes) is often treated as an acute disease.
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adjusted average per capital cost (AAPCC)
The basis for HMO or CMP reimbursement under Medicare-risk contracts. The average monthly amount recieved per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector.
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adverse selection
A tendency for utilization of health services in a population group to be higher than average. From an insurance perspective, adverse selection occurs when persons with poorer-than-average life expectancy or health status apply for, or continue, insurance coverage to a greater extent than do persons with average or better health expectations.
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affiliation
An agreement (usually formal) between two or more otherwise independent entities or individuals which defines how they will relate to each other. Affiliation agreements between hospitals may specify procedures for referring or transferring patients from one facility to another, joint faculty and/or medical staff appointments, teaching relationships, sharing of records or services, or provision of consultation between programs.
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Agency for Health Care Policy and Research (AHCPR)
One of the newest agencies of the U.S. Public Health Service, the AHCPR was created in 1989. The Agency's primary goal is to enhance the quality, appropriateness, and effectiveness of health care services by conducting and sponsoring credible and timely research. It is the Federal government's focal point for health services research, the efforts of which are built upon the work of AHCPR's predecessor, the National Center for Health Services Research and Health Care Technology Assessment.
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alcoholism
A chronic disease manifested by intake of alcoholic beverages in exess of dietary uses, social uses and norms of the community, and which to some extent interferes with the drinker's health and/or his or her social or economic functioning. The definition of alcoholism in both theory and practice is highly variable. Some definitions require either excessive drinking or interference with the drinker's functions rather than both; other definitions require physical signs of drug dependence in addition to the above. There are various systems in use for separating different types of alcoholism and grading its severity.
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allied health personnel
Specially trained and licensed (when necessary) health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, and nurses. The term has no constant or agreed-upon detailed meaning; sometimes being used synonymously with paramedical personnel, sometimes meaning all health workers who perform tasks which must otherwise be performed by a physician, and at other times referring to health workers who do not usually engage in independent practice.
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allowable costs
Items or elements of an institution's costs which are reimbursable under a payment formula. Both Medicare and Medicaid reimburse hospitals on the basis of only certain costs. Allowable costs may exclude, for example, luxury accomodations, costs which are not reasonable expenditures, which are unnecessary, for the efficient delivery of health services to persons covered under the program in question, or depreciation on a capital expenditure which was disapproved by a health planning agency
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alternatives to long term institutional care
The whole range of health, nutritional, housing, and social services designed to keep persons out of institutions, such as skilled nursing facilities, which provide care on a long-term basis. The goal is to provide the range of services necessary to allow the person to continue to function in the home and community environment. Alternatives to long term care usually focus on the aged, disabled and retarded, and include: day care center, foster homes, or homemaker services.
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ambulatory care
All types of health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to recieve services which do not require an overnight stay. See also ambulatory setting and outpatient.
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ambulatory setting
A type of institutional organized health setting in which health services are provided on an outpatient basis. Ambulatory care settings may be either mobile (when the facility is capable of being moved to different locations) or fixed (when the person seeking care must travel to a fixed service site).
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amortization
The act or process of retiring a debt, usually by equal payments at regular intervals over a specific period of time.
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ancillary services
Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care.
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antitrust
A legal term encompassing a variety of efforts on the part of the government to assure that sellers do not conspire to restrain trade or fix prices for their goods or services in the market.
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appropriateness
Appropriate health care is care for which the expected health benefit exceeds the expected negative consequences by a wide enough margin to justify treatment.
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Area Health Education Center (AHEC)
An organization or organized system of health and educational institutions whose purpose is to improve the supply, distribution, quality, use and efficiency of health care personnel in specific medically underserved areas. An AHEC's objectives are to educate and train the health personnel specifically needed by the underserved areas and to decentralize health workforce education, thereby increasing supply and linking the health and educational institutions in scarcity areas.
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association
A term signifying the relationship between two or more events or variables. Events are said to be associated when they occur more frequently together than one would expect by chance. Association does not necessarily imply a casual relationship. Statistical significance testing enables a researcher to determine the likelihood of observing the sample relationship by chance if in fact no association exists in the population that was sampled. The terms "association" and "relationship" are often used interchangeably.
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B

acronym
bad debts
Blue Cross Plan
Blue Shield Plan
board certified


bad debts
Income lost to a provider because of failure of patients to pay amounts owed. Bad debts may sometimes be recovered by increasing charges to paying patients. Some cost-based reimbursement programs reimburse certain bad debts. The impact of the loss of revenue from bad debts may be partially offset for proprietary institutions by the fact that income tax is not payable on income not recieved.
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Blue Cross Plan
A nonprofit, tax exempt insurance plan providing coverage for hospital care and related services. The individual plans should be distinguished from their national association, the Blue Cross Association. Historically, the plans were largely the creation of the hospital industry and designed to provide hospitals with a stable source of revenue, although formal association between Blue Cross and the American Hospital Association ended in 1972. A Blue Cross plan must be a nonprofit community service organization with a governing body whose membership includes a majority of public representatives.
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Blue Shield Plan
A nonprofit, tax exempt insurance plan which provides coverage for physicians' services. Blue Shield coverage is sometimes sold in conjunction with Blue Cross coverage, although this is not always the case.
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board certified
Status granted a medical specialist who completes a required course of training and experience (residency) and passes an examination in his or her specialty. Individuals who have met all requirements except examination are referred to as "board eligible."
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BCA
Blue Cross Association
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C

acronyms
capital
capital costs
capital depreciation
capital expenditure
capital expenditure review
capitation
carve out
case management
case-mix
catastrophic health insurance
catchment area
causality
Centers for Disease Control and Prevention (CDC)
Certificate of Need (CON)
certification
CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)
charity care
chronic care
clinic
coinsurance
community-based care
community health center
Community Mental Health Center
community rating
community rating by class (class rating)
competition
Competitive Medical Plan
comprehensive health planning (CHP)
confidence interval
consumer
continuing medical education (CME)
contractual allowance
contribution margin
coordination of benefits
cost
cost-benefit analysis
cost center
cost containment
cost of goods sold
cost-effectiveness analysis
cost-shifting
covered services
credentialing
current cost
Current Procedural Terminology, fourth edition (CPT-4)
customary charge
Customary, Prevailing and Reasonable (CPR)


capital
Fixed or durable non-labor inputs or factors used in the production of goods and services, the value of such factors, or the money specifically allocated for their aquisition or development. Capital costs include, for example, the buildings, beds and equipment used in the provision of hospital services. Capital assets are usually thought of as permanent and durable as distinguished from consumables such as supplies.
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capital costs
Expenditures for land, facilities, and major equipment. They are distinguished from operating costs, which include such items as labor, supplies and administrative expenses.
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capital depreciation
The decline in value of capital assets (assets of a permanent or fixed nature, e.g., goods and plant) with use over time. The rate and amount of depreciation is calculated by a variety of different methods (e.g., straight line, sumof the digits, declining balance) which often give quite different results. Third-party reimbursement for health services usually includes an amount intended to be equivalent to the capital depreciation in any given period experienced by the provider of a service.
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capital expenditure
An expenditure for the aquisition, replacement, modernization, or expansion of facilities which, under generally accepted accounting principles, is not properly chargeable as an expense of operation and maintainance.
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capital expenditure review
A review of proposed capital expenditures of hospitals and/or other health facilities to determine the need for, and appropriateness of, the proposed capital expenditures. The review is done by a designated regulatory agency and has a sanction attached which prevents or discourages unneeded expenditures.
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capitation
A method of payment for health services in which an individual or institutional provider is paid a fixed amount for each person served, without regard to the actual number or nature of services provided to each person in a set period of time. Capitation is the characteristic payment method in certain health maintainance organizations. It also refers to a method of Federal support of health professional schools. Under these authorizations, each eligable school recieves a fixed payment, called a "capitation grant" from the Federal Government for each student enrolled.
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carve out
Regarding health insurance, an arrangement whereby an employer eliminates coverage for a specific category of services (e.g., vision care, mental health/psychological services and prescription drugs) and contracts with a separate set of providers for those services according to a predetermined fee schedule or capitation arrangement. Carve out may also refer to a method of coordinating dual coverage for an individual.
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case management
The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services.
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case-mix
A measure of the mix of cases being treated by a particular health care provider that is intended to reflect the patients' different needs for rescources. Case mix is generally established by estimating the relative frequency of various types of patients seen by the provider in question during a given time period and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.
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catastrophic health insurance
Heath insurance which provides protection against the high cost of treating severe or lengthy illnesses or disability. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsability of another insurance policy up to a maximum limit of liability.
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catchment area
A geographic area defined and served by a health program or institution such as a hospital or community mental health center, which is delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. By definition all residents of the area needing the services of the program are usually eligible for them, although eligibility may also depend on additional criteria.
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causality
Relating causes to the effect they produce. Most of epidemiology concerns causality, and several types of causes can be distinguished. A cause is termed "necessary" when a particular variable must always precede an effect. The effect need not be the sole result of the one variable. A cause is termed "sufficient" when a particular variable inevitably initiates or produces an effect. Any given cause may be necessary, sufficient, neither, or both.
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Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention, based in Atlanta, Georgia, is the Federal agency charged with protecting the nations' public health by providing direction in the prevention and control of communicable and other diseases and responding to public health emergencies. CDC is the U.S. Public Health Service agency that led efforts to prevent such diseases as malaria, polio, smallpox, toxic shock syndrome, Legionnaire's disease and, more recently, acquired immunodeficiency syndrome (AIDS) and tuberculosis. CDC's responsibilities as the nation's prevention agency have expanded over the years and will continue to evolve as the agency addresses contemporary threats to health, such as injury, environmental and occupational hazards, behavioral risks, and chronic diseases.
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Certificate of Need (CON)
A certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility, aquire major new medical equipment, modify a health facility, or offer a new or different health service. Such issuance recognizes that a facility or service, when available, will meet the needs of those for whom it is intended. CON is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services.
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certification
The process by which a governmental or nongovernmental agency or association evaluates and recognizes an individual, institution, or educational program as meeting predetermined standards. One so recognized is said to be "certified." It is essentially synonymous with accreditation, except that certification is usually applied to individuals, and accreditation to institutions. Certification programs are generally nongovernmental and do not exclude the uncertified from practice as do licensure programs.
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CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)
A Department of Defense program supporting private sector care for military dependents.
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charity care
Generally refers to physician and hospital services provided to persons who are unable to pay for the cost of services, especially those who are low-income, uninsured and underinsured. A high proportion of the costs of charity care is derived from services for children and pregnant women(e.g., neonatal intensive care).
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chronic care
Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.
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chronic disease
A disease which has one or more of the following characteristics: is permanant, leaves residual disability; is caused by nonreversible pathological alternation, requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.
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clinic
A facility, or part of one, devoted to diagnosis and treatment of outpatients. "Clinic" is irregularly defined. It may either include or exclude physicians' offices; may be limited to describing facilities which serve poor or public patients; and may be limited to facilities in which graduate or undergraduate medical education is done.
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coinsurance
A cost-sharing requirement under a health insurance policy. It provides that the insured party will assume a portion of the costs of covered services. The health insurance policy provides that the insurer will reimburse a specified percentage of all, or certain specified, covered medical expenses in excess of any deductable amounts payable by the insured. The insured is then liable for the remainder of the costs until their maximum liability is reached.
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community-based care
The blend of health and social services provided to an individual or family in their place of residence for the purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability.
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community health center
An ambulatory health care program (defined under section 330 of the Public Health Service Act) usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs; sometimes known as a "neighborhood health center." Community health centers attempt to coordinate Federal, State and local rescources in a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
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Community Mental Health Center (CMHC)
An entity which provides comprehensive mental health services (principally ambulatory), primarily to individuals residing or employed in a defined catchment area.
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community rating
A method of calculating health plan premiums using the average cost of actual or anticipated health services for all subscribers within a specific geographic area. The premium does not vary for different groups or subgroups of subscribers on the basis of their specific claims experience.
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Community rating by class (class rating)
For federally qualified HMOs, the Community Rating by Class (CRC)-- adjustment of community- rated premiums on the basis of such factors as age, sex, family size, marital status and industry classification. These health plan premiums reflect the experience of all enrollees of a given class within a specific geographic area, rather than the experience of any one employer group.
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competition
A characteristic of market economics in which buyers choose from among alternative goods and services made available in the market by two or more sellers. In a classic competitive market, there are many buyers and many sellers.
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Competitive Medical Plan (CMP)
A state-licensed entity, other than a federally qualified HMO, that signs a Medicare Risk Contract and agrees to assume financial risk for providing care to Medicare eligables on a prospective, prepaid basis.
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comprehensive health planning (CHP)
Health planning that encompasses all personal factors and community programs which impact on people's health.
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confidence interval
A range within which an estimate is deemed to be close to the actual value being measured. In statistical measurements, estimates cannot be said to be exact measures, but rather are defined in terms of their probability of matching the value of the thing being measured.
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consumer
One who may recieve or is receiving health services. While all people at times consume health services, a consumer, as the term is used in health legislation and programs, is usually someone who is not associated in any direct or indirect way with the provision of health services.
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continuing medical education (CME)
Formal education obtained by a health professional after completing his or her degree and full- time postgraduate training. For physicians, some States require CME (usually 50 hours per year) for continued licensure, as do some specialty boards for certification.
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contractual allowance
The difference between what hospitals bill and what they receive in payment from third party payers, most commonly government programs; also known as contractual adjustment.
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contribution margin
Revenue from sales less all variable expenses.
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coordination of benefits (COB)
Procedures used by insurers to avoid duplicate payment for losses insured under more than one insurance policy. A coordination of benefits, or "nonduplication," clause in either policy prevents double payment by making one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered. Standard rules determine which of two or more plans, each having COB provisions, pays its benefits in full and which becomes the supplementary payer on a claim.
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cost
Expenses incurred in the provision of services or goods. Many different kinds of costs are defined and used (see allowable, indirect, and operating costs). Charges, the price of a service or amount billed an individual or third party, may or may not be equal to service costs.
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cost-benefit analysis
An analytic method in which a program's cost is compared to the program's benefits for a period of time, expressed in dollars, as an aid in determining the best investment of rescources. For example, the cost of establishing an immunization service might be compared with the total cost of medical care and lost productivity which will be eliminated as a result of more persons being immunized. Cost-benefit analysis can also be applied to specific medical tests and treatments.
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cost center
An accounting device whereby all related costs attributable to some "financial center" within an institution, such as a department or program are segregated for accounting or reimbursement purposes.
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cost containment
A set of steps to control or reduce inefficiencies in the consumption, allocation, or production of health care services which contribute to higher than necessary costs. Ineffciencies in consumption can occur when health services are inappropriately utilized; ineffciencies in allocation exist when health services could be delivered in less costly settings without loss of quality; and ineffciencies in production exist when the cost of producing health services could be reduced by using a different combination of rescources.
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cost of goods sold
Inventoriable costs that are expensed because the units are sold; equals beginning inventory plus cost of goods purchased or manufactured minus ending inventory.
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cost-effectiveness analysis
A method of comparing alternative ways for achieving a specific set of results. Alternatives are compared on the basis of the ratio of the cost of each alternative to its estimated future effect on objectives which need not be measured in financial terms.
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cost-shifting
The condition which occurs when health care providers are not reimbursed or not fully reimbursed for providing health care so charges to those who pay must be increased. Typically results from providing health care to the medically indigent or the Medicare patients.
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covered services
Health care services covered by an insurance plan.
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credentialing
The recognition of professional or technical competence. the credentialing process may include registration, certification, licensure, professional association membership, or the award of a degree in the field. Certification and licensure affect the supply of health personnel by controlling entry into practice and influence the stability of the labor force by affecting geographic distribution, mobility, and retention of workers. Credentialing also determines the quality of personnel by providing standards for evaluating competence and by defining the scope of functions and how personnel may be used.
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current cost
Cost stated in terms of current values (of productive capacity) rather than in terms of aquisition cost.
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Current Procedural Terminology, fourth edition (CPT-4)
A manual that assigns five digit codes to medical services and procedures to standardize claims processing and data analysis.
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customary charge
One of the factors determining a physician's payment for a service under Medicare. Calculated as the physician's median charge for that service over a prior 12-month period.
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Customary, Prevailing, and Reasonable (CPR)
Current method of paying physicians under Medicare. Payment for a service is 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.
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D

acronyms
debt service
deductible
default
defined benefit
defined contribution
deinstitutionalization
demand
dental health services
developmental disability (DD)
Diagnosis Related Groups (DRGs)
direct cost
disability
disease
drug abuse


debt service
Required payments for interest on and retirement of a debt; the amount needed, supplied, or accrued for meeting such payments during any given accounting period; a budget or operating statement heading for such items.
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deductible
The amount of loss or expense that must be incurred by an insured or otherwise covered individual before an insurer will assume any liability for all or part of the remaining cost of covered services. Deductibles may be either fixed-dollar amounts or the value of specified services (such as two days of hospital care or one physician visit). Deductibles are usually tied to some reference period over which they must be incurred, e.g, $100 per calendar year, benefit period, or spell of illness.
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default
Failure to pay debt service when due.
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defined benefit
Funding mechanisms for pension plans that can also be applied to health benefits. Typical pension approaches include: (1) pegging benefits to a percentage of an employee's average compensation over his entire service or over a particular number of years; (2) calculation of a flat monthly payment; (3) setting benefits based upon a definite amount for each year of service or as a flat dollar amount for each year of service, either as a percentage of compensation for each year of service or as a flat dollar amount for each year of service.
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defined contribution
Funding mechanism for pension plans that can also be applied to health benefits based on a specific dollar contribution, without defining services to be provided.
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deinstitutionalization
Policy which calls for the provision of supportive care and treatment for medically and socially dependent individuals in the community rather than in an institutional setting.
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demand
In health economics, the amount of a good or service consumers are willing and able to buy at varying prices, given constant income and other factors. Demand should be distinguished from utilization (the amount of services actually used) and need (which has a normative connotation and relates to the amount of goods or services which should be consumed based on professional value judgments).
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dental health services
All services designed or intended to promote, maintain, or restore dental health including educational, preventive, and theraputic services.
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developmental disability (DD)
A severe, chronic disability which is attributable to a mental or physical impairment or combination of mental and physical impairments; is manifested before the person attains age 22; is likely to continue indefinitely; results in substantial functional limitations in three or more of the following areas of major life activity self-care, receptive and expressive language, learning, mobility, self-direction, capacity of independent living, economic self-sufficiency; and reflects the person's needs for a combination and sequence of special, interdisciplinary, or generic care treatments of services which are of lifelong or extended duration and are individually planned and coordinated.
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Diagnosis Related Groups (DRGs)
Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. DRGs are the case-mix measure used in Medicare's prospective payment system.
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direct cost
A cost which is identifiable directly with a particular activity, service, or product of the program experience the costs. These costs do not include the allocation of costs to a cost center which are not specifically attributable to that cost center.
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disability
Any limitation of physical, mental, or social activity of an individual as compared with other individuals of similar age, sex, and occupation. Frequently refers to limitation of a person's usual or major activities, most commonly vocational. there are varying types (functional, vocational, learning), degrees (partial, total), and durations (temporary, permanent) of disability. Public programs often provide benefits for specific disabilities, such as total and permanent.
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disease
May be defined as a failure of the adaptive mechanisms of an organism to counteract adequately, normally, or appropriately to stimuli and stresses to which it is subjected, resulting in a disturbance in the function or structure of some part of the organism. This definition emphasizes that disease is multifactorial and may be prevented or treated by changing any or a combination of factors. Disease is a very elusive and difficult concept to define, being largely socially defined. Thus, criminality and drug dependence are presently seen by some as diseases, when they were previously considered to be moral or legal problems.
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drug abuse
Persistent or sporadic drug use inconsistent with or unrelated to acceptable medical or cultural practice. The definition of drug abuse is highly variable, sometimes also requiring excessive use of a drug, unnecessary use (thus incorporating recreational use), dependence, or illegal use.
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E

acronyms
Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)
effectiveness
efficacy
efficiency
emergency medical services (EMS)
Employee Retirement Income Security Act (ERISA)
epidemic
epidemiology
etiology
evaluation
exclusive provider arrangement (EPA)
expenditure target (ET)
experience rating
exposure


Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT)
A program mandated by law as part of the Medicaid program. The law requires that all states have in effect a program for eligable children under 21 to ascertain their physical or mental defects and to provide such health care treatments and other measures to correct or ameliorate defects and chronic conditions discovered. The State programs also have active outreach components to inform eligible persons of the benefits available to them, to provide screening, and if necessary, to assist in obtaining appropriate treatment.
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effectiveness
A particular application of efficacy, i.e., it reflects the performance of an intervention under ordinary conditions by the average practitioner for the typical patient.
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efficacy
The probabilty of benefit to individuals in a defined population from a medical technology applied to a given medical problem under ideal conditions of use.
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efficiency
"Productive" effciency describes the performance of a service or delivery of medical care of a given quality with the least expenditure of rescources. "Allocative" efficiency concerns not only whether care is provided as cheaply as possible given its cost and quality, but also whether the costs expended for the additional care are worth the benefits to be gained.
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emergency medical services (EMS)
Services utilized in responding to the percieved individual need for immediate treatment for medical, physiological, or psychological illness or injury.
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Employee Retirement Income Security Act (ERISA)
A Federal act, past in 1974, that established new standards and reporting/disclosure requirements for the employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from State insurance laws.
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epidemic
A group of cases of a specific disease or illness clearly in excess of what one would normally expect in a particular geographic area. There is no absolute criterion for using the term epidemic; as standards and expectations change, so might the definition of an epidemic, e.g., an epidemic of violence.
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epidemiology
The study of the patterns of determinants and antecedents of disease in human populations. Epidemiology utilizes biology, clinical medicine, and statistics in an effort to understand the etiology (causes) of illness and/or disease. The ultimate goal of the epidemiologist is not merely to identify underlying causes of a diseas but to apply findings to disease prevention and health promotion.
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etiology
Cause. A term used by epidemiologists.
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evaluation
In health services research, a systematic analysis of the degree to which a program or initiative has achieved, or is capable of achieving, its goals and objectives. In medicine, an analysis of a patient's condition.
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exclusive provider arrangement (EPA)
An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with some exceptions for emergency and out of area services).
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expenditure target (ET)
A mechanism to adjust fee updates (or the fees themselves) based on how actual expenditures in an area compare to a target for those expenditures.
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experience rating
A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group.
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exposure
A general term used to describe contact with a risk factor. An exposure can be a physical agent (e.g., radiation) or a behavior (i.e., excessive drinking).
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F

acronyms
family practice
favorable selection
fee-for-service
fee schedule
fiduciary
financial feasibility
foreign medical graduate (FMG)


family practice
A form of specialty practice in which physicians provide continuing comprehensive primary care within the context of the family unit.
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favorable selection
A tendency for utilization of health services in a population group to be lower than expected or estimated.
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fee-for-service
Method of billing for health services under which a physician or other practitioner charges separately for each patient encounter or service rendered; it is the method of billing used by the majority of U.S. country's physicians. Under a fee-for-service payment system, expenditures increase if the fees themselves increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. This system contrasts with salary, per capita, or other prepayment systems, where the payment to the physician is not changed with the number of services actually used.
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fee schedule
An exhaustive list of physician services in which each entry is associated with a specific monetary amount that represents the approved payment level for a given insurance plan.
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fiduciary
Relating to, or founded upon, a trust of confidence. A fiduciary relationship exists where an individual or organization has an explicit or implicit obligation to act in behalf of another person's or organization's interests in matters which affect the other person or organization. A physician has such a relation with his patient, and a hospital trustee has one with a hospital.
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financial feasibility
The projected ability of a provider to pay the capital and operating costs associated with the delivery of a proposed health care service.
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foreign medical graduate (FMG)
A physician who graduated from a medical school outside the United States, usually Canada. U.S. citizens who go to medical school abroad are classified as foreign medical graduates (sometimes distinguished as USFMGs), just as foreign-born persons who are not trained in a medical school in this country. U.S. citizens represent only a small portion of the FMG group.
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Index

G

acronyms
general practice
global budgeting
global fee
goal
gross margin
group practice


general practice
A form of practice in which physicians without specialty training provide a wide range of primary health care services to patients.
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global budgeting
A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will recieve each year. Global budgeting may also be mandated under a universal health insurance system.
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global fee
A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care.
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goal
A statement of expectations of desired, attainable levels of health status and/or health system performance.
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gross margin
Net sales minus goods sold; the difference between sales revenues and manufacturing costs as an intermediate step in the computation of operating profits or net income.
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group practice
A formal association of three or more physicians or other health professionals providing health services. Income from the practice is pooled and redistributed to the members of the group according to some prearranged plan (often, but not necessarily, through partnership). Groups vary a great deal in size, composition, and financial arrangements.
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Index

H

acronyms
handicapped
health
Health Care Financing Administration
health education
health facilities
health insurance
health maintenance organization (HMO)
Health Manpower Shortage Area (HMSA)
health personnel
health planning
health promotion
Health Rescources and Services Administration (HRSA)
health service area
health status
Health Systems Agency (HSA)
Hill-Burton
holism
home health care
hospice
hospital


handicapped
As defined by section 504 of the Rehabilitation Act of 1973, any person who has a physical or mental impairment which substantially limits one or more major life activity, has a record of such impairment, or is regarded as having such an impairment.
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health
The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anotomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms of morbidity and mortality.
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Health Care Financing Administration (HCFA)
The Government agency within the Department of Health and Human Services which directs the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs.
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health education
Any combination of learning opportunities designed to facilitate voluntary adaptions of behavior (in individuals, groups, or communities) conducive to health.
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health facilities
Collectively, all physical plants used in the provision of health services; usually limited to facilities which were built for the purpose of providing health care, such as hospitals and nursing homes. They do not included an office building which includes a physician's office. Health facility classifications include: hospitals (both general and specialty), long-term care facilities, kidney dialysis treatment centers, and ambulatory surgical facilities.
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health insurance
Financial protection against the medical care costs arising fromm disease or accidental bodily injury. Such insurance usually covers all or part of the medical costs of treating the disease or injury. Insurance may be obtained on either an individual or group basis.
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health maintenance organization (HMO)
An entity with four essential attributes: (1) An organized system providing health care in a geographic area, which accepts the responsibility to provide or otherwise assure the delivery of; (2) an agreed-upon set of basic and supplemental health maintenance and treatment services to (3) a voluntarily enrolled group of persons; and (4) for which services the entity is reimbursed through a predetermined fixed, periodic prepayment made by, or on behalf of, each person or family unit enrolled. The payment is fixed without regard to the amounts of actual services provided to an individual enrollee. Individual practice associations involving groups or independent physicians can be included under the definition.
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Health Manpower Shortage Area (HMSA)
An area or group which the U.S. Department of Health and Human Services designates as having an inadequate supply of health care providers. HMSAs can include: (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated to prevent members of the group from using local providers, or (3) medium and maximum-security correctional institutions and public or non-profit private residential facilities.
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health personnel
Collectively, all persons working in the provision of health services, whether as individual practitioners or employees of health institutions and programs, whether or not professionally trained, and whether or not subject to public regulation. Facilities and health personnel are the principal health rescources used in providing health services.
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health planning
Planning concerned with improving health, whether undertaken comprehensively for a whole community or for a particular population, type of health service, institution, or health program. The components of health planning include: data assembly and analysis, goal determination, action recommendation, and implementation strategy.
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health promotion
Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and environmental adaptions that will improve or protect health.
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Health Resources and Services Administration (HRSA)
One of the eight agencies of the U.S. Public Health Service, HRSA has responsibility for addressing resource issues relating to acess, equity and quality of health care, particularly to the disadvantaged and underserved. HRSA provides leadership to assure the support and delivery of primary health care services, particularly in underserved areas, and the development of qualified primary care health professionals and facilities to meet the health needs of the nation. HRSA focuses on support of states and communities in their efforts to plan, organize, and deliver primary health care, as well as strengthen the overall public health system.
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health service area
Geographic area designated on the basis of such factors as geography, political boundaries, population, and health resources, for the effective planning and development of health services.
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health status
The state of health of a specified individual, group or population. It may be measured by obtaining proxies such as people's subjective assessments of their health; by one or more indicators of mortality and morbidity in the population, such as longevity or maternal and infant mortality; or by using the incidence or prevelence of major diseases (communicable, chronic, or nutritional). Conceptually, health status is the proper outcome measure for the effectiveness of a specific population's medical care system, although attempts to relate effects of available medical care to variations in health status have proved difficult.
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Health Systems Agency (HSA)
A health planning agency created under the National Health Planning and Rescources Development Act of 1974. HSAs were usually nonprofit private organizations and served defined health service areas as designated by the states.
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Hill-Burton
Coined from the names of the principal sponsors of the Public Law 79-725 (the Hospital Survey and Construction Act of 1946); this program provided Federal support for the construction and modernization of hospitals and other health facilities. Hospitals that have recieved Hill-Burton funds incur and obligation to provide a certain amount of charity care.
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holism
Refers to the integration of mind, body, and spirit of a person and emphasizes the importance of perceiving the individual (regarding physical symptoms) in a "whole" sense. Holism teaches the the health care system must extend its focus beyond solely the physical aspects of disease and particular organ in question, to concern itself with the whole person and the interrelationships between the emotional, social, spiritual, as well as physical implications of disease and health.
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home health care
Health services rendered in the home to the aged, disabled, sick or convalescent individuals who do not need institutional care. The services may be provided by a visiting nurse association (VNA), home health agency, county public health department, hospital, or other organized community group and may be specialized or comprehensive. The most common types of home health care are the following-- nursing services; speech, physical, occupational and rehabilitation therapy; homemaker services; and social services.
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hospice
A program which provides palliative and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or another community agency. Originally a medieval name for a way station for crusaders where they could be replenished, refreshed, and cared for, hospice is used here for an organized program of care for people going through life's "last station." The whole family is considered the unit of care, and care extends through their period of mourning.
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hospital
An institution whose primary funcition is to provide inpatient diagnostic and theraputic services for a variety of medical conditions, both surgical and nonsurgical. In addition, most hospitals provide some outpatient services, particularly emergency care. Hospitals may be classified by length of stay (short-term or long-term), as teaching or nonteaching, by major type of service (psychiatric, tuberculosis, general, and other specialties, such as maternity, pediatric, or ear, nose and throat), and by type of ownership or control (Federal, State, or local government; for-profit and nonprofit). The hospital system is dominated by the short-term, general, nonprofit community hospital, often called a voluntary hospital.
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I

acronyms
incidence
indemnity
independent practice association (IPA)
indigent care
indirect cost
inpatient
institutional health services
instrumental activities of daily living (IADL)
interest
intermediate care facility (ICF)
intervention or intervention strategy
inventory


incidence
In epidemiology, the number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. Incidence measures morbidity or other events as they happen over a period of time. Examples include the number of accidents occurring in a manufactuing plant during a year in relation to the number of employees in the plant, or the number of cases of mumps occurring in a school during a month in relation to the number of pupils enrolled in the school. It usually refers only to the number of new cases, particularly of chronic diseases.
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indemnity
Health insurance benefits provided in the form of cash payments rather than services. An indemnity insurance contract usually defines the maximum amounts which will be paid for the covered services.
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independent practice association (IPA)
An organized form of prepaid medical practice in which participating physicians remain in their independent office settings, seeing both enrollees of the IPA and private-pay patients. Participating physicians may be reimbursed by the IPA on a fee-for-service basis or a capitation basis.
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indigent care
Health services provided to the poor or those unable to pay. Since many indigent patients are not eligible for Federal or State programs, the costs which are covered by Medicaid are generally recorded separately from indigent care costs.
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indirect cost
A cost which cannot be indentified directly with a particular activity, service, or product of the entity incurring the cost. Indirect costs are usually apportioned among an entity's services in proportion to each service's share of direct costs.
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inpatient
A person who has been admitted at least overnight to a hospital or other health facility (which is therefore responsible for his or her room and board) for the purpose of receiving diagnostic treatment or other health services.
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institutional health services
Health services delivered on an inpatient basis in hospitals, nursing homes, or other inpatient institutions. The term may also refer to services delivered on an outpatient basis by departments or other organizational units of, or sponsored by, such institutions.
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instrumental activities of daily living (IADL)
An index or scale which 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.
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interest
The cost incurred for borrowing funds. Interest is usually expressed as a percentage of a total loan.
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intermediate care facility (ICF)
An institution which is licensed under State law to provide on a regular basis, health-related care and services to individuals who do not require the degree of care or treatment which a hospital or skilled nursing facility is designed to provide. Public institutions for care of the mentally retarded or people with related conditions are also included in the definition. The distinction between "health-related care and services" and "room and board" has often proven difficult to make but is important because ICFs are subject to quite different regulations and coverage requirements than institutions which do not provide health-related care and services.
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intervention or intervention strategy
A generic term used in public health to describe a program or policy designed to have an impact on an illness or disease. Hence a mandatory seat belt law is an intervention designed to reduce automobile-related fatalities.
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inventory
A detailed description of quantities and locations of different kinds of facilities, major equipment, and personnel which are available in a geographic area and the amount, type and distribution of services these resources can support.
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J

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A national, private, nonprofit organization whose purpose is to encourage the attainment of uniformly high standards of institutional medical care. Established guidelines for the operation of hospitals and other health facilities and conducts survey and accreditation programs.
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L

acronyms
license/licensure
life safety code
long-term care


license/licensure
A permission granted to an individual or organization by a competent authority, usually public to engage lawfully in a practice, occupation, or activity. Licensure is the process by which the license is granted. It is usually granted on the basis of examination and/or proof of education rather than on measures of performance. A license is usually permanent but may be conditioned on annual payment of a fee, proof of continuing education, or proof of competence.
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life safety code
A fire safety code prepared by the National Fire Protection Association. The provisions of this code relating to hospitals and nursing facilities must (except in instances where a waiver is granted) be met by facilities certified for participation under Medicare and Medicaid. The code is based on optimum (non minimum) standards.
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long-term care
A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the cronically ill, aged, disabled or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded, and mental hospitals. Ambulatory services such as home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.
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Index

M

acronyms
magnetic resonance imaging (MRI)
malpractice
managed care
margin
maximum allowable actual charge (MAAC)
Medicaid (Title XIX)
Medicaid notch
medical audit
medically indigent
medically underserved population
Medicare (Title XVII)
medicare risk contract
mental health
mental health services
mental illness
merit good
modernization
morbidity
mortality


magnetic resonance imaging (MRI)
This relatively new form of diagnostic radiology is a method of imaging body tissues that uses the response or resonance of the nuclei of the atoms of one of the bodily elements, typically hydrogen or phosphorus, to externally applied magnetic fields.
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malpractice
Professional misconduct or failure to apply ordinary skill in the performance of a professional act. A practitioner is liable for damages or injuries caused by malpractice. For some professions like medicine, malpractice insurance can cover the cost of defending suits instituted against the professional and/or any damages assessed by the court, usually up to a maximum limit. To prove malpractice requires that a patient demonstrate some injury and that the injury be caused by negligence.
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managed care
Any form of health plan that initiates selective contracting to channel patients to a limited number of providers and that requires utilization review to control unnecessary use of health services.
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margin
Revenue less specified expenses.
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maximum allowable actual charge (MAAC)
A limitation on billed charges for Medicare services provided by nonparticipating physicians. For physicians with charges exceeding 115 percent of the prevailing charge for nonparticipating physicians, MAACs limit increases in actual charges to 1 percent a year. For physicians whose charges are less than 115 percent of the prevailing, MAACs limit actual charge increases so they may not exceed 115 percent.
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Medicaid (Title XIX)
A Federally aided, State-operated and administered program which provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad Federal guidelines, States determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program.
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Medicaid notch
The reduction in real income that occurs when increased earnings removes a person from not only public cash-assistance programs, and from Medicaid
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medical audit
Detailed retrospective review and evaluation of selected medical records by qualified professional staff. Medical audits are used in some hospitals, group practices, and occasionally in private performance by comparing it with accepted criteria, standards, and current professional judgement. A medical audit is usually concerned with the care of a given illness and is undertaken to identify deficiencies in that care in anticipation of educational programs to improve it.
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medically indigent
People who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance.
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medically underserved population
A population group experiencing a shortage of personal health services. A medically underserved population may or may not reside in a particular medically underserved area or be defined by its place of residence. Thus, migrants, American Indians, or the inmates of a prison or mental hospital may constitute such a population. The term is defined and used to give priority for Federal assistance (e.g., the National Health Service Corps).
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Medicare (Title XVIII)
A U.S. health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured. It consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B).
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medicare risk contract
An agreement by an HMO or competitive medical plan to accept a fixed dollar reimbursement per Medicare enrollee, derived from costs in the fee-for-service sector, for delivery of a full range of prepaid health services.
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mental health
The capacity in an individual to function effectively in society. Mental health is a concept influenced by biological, environmental, emotional, and cultural factors and is highly variable in definition, depending on time and place. It is often defined in practice as the absence of any identifiable or significant mental disorder and sometimes improperly used as a synonym for mental illness.
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mental health services
Comprehensive mental health services, as defined under some State laws and Federal statutes include: inpatient care, outpatient care, day care, and other partical hospitalization and emergency services; specialized services for the mental health of children; specialized services for the mental health of the elderly; consultation and education services; assistance to courts and other public agencies in screening catchment area residents; follow-up care for catchment area residents discharged from mental health facilities or who would require inpatient care without such halfway house services; and specialize programs for the prevention, treatment and rehabilitation of alcohol and drug offenders.
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mental illness
All forms of illness in which psychological, emotional, or behavioral disturbances are the dominating feature. The term is relative and variable in different cultures, schools of thought, and definitions. It includes a wide range of types and severities.
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merit good
A good or service which is societally sanctioned and deemed worthy of use or consumption by the general population. Often, a merit good is publicly provided or subsidized in order to assure widespread availability. Primary education is an example of a merit good which is made compulsory by the Government.
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modernization
Remodeling, renovation, or sometimes, replacement of health facilities and equipment to bring them up to current construction standards, into compliance with fire and safety codes, or to meet contemporary health delivery needs.
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morbidity
The extent of illness, injury, or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.
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mortality
Death. Used to describe the relation of deaths to the population in which they occur. The mortality rate (death rate) expresses the number of deaths in a unit of population within a prescribed time and may be expressed as crude death rates (e.g., total deaths in relation to total population during a year) or as death rates specific for diseases and, sometimes, for age, sex, or other attributes (e.g., number of deaths from cancer in white males in relation to the white male population during a given year).
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Index

N

acronyms
natural history of disease
need
neighborhood health center
nurse
nurse practitioner
nursing home


natural history of disease
This term refers to the fact that virtually all illnesses and diseases have certain predictable and regular patterns associated with them, i.e., a natural history. Understanding something of a natural history of a disease is a necessity if an effective intervention program is to be implemented.
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need
In health services, need has a normative connotation (i.e., the amount of a good or service which should be consumed). Because of the technical nature of medical care this value judgement is generally made by the health professional, rather than the consumer of these services. In health planning, need is the appropriate amount of health facilities and services required for a given area.
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neighborhood health center
An ambulatory health care program usually serving a catchment area which has scarce or nonexistent health services or a population with special health needs and is often know as a community health center. Neighborhood health centers attempt to coordinate Federal, State, and local rescources in a single organization capable of delivering both health care and related social services to a defined population.
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nurse
An individual trained to care for the sick, aged, or injured. A nurse can be defined as a professional qualified by education and authorized by law to practice nursing. There are many different types, specialties, and grades of nurses.
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nurse practitioner
A registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. Nurse practitioners generally function under the supervision of a physician but not necessarily in his or her presence. They are usually salaried rather than reimbursed on a fee-for-service basis, although the supervising physician may recieve fee-for-service reimbursement for their services.
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nursing home
Includes a wide range of institutions which provide various levels of maintainance and personal or nursing care to people who are unable to care for themselves and who have health problems which range from minimal to very serious. The term includes free-standing institutions, or identifiable components of other health facilities which provide nursing care and related services, personal services, and residential care. Nursing homes include skilled nursing facilities and extended care facilities but not boarding homes.
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O

acronyms
occupancy rate
occupational health services
open enrollment
operating cost
operating margin
outcomes research
outlier
outpatient
overhead


occupancy rate
A measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
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occupational health services
Health services concerned with the physical, mental, and social well-being of an individual in relation to his or her working environment and with the adjustment of individuals to their work. The term applies to more than the safety of the workplace and includes health and job satisfaction. In the U.S., the principal Federal statute concerned with occupational health is the Occupational Safety and Health Act administered by the Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH).
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open enrollment
A method for assuring that insurance plans, especially prepaid plans, do not exclusively select good risks. Under an open enrollment requirement, a plan must accept all who apply during a specific period each year.
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operating cost
In the health field, the financial requirements necessary to operate an activity which provides health services. These costs normally include the costs of personnel, materials, overhead, depreciation, and interest.
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operating margin
Revenues from sales minus current cost of goods sold. A measure of operating efficiency that is independent of the cost flow assumption for inventory. Sometimes called "current (gross) margin".
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outcomes research
Research on measures of changes in patient outcomes, that is, patient health status and satisfaction, resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of many other factors that influence patients' health and satisfaction.
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outlier
A hospital admission requiring either substantially more expense or a much longer stay than average. Under DRG reimbursement, outliers are given exceptional treatment (subject to peer review organization review).
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outpatient
A patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. Usually, it does not mean people receiving services from a physician's office or other program which also does not provide inpatient care.
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overhead
The general costs of operating an entity which are allocated to all the revenue producing operations of the entity but which are not directly attributable to a single activity. For a hospital, these costs normally include maintenance of plant, occupancy costs, housekeeping, administration, and others.
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Index

P

passive intervention
patient origin study
peer review
physician assistant (PA)
Physician Payment Review Commission (PPRC)
planning
point of service
policy
poverty area
preadmission certification
precision
preferred provider arrangement (PPA)
Preferred Provider Organization (PPO)
prepayment
prevailing charge
prevalence
preventive medicine
primary care
primary prevention
probability (P value)
prospective payment
Prospective Payment Assessment Commission (ProPAC)
provider
public good
public health


passive intervention
Health promotion and disease prevention initiatives which do not require the direct involvement of the individual (e.g., fluoridation programs) are termed "passive". Most often these types of initiatives are Government sponsored.
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patient origin study
A study, generally undertaken by an individual health program or health planning agency, to determine the geographic distribution of the residences of the patients served by one or more health programs. Such studies help define catchment and medical trade areas and are useful in locating and planning the development of new services.
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peer review
Generally, the evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by other members of the profession (peers). Frequently, peer review refers to the activities of the Professional Review Organizations, and also to review of research by other researchers.
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physician assistant (PA)
Also known as a physician extender, a PA is a specially trained and licensed or otherwise credentialed individual who performs tasks, which might otherwise be performed by a physician, under the direction of a supervising physician.
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Physician Payment Review Commission (PPRC)
In 1986, the Congress created the Physician Payment Review Commission to advise it on reforms of the methods used to pay physicians under the Medicare program. The Commission has conducted analyses of physician payment issues and worked closely with the Congress to bring about comprehensive reforms in Medicare physician payment policy. Its recommendations formed the basis of 1989 legislation that created the RBRVS, a rescource-based fee schedule limiting the amount physicians may charge patients.
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planning
The conscious design of a desired future state (described in a plan by its goals and objectives); including; description of, and selection among, alternative means of achieving the goals and objectives; the conduct of the activities necessary to the design process (such as data gathering and analysis); and the activities necessary to assure that the plan is achieved.
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point of service
A health insurance benefits program in which subscribers can select betweeen different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of medical services, rather than making the selection between delivery systems at time of open enrollment at place of employment. Typically, the costs associated with recieving care from HMO providers are less than when care is rendered by PPO or noncontracting providers.
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policy
A course of action adopted and pursued by a government, party, statesman, or other individual or organization; any course of action adopted as proper, advantageous, or expedient. The term is sometimes used less actively to describe any stated position on matters at issue, i.e., an organization's policy statement on national health insurance. Policies bear the same relationship to rules (regulations) as rules do to law, except that unlike regulations, they do not have the force of law.
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poverty area
An urban or rural geographic area with a high proportion of low income families. Normally, average income is used to define a poverty area, but other indicators, such as housing conditions, illegitimate birth rates, and incidence of juvenile delinquency, are sometimes added to define geographic areas with poverty conditions.
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preadmission certification
A process under which admission to a health institution is reviewed in advance to determine need and appropriateness and to authorize a length of stay consistent with norms for evaluation.
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precision
In statistics, the quality of being sharply defined or stated. One measure of precision is the number of distinguishable alternatives from which a measurement was selected, sometimes indicated by the number of significant digits in the measurement. Precision can be contrasted with accuracy, which is the degree of conformity of a measure to a standard or true value. Often, however, this contrast is not relevant, because the true value is not known.
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preferred provider arrangement (PPA)
Selective contracting with a limited number of health care providers, often at reduced or pre-negotiated rates of payment.
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Preferred Provider Organization (PPO)
Formally organized entity generally consisting of hospital and physician providers. The PPO provides health care services to purchasers usually at discounted rates in return for expediated claims payment and a somewhat predictable market share. In this model, consumers have a choice of using PPO or non-PPO providers; however, financial incentives are built in to benefit structures to encourage utilization of PPO providers.
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prepayment
Usually refers to any payment to a provider for anticipated services (such as an expectant mother paying in advance for maternity care). Sometimes prepayment is distinguished from insurance as referring to payment to organizations which, unlike an insurance company, take responsibility for arranging for, and providing, needed services as well as paying for them (such as health maintenance organizations, prepaid group practices, and medical foundations).
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prevailing charge
One of the factors determining a physician's payment for a service under Medicare, set as a percentile of customary charges of all physicians in the locality.
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prevalence
The number of cases of disease, infected persons, or persons with some other attribute, present at a particular time and in relation to the size of the population from which drawn. It can be a measurement of morbidity at a moment in time, e.g., the number of cases of hemophilia in the country as of the first of the year.
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preventive medicine
Care which has the aim of preventing disease or its consequences. It includes health care programs aimed at warding off illnesses (e.g., immunizations), early detection of disease (e.g., Pap smears), and inhibiting further deterioration of the body (e.g. exercise or prophylactic surgery). Preventive medicine developed following discovery of bacterial diseases and was concerned in its early history with specific medical control measures taken against the agents of infectious diseases. Preventive medicine is also concerned with general preventive measures aimed at improving the healthfulness of the environment. In particular, the promotion of health through altering behavior, especially using health education, is gaining prominence as a component of preventive care.
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primary care
Basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system. Primary care is considered comprehensive when the primary provider takes responsibility for the overall coordination of the care of the patient's health problems, be they biological, behavioral, or social. The appropriate use of consultants and community rescources is an important part of effective primary care. Such care is generally provided by physicians but is increasingly provided by other personnel such as nurse practitioners or physician assistants.
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primary prevention
The prevention of an illness or disease before any symptoms manifest themselves.
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probability (P value)
The likelihood that an event will occur. When looking at differences between data samples, statistical techniques are used to determine if the differences are likely to reflect real differences in the whole group from which the sample is drawn or if they are simply the result of random variation in the samples. For example, a probability (or P value) of one percent indicates that the differences observed would have occured by chance in one out of a hundred samples drawn from the same data.
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prospective payment
Any method of paying hospitals or other health programs in which amounts or rates of payment are established in advance for a defined period (usually a year). Institutions are paid these amounts regardless of the costs they actually incur. These systems of payment are designed to introduce a degree of constraint on charge or cost increases by setting limits on amounts paid during a future period. In some cases, such systems provide incentives for improved efficiency by sharing savings with institutions that perform at lower than anticipated costs. Prospective payment contrasts with the method of payment originally used under Medicare and Medicaid (as well as other insurance programs) where institutions were reimbursed for actual expenses incurred.
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Prospective Payment Assessment Commission (ProPAC)
In 1983, the Congress created the Prospective Payment Assessment Commission to advise the secretary of the Department of Health and Human Services on Medicare's diagnosis related group-based prospective payment system. Its members are appointed by the director of the Office of Technology Assessment. The commission's main responsibilties include recommending an appropriate annual percentage change in DRG payments; recommending needed changes in the DRG classification system and individual DRG weights; collecting and evaluating data on medical practices, patterns, and technology; and reporting on its activities.
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provider
Hospital or licensed health care professional or group of hospitals or health care professionals that provide health care services to patients. May also refer to medical supply firms and vendors of durable medical equipment.
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public good
A good or service whose benefits may be provided to a group at no more cost than required to provide it for one person. The benefits of the good are indivisible and individuals cannot be excluded. For example, a public health measure that eradicates smallpox protects all, not just those paying for the vaccination.
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public health
The science dealing with the protection and improvement of community health by organized community effort. Public health activities are generally those which are less amenable to being undertaken by individuals or which are less effective when undertaken on an individual basis and do not typically include direct personal health services. Public health activities include: immunizations; sanitation; preventive medicine, quarantine and other disease control activities; occupational health and safety programs; assurance of the healthfulness of air, water, and food; health education; epidemiology, and others.
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Q

quality of care
Can be defined as a measure of the degree to which delivered health services meet established professional standards and judgements of value to the consumer. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes, given the existing state of medical service and art. Quality is frequently described as having three dimensions: quality of input rescources (certification and/or training of providers); quality of the process of services delivery (the use of appropriate procedures for a given condition); and quality of outcome of service use (actual improvement in condition or reduction of harmful effects).
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R

rate
rate review
regression analysis
rehabilitation
reimbursement
reinsurance
relative risk
relative value scale (RVS)
relative value studies (also California Relative Value Studies)
retrospective reimbursement
risk or risk factor


rate
A measure of the intensity of the occurence of an event. For example, the mortality rate equals the number who die in one year divided by the number at risk of dying. Rates are usually expressed using a standard denominator such as 1,000 or 100,000 persons.
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rate review
Review by a Government or private agency of a hospital's budget and financial data, performed for the purpose of determining the reasonableness of the hospital rates and evaluating proposed rate increases.
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regression analysis
Given data on a dependent variable and an independent variable, regression analysis involves finding the "best" mathematical model (within some restricted form) to describe the dependent variable as a function of the independent variable or to predict the dependent from the independent variable. Multiple regression analysis considers a dependent variable as a function of more than one independent variable.
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rehabilitation
The combined and coordinated use of medical, social, educational, and vocational measures for training or retraining individuals disabled by disease or injury to the highest possible level of functional ability. Several different types of rehabilitation are distinguished: vocational, social, psychological, medical, and educational.
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reimbursement
The process by which health care providers receive payment for their services. Because of the nature of the health care environment, providers are often reimbursed by third parties who insure and represent patients.
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reinsurance
The resale of insurance products to a secondary market thereby spreading the costs associated with underwriting.
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relative risk
The rate of disease in one group exposed to a particular factor (e.g., a toxic spill) divided by the rate in another group which is not exposed. A relative risk of one (1) indicates that the two groups have the same rate of disease.
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relative value scale (RVS)
A list of all physician services containing a cardinal ranking of those services with respect to some conception of value, such that the difference between the numerical rankings for any two services is a measure of the difference in value between those services. Two common measures of value used in relative value scales are rescources used and charges.
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relative value studies (also California Relative Value Studies)
Coded listing of professional services with unit values to indicate relative complexity as measured by time, skill and overhead costs. Third party payers often assign a dollar value to units to calculate provider reimbursement.
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retrospective reimbursement
Payment made after-the-fact for services rendered on the basis of costs incurred by the facility. See also prospective payment.
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risk or risk factor
Risk is a term used by epidemiologists to quantify the likelihood that something will occur. A risk factor is something which either increases or decreases an individual's risk of developing a disease. However, it does not mean that, if exposed, an individual will definately contract a particular disease.
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S

acronym
screening
secondary care
secondary opinions
secondary prevention
self-funding of health benefits
service period
severity of illness
shadow pricing
shared services
skilled nursing facility (SNF)
sole community hospital (SCH)
solo practice
specialist
spend down
standard error
standards
Substance Abuse and Mental Health Service Administration (SAMHSA)
supply
survey
symptomatic


screening
The use of the quick procedures to differentiate apparently well persons who have a disease or a high risk of disease from those who probably do not have the disease. It is used to identify high risk individuals for more definitive study or follow-up. Multiple screening (or multiphasic screening) is the combination of a battery of screening tests for various diseases performed by technicians under medical direction and applied to large groups of apparently well persons.
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secondary care
Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologists, urologists, dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.
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secondary opinions
In cases involving nonemergency or elective surgical procedures, the practice of seeking judgment of another physician in order to eliminate unnecessary surgery and contain the cost of medical care.
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secondary prevention
Early diagnosis, treatment and follow-up. Secondary prevention activities start with the assumption that illness is already present and that primary prevention was not successful and the goal is to diminish the impact of disease or illness through early detection, diagnosis and treatment. For example, blood pressure screening, treatment, and follow-up programs.
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self-funding of health benefits
An employer or group of employers sets aside funds to cover the cost of health benefits for their employees. Benefits may be administered by the employer(s) or handled through an administrative service only agreement with an insurance carrier or third-party administrator. Under self-funding, it is generally possible to purchase stop-loss insurance that covers expenditures above a certain aggregate claim level and/or covers catastrophic illness or injury when individual claims reach a certain dollar threshold.
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service period
Period of employment that may be required before an employee is eligible to participate in an employer-sponsored health plan, most commonly one to three months.
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severity of illness
A risk prediction system to correlate the "seriousness" of a disease in a particular patient with the statistically "expected" outcome (e.g., mortality, morbidity, efficiency of care). Most effectively, severity is measured at or soon after admission, before therapy is initiated, giving a measure of pretreatment risk.
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shadow pricing
Within a given employer group, pricing of premiums by HMO(s) based upon the cost of indemnity insurance coverage, rather than strict adherence to community rating or experience rating criteria.
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shared services
The coordinated, or otherwise explicitly agreed upon, sharing of responsibility for provision of medical or nonmedical services on the part of two or more otherwise independent hospitals or other health programs. The sharing of medical services might include an agreement that one hospital provide all pediatric care needed in a community and no obstetrical services while another provide obstetrics and no pediatrics. Examples of shared nonmedical services would include joint laundry or dietary services for two or more nursing homes.
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skilled nursing facility (SNF)
A nursing care facility participating in the Medicaid and Medicare programs which meets specified requirements for services, staffing and safety.
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sole community hospital (SCH)
A hospital which (1) is more than 50 miles from any similar hospital, (2) is 25 to 50 miles from a similar hospital and isolated from it at least one month a year as by snow, or is the exclusive provider of services to at least 75 percent of its service area populations, (3) is 15 to 25 miles from any similar hospital and is isolated from it at least one month a year, or (4) has been designated as SCH under previous rules. The Medicare DRG program makes special optional payment provisions for SCHs, most of which are rural, including providing that their rates are set permanently so that 75 percent of their payment is hospital-specific and only 25 percent is based on regional DRG rates.
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solo practice
Lawful practice of a health occupation as a self-employed individual. Solo practice is by definition private practice but is not necessarily general practice or fee-for-service practice (solo practitioners may be paid by capitation, although fee-for-service is more common). Solo practice is common among physicians, dentists, podiatrists, optometrists, and pharmacists.
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specialist
A physician, dentist, or other health professional who is specially trained in a certain branch of medicine or dentistry related to specific other services or procedures (e.g., surgery, radiology, pathology); certain age categories of patients (e.g., pediatrics, geriatrics); certain body systems (e.g., dermatology, orthopedics, cardiology); or certain types of diseases (e.g., allergy, psychiatry, peridontics). Specialists usually have advanced education and training related to their specialties.
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spend down
The amount of expenditures for health care services, relative to income, that qualifies an individual for Medicaid in States that cover categorically eligible, medically indigent individuals. Eligibility is determined on a case-by-case basis.
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standard error
In statistics, the standard error is defined as the standard deviation of an estimate. That is, multiple measurements of a given value will generally group around the mean (or average) value in a normal distribution. The shape of this distribution is known as the standard error.
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standards
Generally, a measure set by a competent authority as the rule for measuring quantity or quality. Conformity with standards is usually a condition of licensure, accreditation, and sometimes, payment for services. Standards may be defined most often in relation to: the actual or predicted effects of care; the performance or credentials of professional personnel; and the physical plant, governance and administration of facilities and programs.
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Substance Abuse and Mental Health Services Administration (SAMHSA)
The mission of SAMHSA is to provide, through the U.S. Public Health Service, a national focus for the Federal effort to promote effective strategies for the prevention and treatment of addictive and mental disorders. SAMHSA is primarily a grant-making organization, promoting knowledge and scientific state-of-the-art practice. SAMHSA strives to reduce barriers to high quality, effective programs and services for individuals who suffer from, or are at risk for, these disorders, as well as for their families and communities.
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supply
In health economics, the quantity of services provided or personnel in a given area.
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survey
An investigation in which information is systematically collected. A population survey may be conducted by face-to-face inquiry, by self-completed questionnaires, by telephone, by postal service, or in some other way. Each method has its advantages and disadvantages. The generalizability of results depends upon the extent to which those surveyed are representative of the entire population.
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symptomatic
Someone who has symptoms of a disease or illness is symptomatic. Someone who has smoked all their life and has a heavy cough is said to be symptomatic. A heavy lifelong smoker who has not yet developed symptoms is said to be pre-symptomatic.
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SAMHSA
Substance Abuse and Mental Health Services Administration
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T

technology assessment
tertiary care
tertiary prevention
third-party payer
Title XVII (Medicare)
Title XIX (Medicaid)
type I error
type II error


technology assessment
A comprehensive form of policy research that examines the technical, economic, and social consequences of technological applications. It is especially concerned with unintended, indirect, or delayed social impacts. In health policy, the term has come to mean any form of policy analysis concerned with medical technology, especially the evaluation of efficacy and safety.
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tertiary care
Services provided by highly specialized providers (e.g. neurologists, neurosurgeons, thoracic surgeons, intensive care units). Such services frequently require highly sophisticated equipment and support facilities. The development of these services has largely been a function of diagnostic and theraputic advances attained through basicand clinical biomedical research.
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tertiary prevention
Prevention activities which focus on the individual after a disease or illness has manifested itself. The goal is to reduce long-term effects and help individuals better cope with symptoms.
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third-party payer
Any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. Such payments are called third-party payments and are distinguished by the separation among the individual receiving the service (the first party), the individual or institution providing it (the second party), and the organization paying for it (third party).
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Title XVIII (Medicare)
The title of the Social Security Act which contains the principal legislative authority for the Medicare program and therefore a common name for the program.
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Title XIX (Medicaid)
The title of the Social Security Act which contains the principal legislative authority for the Medicaid program and therefore a common name for the program.
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type I error
Also known as "false positive" or "alpha error." An incorrect judgement or conclusion that occurs when an association is found between variables where, in fact, no association exists. In an experiment, for example, if the experimental procedure does not really have any effect, chance or random error may cause the researcher to conclude that the experimental procedure did have an effect.
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type II error
Also known as "false negative" or "beta error." An incorrect judgement or conclusion that occurs when no association is found between variables where in fact, an association does exist. In a medical screening, for example, a negative test result may occur by chance in a subject who posesses the attribute for which the test is conducted.
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U

uncompensated care
underinsured
uninsured
usual, customary and reasonable (UCR) fees
utilization
utilization review


uncompensated care
Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs for these services may be covered through cost-shifting. Not all uncompensated care results from charity care. It also includes bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bill.
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underinsured
People with public or private insurance policies that do not cover all necessary medical services, resulting in out-of pocket expenses that exceed their ability to pay.
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uninsured
People who lack public or private health insurance.
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usual, customary and reasonable (UCR) fees
The use of fee screens to determine the lowest value of physician reimbursement based on: (1) the physician's usual charge for a given procedure, (2) the amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and (3) the reasonable cost of services for a given patient after medical review of the case.
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utilization
Use; commonly examined in terms of patterns or rates of use of a single service or type of service, e.g., hospital care, physician visits, prescription drugs. Use is also expressed in rates per unit of population at risk for a given period.
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utilization review
Evaluation of the necessary, appropriateness, and efficiency of the use of medical services, procedures, and facilities. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, length of a stay, and discharge practices, both on a concurrent and retrospective basis. Utilization review can be done by a peer review group, or a public agency.
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V

vital statistics
Statistics relating to births (natality), deaths (mortality), marriages, health and disease (morbidity). Vital statistics for the United States are published by the National Center for Health Statistics.
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W

wellness
A dynamic state of physical, mental, and social well being; a way of life which equips the individual to realize the full potential of his or her capabilities and to overcome and compensate for weakness; a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self-responsibility. Wellness has been viewed as the result of four key factors over which an individual has varying degrees of control: human biology, environment, health care organization (system), and lifestyle.
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working capital
The sum of an institution's short-term or current assets including cash, marketable (short-term) securities, accounts receivable, and inventories. Net working capital is defined as the exess of total current assets over total current liabilities.
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Acknowledgements

This glossary has been compiled and periodically updated and edited by the Alpha Center. Major sources of original definitions include:

• A Discursive Directory of Health Care prepared by the staff of the Subcommittee on Health and the Environment of the Committee of Interstate and Foreign Commerce, U.S. House of Representatives, February 1976.
• Hospital Administration Terminology prepared by the American Hospital Association in 1982.
• Compilation of Acronyms and Terms prepared by the Health and Life Sciences Division, Office of Technology Assessment, U.S. Congress, August 1986.
• The McGraw-Hill Essential Dictionary of Health Care prepared by Lee Hyde, M.D., New York: McGraw-Hill Book Company, 1988.
• American Medical News, glossary of Medicare terminology compiled by Howard Larkin, July 6/13, 1992, p. 17-20.