AHSR (Academy for Health Services Research and Health Policy)

http://www.academyhealth.org/publications/glossary.htm

AHRQ (Agency for Healthcare Research and Quality)

http://www.ahrq.gov/qual/hcqgloss.htm

Abdominal cavity—The part of the body between the bottom of the ribs and the top of the thighs, containing most of the digestive and urinary systems along with some reproductive organs. (AHRQ-Glossary)

access
An individual's ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

active error
An error that occurs at the level of the front line operator and whose effects are felt almost immediately. (AHSR-Del. and Fin. Terms)

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 from one place to another. (AHSR-Del. and Fin. Terms)

acute care
Medical treatment rendered to individuals whose illnesses 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 (AHSR-Del. and Fin. Terms).

acute disease
A disease which is characterized by a single episode of a relatively short duration from which the patient returns to his/her 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. (AHSR-Del. and Fin. Terms)

adjusted average per capita cost
(AAPCC) The basis for HMO or CMP reimbursement under Medicare-risk contracts. The average monthly amount received per enrollee is currently calculated as 95 percent of the average costs to deliver medical care in the fee-for-service sector. (AHSR-Del. and Fin. Terms)

adverse drug reaction (ADR)
An undesirable response associated with use of a drug that compromises therapeutic efficacy, enhances toxicity, or both. (AHSR-Del. and Fin. Terms)

adverse event
In a medical context, an injury resulting from a medical intervention. (AHSR-Del. and Fin. Terms)

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 health status apply for, or continue, insurance coverage to a greater extent than do persons with average or better health expectations. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Agency for Health Care Policy and Research (AHCPR)
See Agency for Healthcare Research and Quality (AHSR-Del. and Fin. Terms)

Aid to Families with Dependent Children (AFDC)
A program established by the Social Security Act of 1935 and eliminated by welfare reform legislation in 1996. AFDC provided cash payments to needy children (and their caretakers) who lacked support because at least one parent was unavailable. Families had to meet income and resource criteria specified by the state to be eligible. AFDC has been replaced by a new block grant program, but AFDC standards are retained for use in Medicaid. (AHSR-Del. and Fin. Terms)
See Temporary Assistance to Needy Families

all patient diagnosis related groups (APDRG)
An enhancement of the original DRGs, designed to apply to a population broader than that of Medicare beneficiaries, who are predominately older individuals. The APDRG set includes groupings for pediatric and maternity cases as well as of services for HIV-related conditions and other special cases. (AHSR-Del. and Fin. Terms)

all-payer system
A system in which prices for health services and payment methods are the same, regardless of who is paying. For instance, in an all-payer system, federal or state government, a private insurer, a self-insured employer plan, an individual, or any other payer could pay the same rates. The uniform fee bars health care providers from shifting costs from one payer to another. (AHSR-Del. and Fin. Terms)
See cost shifting

American Association of Health Plans (AAHP)
The AAHP, located in Washington, DC, represents more than 1,000 HMOs, PPOs and other network-based plans. Together they care for close to 140 million Americans nationwide. AAHP was created in 1996 by the merger of the Group Health Association of America (GHAA) and the American Managed Care and Review Association (AMCRA). The merger of the two groups created a new organization, that delivers a unified message about the modern style of health care delivery pioneered by HMOs, PPOs and similar health plans (AHSR-Del. and Fin. Terms).

any willing provider laws
Laws that require managed care plans to contract with all health care providers that meet their terms and conditions. (AHSR-Del. and Fin. Terms)

Aorta—The main artery in the body, carrying oxygenated blood from the heart to other arteries in the body. (AHRQ-Glossary)

Appendectomy—Surgical removal of the appendix to treat appendicitis.

Appendicitis—Inflammation of the appendix.

Appendix—Short, tubelike structure that branches off the large intestine; does not have any known function.

Arteriography—Roentgenography of arteries after injection of radiopaque material into the blood stream. (AHRQ-Glossary)

Artery—A large blood vessel that carries blood from the heart to tissues and organs in the body. (AHRQ-Glossary)

Arthroplasty—The surgical repair of a joint. (AHRQ-Glossary)

assignment
A process in which a Medicare beneficiary agrees to have Medicare's share of the cost of a service paid directly ("assigned") to a doctor or other provider, and the provider agrees to accept the Medicare approved charge as payment in full. Medicare pays 80 percent of the cost and the beneficiary 20 percent, for most services. (AHSR-Del. and Fin. Terms)
See participating physician.

avoidable hospital condition
Medical diagnosis for which hospitalization could have been avoided if ambulatory care had been provided in a timely and efficient manner. (AHSR-Del. and Fin. Terms)

balance billing
In Medicare and private fee-for-service health insurance, the practice of billing patients for charges that exceed the amount that the health plan will pay. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge. (AHSR-Del. and Fin. Terms)
See approved charge and participating physician.

beneficiary
An individual who receives benefits from or is covered by an insurance policy or other health care financing program. (AHSR-Del. and Fin. Terms)

biased selection
The market imperfection that results from the uneven grouping of risks among competing subscribers. Biased selection includes favorable selection (attracting good risks and repelling bad ones) as well as adverse selection (the reverse). Biased selection can occur naturally, according to historical or accidental patterns, or it can occur strategically, according to conscious choices by either subscribers or insurers. (AHSR-Del. and Fin. Terms)

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. A Blue Cross plan should be a nonprofit community service organization with a governing body whose membership includes a majority of public representatives. (AHSR-Del. and Fin. Terms)

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 (AHSR-Del. and Fin. Terms)

board certified
Status granted a medical specialist who completes a required course of training and experience (residency) and passes an examination in his/her specialty. Individuals who have met all requirements except examination are referred to as "board eligible." (AHSR-Del. and Fin. Terms)

Boren Amendment
Part of the Medicaid law, known by the name of its principal Congressional sponsor. It provides that state payment for hospitals and nursing facilities must be reasonable and adequate to meet the costs incurred by efficiently and economically operated facilities to provide care and services meeting state and federal standards. (AHSR-Del. and Fin. Terms)

Conceived in 1994, the California Cooperative Healthcare Reporting Initiative (CCHRI) is a collaboration of purchasers, health plans, and providers dedicated to giving California’s consumers important information about health plans. CCHRI is governed by an executive committee consisting of 15 elected representatives (five each from participating health plans, purchasers, and providers) that meets monthly. The Pacific Business Group on Health (PBGH), a coalition of large purchasers, is responsible for administering the program. (AHRQ)

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 expenditures. The review is done by a designated regulatory agency and has a sanction attached which prevents or discourages unneeded expenditures. (AHSR-Del. and Fin. Terms)

Cardioverter/defibrillator—A device which delivers a measured electrical shock to arrest fibrillation of the heart (ventricle). (AHRQ-Glossary)

carrier
A private organization, usually an insurance company, that finances health care. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

case-based
Refers to a single patient or case. (AHSR-Del. and Fin. Terms)

case management
The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. (AHSR-Del. and Fin. Terms)

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 resources. 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. (AHSR-Del. and Fin. Terms)

case severity
A measure of intensity or gravity of a given condition or diagnosis for a patient. (AHSR-Del. and Fin. Terms)

categorically needy
Persons whose Medicaid eligibility is based on their family, age or disability status. Persons not falling into these categories cannot qualify, no matter how low their income. The Medicaid statute defines over 50 distinct population groups as potentially eligible, including those for which coverage is mandatory in all states and those that may be covered at a state's option. The scope of covered services that states provide to the categorically needy is much broader than the minimum scope of services for the other, optional groups receiving Medicaid benefits. (AHSR-Del. and Fin. Terms)

Catheterization—A technique in which a hollow, flexible tube is used to drain body fluids (such as urine), to introduce fluids into the body, or to examine or widen a narrowed vein or artery.(AHRQ-Glossary)

Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention, based in Atlanta, Georgia, 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. Within the U.S. Public Health Service, CDC is the 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 evolve as the agency addresses contemporary threats to health, such as injury, environmental and occupational hazards, behavioral risks, and chronic diseases. (AHSR-Del. and Fin. Terms)

Certificate of Need (CON)
A certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility, acquire 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. (AHSR-Del. and Fin. Terms)

certification
The process by which a governmental or non-governmental 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 non-governmental and do not exclude the uncertified from practice as do licensure programs. (AHSR-Del. and Fin. Terms)

CHAMPUS (Civilian Health and Medical Program of the Uniformed Services)
A former Department of Defense health care program for members of the military, eligible dependents, and military retirees. (AHSR-Del. and Fin. Terms)
See TRICARE

chronic disease
A disease which has one or more of the following characteristics: is permanent, 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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

clinical condition
A diagnosis (e.g., cerebrovascular hemorrhage) or a patient state that may be associated with more than one diagnosis (such as paraplegia) or that may be as yet undiagnosed (such as low back pain).(AHSR-Del. and Fin. Terms)

clinical event
Services provided to patients (items of history taking, physical examination, preventative care, tests, procedures, drugs, advice) or information on clinical condition or on patient state used as a patient outcome.(AHSR-Del. and Fin. Terms)

clinical performance measures
Instruments that estimate the extent to which a health care provider: delivers clinical services that are appropriate for each patient's condition; provides them safely, competently, and in an appropriate time frame; and achieves desired outcomes in terms of those aspects of patient health and patient satisfaction that can be affected by clinical services. (AHSR-Del. and Fin. Terms)

clinical practice guidelines
Systematically developed statements to assist practitioners; and patients' decisions about health care to be provided for specific clinical circumstances. (AHSR-Del. and Fin. Terms)

coinsurance
A cost-sharing requirement under a health insurance policy. It provides that the insured party will assume a portion or percentage 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 deductible amounts payable by the insured. The insured is then liable for the remainder of the costs until their maximum liability is reached. (AHSR-Del. and Fin. Terms)

co-morbiditiesConditions that exist at the same time as the primary condition in the same patient (e.g., hypertension is a co-morbidity of many conditions such as diabetes, ischemic heart disease, end-stage renal disease, etc.). (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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 "neighborhood health center." Community health centers attempt to coordinate Federal, State, and local resources 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 health care services needed by its patient population. (AHSR-Del. and Fin. Terms)

Community Health Management Information Systems (CHMIS)
An automated communication network supporting the transfer of clinical and financial information, currently under development with the support of the John A. Hartford Foundation. (AHSR-Del. and Fin. Terms)

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.(AHSR-Del. and Fin. Terms)

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 to reflect their specific claims experience or health status. Under modified community rating (the most common form), rates may vary based on subscribers' specific demographic characteristics (such as age and gender), but rate variation based on individuals' health status, claims experience, or policy duration is prohibited. "Pure" community rating prohibits rate variation based on demographic as well as health factors, and all subscribers in an area pay the same rate. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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 eligibles on a prospective, prepaid basis. (AHSR-Del. and Fin. Terms)

Computerized Needs-oriented Quality Measurement Evaluation System (CONQUEST)
CONQUEST was developed by the Agency for Healthcare Research and Quality (AHRQ) as a tool that permits users to collect and evaluate health care quality measures to find those suited to or adaptable to their needs. CONQUEST has interlocking databases describing "Measures" and clinical "Conditions." The Measure Database contains information on clinical performance measures-tools to assess the quality of the health care delivered by providers. The Condition Database contains information on incidence, prevalence, cost and utilization, co-morbidities, risk factors, treatments, and guidelines. These databases link by codes for clinical services and health outcomes related to specific measures and conditions. (AHSR-Del. and Fin. Terms)

Consumer Assessment of Health Plans(r) (CAHPS)
CAHPS is a 5-year project funded by the Agency for Healthcare Research and Quality (AHRQ) to help consumers identify the best health care plans and services for their needs. The goals of CAHPS are to (1) develop and test questionnaires that assess health plans and services, (2) produce easily understandable reports for communicating survey information to consumers, and (3) evaluate the usefulness of these reports for consumers in selecting health care plans and services. CAHPS builds on previous focus groups and research about consumer needs for health care decision making as well as public and private survey and report card efforts. The Health Care Financing Administration (HCFA) uses CAHPS to assist Medicare beneficiaries in choosing among managed care and fee-for-service plans. HCFA works with States to support their implementation of Medicaid CAHPS in sites where it is being used, and promotes its use in Child Health Insurance Programs. (AHSR-Del. and Fin. Terms)

http://www.CAHPS®-sun.org
Phone: 800-492-9261

continuing medical education (CME)
Formal education obtained by a health professional after completing his/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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

copayment
A form of cost sharing in which a fixed amount of money is paid by the insured for each health care service provided. (AHSR-Del. and Fin. Terms)

Coronary arteries—The arteries that branch off from the aorta and supply oxygen-rich blood to the heart muscle. (AHRQ-Glossary)

Coronary artery bypass graft (CABG) surgery—An operation in which a piece of vein or artery is used to bypass a blockage in a coronary artery; performed to prevent myocardial infarction (heart attack) and relieve angina pectoris (chest pain due to reduced blood flow to heart muscles). (AHRQ-Glossary)

cost-based reimbursement
Payment made by a health plan or payor to health care providers based on the actual costs incurred in the delivery of care and services to plan beneficiaries. This method of paying providers is still used by some plans; however, cost-based reimbursement is being replaced by prospective payment and other payment mechanisms. (AHSR-Del. and Fin. Terms)

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 resources. 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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

cost sharing
Any provision of a health insurance policy that requires the insured individual to pay some portion of medical expenses. The general term includes deductibles, copayments, and coinsurance. (AHSR-Del. and Fin. Terms)

cost effectiveness analysis (CEA)
A form of analysis that seeks to determine the costs and effectiveness of a medical intervention compared to similar alternative interventions to determine the relative degree to which they will obtain the desired health outcome(s). Cost effectiveness analysis can be applied to any of a number of standards such as median life expectancy or quality of life following an intervention. (AHSR-Del. and Fin. Terms)

cost-shifting
Recouping the cost of providing uncompensated care by increasing revenues from some payers to offset losses and lower net payments from other payers. (AHSR-Del. and Fin. Terms)

coverage
The guarantee against specific losses provided under the terms of an insurance policy. Coverage is sometimes used interchangeably with benefits or protection, and is also used to mean insurance or insurance contract. (AHSR-Del. and Fin. Terms)

coverage decision
A policy decision about categories of health interventions or benefits that will be provided to a population of patients as part of the contract between a health plan and a beneficiary. (AHSR-Del. and Fin. Terms)

covered services
Health care services covered by an insurance plan. (AHSR-Del. and Fin. Terms)

critical access hospital (CAH)
A rural hospital designation established by the Medicare Rural Hospital Flexibility Program (MRHFP) enacted as part of the 1997 Balanced Budget Act. Rural hospitals meeting criteria established by their State may apply for critical access hospital status. Designated hospitals are reimbursed based on cost (rather than prospective payment), must comply with Federal and State regulations for CAHs, and are exempt from certain hospital staffing requirements. (AHSR-Del. and Fin. Terms)
See Medicare Rural Hospital Flexibility Program

cultural competence
A practitioner's or institution's understanding of and sensitivity to the cultural background and primary language of patients in any component of service delivery, including patient education materials, questionnaires, office or health care organization setting, direct patient care, and public health campaigns.(AHSR-Del. and Fin. Terms)

Current Population Survey (CPS)
A national survey conducted annually by the U.S. Department of Commerce, Bureau of the Census, the CPS gathers information on the noninstitutionalized population of the United States. The CPS is the most commonly reported source for the number of persons without health insurance and other information about this population. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

-D-

DD: Developmental Disability (AHSR-Acronyms)

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/her 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, either as a percentage of compensation for each year of service or as a flat dollar amount for each year of service. (AHSR-Del. and Fin. Terms)

defined contribution
Funding mechanism for pension plans that can also be applied to health benefits based on a specific dollar contribution, without defining the services to be provided. (AHSR-Del. and Fin. Terms)

de-identification
A process whereby information that could identify the clinician, the reporter, the health care institution, or another organization involved in a medical error are removed from an error report after it is received. This process is used to maintain records of factors that could cause errors, but assure those who report errors that their reports will not be used in civil lawsuits against them.
See anonymous reporting 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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

direct patient care
Any activities by a health professional involving direct interaction, treatment, administration of medications or other therapy or involvement with a patient. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

discharge
The release of a patient from a provider's care, usually referring to the date at which a patient checks out of a hospital. (AHSR-Del. and Fin. Terms)

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 multi factorial and may be prevented or treated by changing any or a combination of the 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. (AHSR-Del. and Fin. Terms)

disease management
The process of identifying and delivering, within selected patient populations (e.g. patients with asthma or diabetes) the most efficient, effective combination of resources, interventions or pharmaceuticals for the treatment or prevention of a disease. Disease management could include team-based care where physicians and/or other health professionals participate in the delivery and management of care. It also includes the appropriate use of pharmaceuticals. (AHSR-Del. and Fin. Terms)

Disproportionate Share (DSH) Adjustment
A payment adjustment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large volume of low-income patients. (AHSR-Del. and Fin. Terms)

electronic data interchange (EDI)
The mutual exchange of routine information between business using standardized, machine-readable formats (AHSR-Del. and Fin. Terms).

emergency medical services (EMS)
Services utilized in responding to the perceived individual need for immediate treatment for medical, physiological, or psychological illness or injury. (AHSR-Del. and Fin. Terms)

Employee Retirement Income Security Act (ERISA)
A Federal act passed in 1974 that established new standards and reporting/disclosure requirements for 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. (AHSR-Del. and Fin. Terms)

encounter
A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions. (AHSR-Del. and Fin. Terms)

Endoscopy—The visual inspection of any cavity of the body by means of an endoscope.(AHRQ-Glossary)

Enterostomy—Creation of an artificial external opening or fistula in the intestines.(AHRQ-Glossary)

enterprise liability
A plan relating to tort reform in which medical liability is shifted from physicians to health plans (e.g. HMOs). Under such a system, patients would sue the health plan rather than the physician, thereby providing physicians immunity from medical liability. (AHSR-Del. and Fin. Terms)

evidence-based decision making
In a health policy context, evidence-based decision making is the application of the best available scientific evidence to policy decisions about specific medical treatments or changes in the delivery system. The goals of evidence-based decision making are to improve the quality of care, increase the efficiency of care delivery, and improve the allocation of health care resources. (AHSR-Del. and Fin. Terms)

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). (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

experience rating
A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group. (AHSR-Del. and Fin. Terms)

family practice
A form of specialty practice in which physicians provide continuing comprehensive primary care within the context of the family unit. (AHSR-Del. and Fin. Terms)

favorable selection
A tendency for utilization of health services in a population group to be lower than expected or estimated. (AHSR-Del. and Fin. Terms)

Federal Employees Health Benefits Program (FEHBP)
A voluntary health insurance subsidy program administered by the Office of Personnel Management for civilian employees (including retirees and dependents) of the federal government. Enrolles select from a number of approved plans, the costs of which are primarily borne by the government. (AHSR-Del. and Fin. Terms)

Federal Poverty Level (FPL)
The amount of income determined by the federal Department of Health and Human Services to provide a bare minimum for food, clothing, transportation, shelter, and other necessities. FPL is reported annually and varies according to family size (e.g., for a family of three in 1999, the FPL was $13,880, or $1,157 per month). Public assistance programs usually define income limits in relation to FPL. (AHSR-Del. and Fin. Terms)

Federally Qualified Health Center (FQHC)
A health center in a medically under-served area that is eligible to receive cost-based Medicare and Medicaid reimbursement and provide direct reimbursement to nurse practitioners, physician assistants and certified nurse midwives. Federal legislation creating the FQHC category was enacted in 1989. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Femur—The bone located between the hip and the knee; the thighbone.(AHRQ-Glossary)

Fetus—The term used to refer to an unborn child from 8 weeks after fertilization to birth.(AHRQ-Glossary)

fiduciary
Relating to, or founded upon, a trust or 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/her patient, and a hospital trustee has one with a hospital. (AHSR-Del. and Fin. Terms)

The Foundation for Accountability (FACCT)
FACCT is a not-for-profit organization dedicated to helping Americans make better health care decisions. FACCT's board of trustees is made up of consumer organizations and purchasers of health care services and insurance representing 80 million Americans. FACCT creates tools that help people understand and use quality information, develops consumer-focused quality measures, supports public education about health care quality, supports efforts to gather and provide quality information, and encourages health policy to empower and inform consumers.(AHSR-Del. and Fin. Terms)

Gastrointestinal tract—The part of the digestive system that includes the mouth, esophagus, stomach, and intestines. (AHRQ-Glossary)

Gastrostomy—The surgical creation of an opening in the abdominal wall into the stomach for drainage or a feeding tube. (AHRQ-Glossary)

guaranteed issue
Requirement that insurance carriers offer coverage to groups and/or individuals during some period each year. HIPAA requires that insurance carriers guarantee issue of all products to small groups (2 - 50). Some State laws exceed HIPAA's minimum standards and require carriers to guarantee issue to additional groups and individuals. (AHSR-Del. and Fin. Terms)

guaranteed renewal
Requirement that insurance carriers renew existing coverage to groups and/or individuals. HIPAA requires that insurance issuers guarantee renewal of all products to all groups and individuals. (AHSR-Del. and Fin. Terms)

general practice
A form of practice in which physicians without specialty training provide a wide range of primary health care services to patients. (AHSR-Del. and Fin. Terms)

Graduate Medical Education (GME)
Medical education after receipt of the Doctor of Medicine (MD) or equivalent degree, including the education received as an intern, resident (which involves training in a specialty) or fellow, as well as continuing medical education. HCFA partly finances GME through Medicare direct and indirect payments. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

guaranteed issue
Requirement that health plans offer coverage to all businesses during some period each year. (AHSR-Del. and Fin. Terms)

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 (anatomical, 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 or morbidity and mortality. Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs) HCUP QIs comprise a set of 33 clinical performance measures that inform hospitals' self-assessments of inpatient quality of care as well as State and community assessments of access to primary care. Developed by the Agency for Healthcare Research and Quality (AHRQ) as a quick and easy-to-use screening tool, HCUP QIs are intended as a starting point in identifying clinical areas appropriate for further, more in-depth study and analysis. HCUP QIs span three dimensions of care: (1) potentially avoidable adverse hospital outcomes, (2) potentially inappropriate utilization of hospital procedures, and (3) potentially avoidable hospital admissions. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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 include 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. (AHSR-Del. and Fin. Terms)

health insurance
Financial protection against the health care costs arising from disease or accidental bodily injury. Such insurance usually covers all or part of the costs of treating the disease or injury. Insurance may be obtained on either an individual or a group basis. Although the term is often used by policymakers to refer to comprehensive coverage, insurers and regulators use it also to refer to other forms of coverage such as long term care insurance, supplemental insurance, specified disease policies, and accidental death and dismemberment insurance. (AHSR-Del. and Fin. Terms)

Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Sometimes referred to as the Kennedy-Kassebaum bill, this legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. (AHSR-Del. and Fin. Terms)

health insurance purchasing cooperatives (HIPCs)
Public or private organizations which secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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 resources used in producing health services. (AHSR-Del. and Fin. Terms)

health plan
An organization that provides a defined set of benefits; this term usually refers to an HMO-like entity, as opposed to an indemnity insurer. (AHSR-Del. and Fin. Terms)

Health Plan Employer Data and Information Set (HEDIS)
A set of performance measures for health plans developed for the National Committee for Quality Assurance (NCQA) that provides purchasers with information on effectiveness of care, plan finances and costs, and other measures of plan performance and quality. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

health policy
An insurance contract consisting of a defined set of benefits.(AHSR-Del. and Fin. Terms)
See health insurance

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 access, equity and quality of health care, particularly to the disadvantaged and under served. HRSA provides leadership to assure the support and delivery of primary health care services, particularly in under served 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. (AHSR-Del. and Fin. Terms)

health risk factors
Chemical, psychological, physiological, or genetic factors and conditions that predispose an individual to the development of a disease. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

health services research
Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities and populations. (AHSR-Del. and Fin. Terms)

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 prevalence 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. (AHSR-Del. and Fin. Terms)

Health Systems Agency (HSA)
A health planning agency created under the National Health Planning and Resources Development Act of 1974. HSAs were usually nonprofit private organizations and served defined health service areas as designated by the States. (AHSR-Del. and Fin. Terms)

health technology assessment (HTA)
The systematic evaluation of properties, effects, or other impacts of health care technology. HTA is intended to inform decision makers about health technologies and may measure the direct or indirect consequences of a given technology or treatment. (AHSR-Del. and Fin. Terms)

Hemodialysis—A method used to treat kidney failure, in which blood is passed through a machine that purifies it and returns it to the body.(AHRQ-Glossary)

HIAA: Health Insurance Association of America (AHSR-Acronyms)
high-risk pool
A subsidized health insurance pool organized by some States as an alternative for individuals who have been denied health insurance because of a medical condition, or whose premiums are rated significantly higher than the average due to health status or claims experience. Commonly operated through an association composed of all health insurers in a State. HIPAA allows States to use high- risk pools as an "acceptable alternative mechanism" that satisfies the statutory requirements for assuring access to health insurance coverage for certain individuals. (AHSR-Del. and Fin. Terms)

Hill-Burton Act
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 received Hill-Burton funds incur an obligation to provide a certain amount of charity care. (AHSR-Del. and Fin. Terms)

hindsight bias
A bias in investigating the cause of a medical error or accident where in retrospect the reviewer simplifies the cause of the error to a single element, overlooking multiple contributing factors. The hindsight bias makes it easy to arrive at a simple solution or to blame an individual, but often makes it difficult to determine the true cause(s) of the error or propose systematic solutions. (AHSR-Del. and Fin. Terms)

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 that 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. (AHSR-Del. and Fin. Terms)

home- and community-based services (HCBS)
Any care or services provided in a patient's place of residence or in a non-institutional setting located in the immediate community. Home- and community-based services may include home health care, adult day care or day treatment, medical equipment services, or other interventions provided for the purpose of allowing a patient to receive care at home or in their community. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

horizontal integration
Merging of two or more firms at the same level of production in some formal, legal relationship. (AHSR-Del. and Fin. Terms)
See vertical integration

hospital
An institution whose primary function is to provide inpatient diagnostic and therapeutic 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 non-teaching, 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. (AHSR-Del. and Fin. Terms)

human factors research
The study of the interrelationships between humans, the tools they use, and the environment in which they live and work. (AHSR-Del. and Fin. Terms)

Ileum—The lowest section of the small intestine, which attaches to the large intestine.(AHRQ-Glossary)

Induction of labor—The use of artificial means to start the process of childbirth.(AHRQ-Glossary)

IMG: International Medical Graduate (AHSR-Acronyms)

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 covered services. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

inpatient
A person who has been admitted at least overnight to a hospital or other health facility (which is therefore responsible for his/her room and board) for the purpose of receiving diagnostic treatment or other health services. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

integrated services network (ISN)
A network of organizations usually including hospitals and physician groups, that provides or arranges to provide a coordinated continuum of services to a defined population and is held both clinically and fiscally accountable for the outcomes of the populations served. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

international medical graduate (IMG)
A physician who graduated from a medical school outside of the United States, usually Canada. U.S. citizens who go to medical school abroad are classified as international medical graduates just as are foreign-born persons who are not trained in a medical school in this country. U.S. citizens represent only a small portion of the IMG group. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

-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. Establishes guidelines for the operation of hospitals and other health facilities and conducts survey and accreditation programs. (AHSR-Del. and Fin. Terms)

Laminectomy—A surgical procedure that removes part of a vertebra to relieve pressure on the spinal cord or a nerve branching from the spinal cord.(AHRQ-Glossary)

Laparoscope—A viewing instrument used to examine and treat disorders in the abdominal cavity; consists of a long tube with an eyepiece, a lens, and often a camera, which allows the image to be viewed on a monitor.(AHRQ-Glossary)

Laparoscopic cholecystectomy—Surgical removal of the gallbladder using a laparoscope.(AHRQ-Glossary)

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. (AHSR-Del. and Fin. Terms)

limited service hospital
A hospital, often located in rural areas, that provides a limited set of medical and surgical services. (AHSR-Del. and Fin. Terms)

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 chronically 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 home health care and assisted living, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care. (AHSR-Del. and Fin. Terms)

major depressive disorder
To be diagnosed with major depressive disorder, a patient must exhibit a depressed mood or loss of interest in most daily activities, plus at least five of nine major symptoms during a two-week period. Major symptoms include: significant weight gain or loss; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of guilt or worthlessness; indecisiveness or impaired ability to concentrate; and recurrent thoughts of death or suicide. (AHSR-Del. and Fin. Terms)

managed behavioral health organization
An organization that assumes the responsibility for managing the behavioral health benefit for an employer or payer organization under a "carve out" arrangement. The management may range from utilization management services to the actual provision of the services through its own organization or provider network. Reimbursement may be on a fee-for-service, shared risk, or full-risk basis. This is a specialty Managed Care Organization (MCO). (AHSR-Del. and Fin. Terms)

management services organization
The management services organization provides administrative and practice management services to physicians. An MSO may typically be owned by a hospital, hospitals, or investors. Large group practices may also establish MSOs to sell management services to other physician groups. (AHSR-Del. and Fin. Terms)

mandatory reporting
A system under which physicians or other health professionals are required by law to inform health authorities when a specified event occurs (i.e. a medical error or the diagnosis of a certain disease). (AHSR-Del. and Fin. Terms)

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 one 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. (AHSR-Del. and Fin. Terms)

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, independent practices for evaluating professional performance by comparing it with accepted criteria, standards, and current professional judgment. 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. (AHSR-Del. and Fin. Terms)

medical error
An error or omission in the medical care provided to a patient. Medical errors can occur in diagnosis, treatment, preventative monitoring, or in the failure of a piece of medical equipment or another component of the medical system. Often, but not always, medical errors result in adverse events such as injury or death. (AHSR-Del. and Fin. Terms)

Medical Expenditure Panel Survey (MEPS)
MEPS is the third in a series of medical expenditure surveys conducted by the AHRQ. It is a nationally representative survey that collects detailed information on the health status, access to care, health care use and expenses, and health insurance coverage of the civilian noninstitutionalized population of the U.S. and nursing home residents. MEPS comprises four component surveys: the Household Component, the Medical Provider Component, the Insurance Component, and the Nursing Home Component. The Household Component is the core survey and is conducted each year using an overlapping panel design to collect data for two calendar years from each sampled household. (AHSR-Del. and Fin. Terms)

medically indigent
Persons who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance. (AHSR-Del. and Fin. Terms)

medically necessary
A treatment or service that is appropriate and consistent with a patient's diagnosis and which, in accordance with locally accepted standards of practice, cannot be omitted without adversely affecting the patent's condition or the quality of care. (AHSR-Del. and Fin. Terms)

medical management information system (MMIS)
A data system that allows payers and purchasers to track health care expenditure and utilization patterns.(AHSR-Del. and Fin. Terms)

medical review criteria
Systematically developed statements that can be used to assess the appropriateness of specific health care decisions, services, and outcomes. (AHSR-Del. and Fin. Terms)

medical savings account (MSA)
An account in which individuals can accumulate contributions to pay for medical care or insurance. Some states give tax-preferred status to MSA contributions, but such contributions are still subject to federal income taxation. MSAs differ from Medical reimbursement accounts, sometimes called flexible benefits or Section 115 accounts, in that they need not be associated with an employer. MSAs are not currently recognized in federal statute. (AHSR-Del. and Fin. Terms)

medically needy
Persons who are categorically eligible for Medicaid and whose income, less accumulated medical bills, is below state income limits for the Medicaid program. (AHSR-Del. and Fin. Terms)
See spend down

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). (AHSR-Del. and Fin. Terms)

Medicare approved charge
The amount Medicare approves for payment to a physician. Typically, Medicare pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. Physicians may bill beneficiaries for an additional amount (the balance) not to exceed 15 percent of the Medicare approved charge.(AHSR-Del. and Fin. Terms)
See balance billing

Medicare Payment Advisory Commission (MedPAC)
MedPAC is an independent federal body that advises the U.S. Congress on issues affecting the Medicare program. It was established by the Balanced Budget Act of 1997 (P.L. 105-33), which merged the Prospective Payment Assessment Commission (ProPAC) and the Physician Payment Review Commission (PPRC). (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Medicare Rural Hospital Flexibility Program (MRHFP)
A limited service hospital program created by the Balanced Budget Act of 1997 and modified by the Balanced Budget Refinement Act in 1999. Under the MRHPF, rural hospitals meeting criteria specified by their State can apply to become critical access hospitals. The Program provides regulatory relief and a cost-based payment option for smaller, low-volume facilities that lack the resources needed to meet hospital staffing and other requirements under Medicare. (AHSR-Del. and Fin. Terms)
See Critical Access Hospital

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. (AHSR-Del. and Fin. Terms)

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). (AHSR-Del. and Fin. Terms)

MR: Mentally Retarded (AHSR-Acronyms)

multiple employer trust (MET)
Arrangement through which two or more employers can provide benefits, including health coverage, for their employees. Arrangements formed by associations of similar employers were exempt from most state regulations. Redefined as a MEWA by the Multiple Employer Welfare Arrangement Act of 1982. (AHSR-Del. and Fin. Terms)

National Committee for Quality Assurance (NCQA)
A national organization founded in 1979 composed of 14 directors representing consumers, purchasers, and providers of managed health care. It accredits quality assurance programs in prepaid managed health care organizations and develops and coordinates programs for assessing the quality of care and service in the managed care industry. (AHSR-Del. and Fin. Terms)

National Health Service Corps (NHSC)
A program administered by the U.S. Public Health Service that places physicians and other providers in health professions shortage areas by providing scholarship and loan repayment incentives. Since 1970, the Corps members have worked in community health centers, migrant centers, Indian health facilities and in other sites targeting under served populations. (AHSR-Del. and Fin. Terms)

network An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. (AHSR-Del. and Fin. Terms)

network adequacy
Standards for provider networks to maintain sufficient numbers and types of providers to assure accessibility of services without unreasonable delays. (AHSR-Del. and Fin. Terms)

no-fault compensation
A proposal that all people injured during medical care be automatically reimbursed, even if the care was not negligent. Patients would forfeit their right to sue and instead be paid out of a pool funded by doctors and hospitals. Theoretically, no-fault compensation would save money currently spent on lawsuits and distribute awards to a wider variety and number of injured people. (AHSR-Del. and Fin. Terms)

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/her or her presence. They are usually salaried rather than reimbursed on a fee-for-service basis, although the supervising physician may receive fee-for-service reimbursement for their services. (AHSR-Del. and Fin. Terms)

nursing home
Includes a wide range of institutions which provide various levels of maintenance 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 care, and residential care. Nursing homes include skilled nursing facilities and extended care facilities but not boarding homes. (AHSR-Del. and Fin. Terms)

occupational health services
Health services concerned with the physical, mental, and social well-being of an individual in relation to his/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). (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

organized delivery system (ODS)
See integrated services network (ISN) (AHSR-Del. and Fin. Terms)

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 the many other factors that influence patients' health and satisfaction. (AHSR-Del. and Fin. Terms)

outlier
A hospital admission requiring either substantially more expense or a much longer length of stay than average. Under DRG reimbursement, outliers are given exceptional treatment (subject to peer review and organization review). (AHSR-Del. and Fin. Terms)

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.(AHSR-Del. and Fin. Terms)

Parenteral—Not through the alimentary canal but rather by injection through some other route, as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intrasternal, intravenous, etc.(AHRQ-Glossary)

participating physician
A physician who agrees by contractual arrangement to accept the rules, terms, and fee schedule of a given health plan or provider network. In Medicare, a physician who signs an agreement to accept assignment on all Medicare claims for one year. (AHSR-Del. and Fin. Terms)
See assignment

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

performance measures
Methods or instruments to estimate or monitor the extent to which the actions of a health care practitioner or provider conform to practice guidelines, medical review criteria, or standards of quality. (AHSR-Del. and Fin. Terms)

Per Member Per Month (PMPM)
A unit of measure referring to health plan costs, revenues, hospital days, or patient visits. (AHSR-Del. and Fin. Terms)

pharmaceutical assistance program
A public program to provide pharmaceutical coverage to those who cannot afford or have difficulty obtaining prescription drugs. Several States operate State-funded pharmaceutical assistance programs, which primarily provide benefits to low-income elderly or persons with disabilities who do not qualify for Medicaid. (AHSR-Del. and Fin. Terms)

pharmacoeconomics
The study of the net economic impact of pharmaceutical treatment on the total cost of delivering health care. (AHSR-Del. and Fin. Terms)

pharmacy benefit manager (PBM)
Many insurance companies, HMOs and self-insured employers contract with PBMs to manage drug benefit coverage for employees and health plan members. Common tools employed by PBMs to manage drug benefits include management of pharmacy networks, implementation of generic substitution and mail-order programs, negotiation of rebates with drug manufacturers, formulary management and clinical programs such as disease management. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

physician-hospital organization (PHO)
A legal entity formed by a hospital and a group of physicians to further mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices and agree to accept managed care patients according to the terms of a professional services agreement with the PHO. The PHO serves as a collective negotiating and contracting unit. It is typically owned and governed jointly by a hospital and shareholder physicians. (AHSR-Del. and Fin. Terms)

physician order entry
Electronic systems in which physicians enter and transmit medication orders as well as orders for radiology, lab work, and other ancillary services. Physician order entry systems help catch and prevent errors by checking physician orders against potential drug to drug interactions, normal dosages, and diagnostic or therapeutic guidelines. Physician order entry systems also prevent medical errors due to misreading of hand-written orders. (AHSR-Del. and Fin. Terms)

Physician Payment Review Commission (PPRC)
Congress created the Physician Payment Review Commission in 1986 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 resource-based fee schedule limiting the amount physicians may charge patients. (AHSR-Del. and Fin. Terms)

population-based services
Health services targeted at populations of patients with specific diseases or disorders (i.e. patients with asthma or diabetes). The concept that the health care can be better administered if patients are examined as populations as well as specific cases is one basis for disease management and managed care. (AHSR-Del. and Fin. Terms)

portability
Requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans. (AHSR-Del. and Fin. Terms)

practice guidelines, parameters
Standards used to guide providers based on accepted clinical treatment protocols for typical cases. (AHSR-Del. and Fin. Terms)

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 the evaluation. (AHSR-Del. and Fin. Terms)

preexisting condition
A medical condition developed prior to issuance of a health insurance policy. Some policies exclude coverage of such conditions is often excluded for a period of time or indefinitely. (AHSR-Del. and Fin. Terms)

preferred provider arrangement (PPA)
Selective contracting with a limited number of health care providers, often at reduced or pre-negotiated rates of payment. (AHSR-Del. and Fin. Terms)

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 expedited 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. (AHSR-Del. and Fin. Terms)

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). (AHSR-Del. and Fin. Terms)

prevailing charge
One of the factors determining a physician's payment for a service under Medicare, set at a percentile of customary charges of all physicians in the locality. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Primary Care Provider (PCP)
A generalist physician (family practice, general internal medicine, general pediatrics, and sometimes obstetrics/gynecology for women patients) who provides primary care services. (AHSR-Del. and Fin. Terms)

primary care case management (PCCM)
The use of a primary care physician to manage the use of medical or surgical care. PCCM programs usually pay for all care in a fee-for-service basis. (AHSR-Del. and Fin. Terms)

primary payer
The insurer obligated to pay losses before any liability is assumed by other, secondary insurers. Medicare, for instance, is a primary payer with respect to Medicaid. (AHSR-Del. and Fin. Terms)

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 responsibilities 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 (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

provider service organization (PSO)
See Provider Sponsored Network and Physician-Hospital Organization (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

purchasing organization
See health insurance purchasing cooperative (HIPC) (AHSR-Del. and Fin. Terms)

quality assurance reform initiative (QARI)
A process developed by the Health Care Financing Administration to develop a health care quality improvement system for Medicaid managed care plans.(AHSR-Del. and Fin. Terms)

Quality Improvement System for Managed Care (QISMC)
QISMC, developed by HCFA, is a system for ensuring that managed care organizations contracting with Medicare and Medicaid protect and improve the health and satisfaction of enrolled beneficiaries. It consists of a set of standards and guidelines for their use. For Medicare, the QISMC standards and guidelines are the equivalent of a program manual. As such, they represent HCFA's administrative interpretation of the Medicare+Choice requirements relating to an organization's operation and performance in the areas of quality measurement and improvement and the delivery of health care and enrollee services. Medicare?? organizations must comply with the QISMC standards and guidelines in order to meet their quality assurance obligations under the Medicare+ Choice regulation and the legislation that it implements, the Balanced Budget Act of 1997 (BBA). For Medicaid, the QISMC standards and guidelines are tools that States may choose to use to ensure that Medicaid managed care organizations meet the comparable quality assurance requirements that the BBA and its implementing regulation establish for them. (AHSR-Del. and Fin. Terms)

quality of care
The degree to which delivered health services meet established professional standards and judgments 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 and minimize risk and other outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources (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). (AHSR-Del. and Fin. Terms)

referral
The process of sending a patient from one practitioner to another for health care services. Health Plans may require that designated primary care providers authorize a referral for coverage of specialty services.(AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

reinsurance
The resale of insurance products to a secondary market thereby spreading the costs associated with underwriting. (AHSR-Del. and Fin. Terms)

report card
A report presented on quality of health services designed to inform patients and health care purchasers of practitioner and organizational performance. (AHSR-Del. and Fin. Terms)

Respiratory system—The organs that carry out the process of respiration. (AHRQ-Glossary)

resource-based relative value scale (RBRVS)
Established as part of the Omnibus Reconciliation Act of 1989, Medicare payment rules for physician services was altered by establishing an RBRVS fee schedule. This payment methodology has three components: a relative value for each procedure, a geographic adjustment factor, and a dollar conversion factor. (AHSR-Del. and Fin. Terms)

retrospective reimbursement
Payment made after-the-fact for services rendered on the basis of costs incurred by the facility.
See also prospective payment (AHSR-Del. and Fin. Terms)

risk adjustment
A process by which premium dollars are shifted from a plan with relatively healthy enrollees to another with sicker members. It is intended to minimize any financial incentives health plans may have to select healthier than average enrollees. In this process, health plans which attract higher risk providers and members would be compensated for any differences in the proportion of their members that require high levels of care compared to other plans. (AHSR-Del. and Fin. Terms)

risk-based capital formula
A method of establishing the minimum amount of capital appropriate for an insurance company to support its overall business operations in consideration of its size, structure, and risk profile. It is used to assess a managed care organizations' financial viability and help prevent insolvency. (AHSR-Del. and Fin. Terms)

risk-bearing entity
An organization that assumes financial responsibility for the provision of a defined set of benefits by accepting prepayment for some or all of the cost of care. A risk-bearing entity may be an insurer, a health plan or self-funded employer, or a PHO or other form of PSN. (AHSR-Del. and Fin. Terms)

risk pool
See high-risk pool (AHSR-Del. and Fin. Terms)

risk sharing
The distribution of financial risk among parties furnishing a service. For example, if a hospital and a group of physicians from a corporation provide health care at a fixed price, a risk-sharing arrangement would entail both the hospital and the group being held liable if expenses exceed revenues. (AHSR-Del. and Fin. Terms)

root cause analysis
A process for identifying the basic or causal factor(s) that underlie variations in performance, including the occurrence or possible occurrence of an error. (AHSR-Del. and Fin. Terms)

rural health clinic (RHC)
A public or private hospital, clinic or physician practice designated by the federal government as in compliance with the Rural Health Clinics Act (Public Law 95-210). The practice must be located in a Medically Under served area or a Health Professions Shortage Area and use a physician assistant and/or nurse practitioners to deliver services. A rural health clinic must be licensed by the state and provide preventive services. (AHSR-Del. and Fin. Terms)

Rural Health Clinics Act
Establishes a reimbursement mechanism to support the provision of primary care services in rural areas. Public Law 95-210 was enacted in 1977 and authorizes the expanded use of physician assistants, nurse practitioners and certified nurse practitioners; extends Medicare and Medicaid reimbursement to designated clinics; and raises Medicaid reimbursement levels to those set by Medicare. (AHSR-Del. and Fin. Terms)

rural health network
Refers to any of a variety of organizational arrangements to link rural health care providers in a common purpose. (AHSR-Del. and Fin. Terms)

Ryan White CARE Act
Through the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, health care and support services are provided for persons living with HIV/AIDS. HRSA administers this Act, which was reauthorized by the Congress in 1996 for 5 years. The metropolitan areas most affected by the HIV epidemic are awarded Title I grants to improve and expand health care. Title II grants to states and territories support essential health care and support services for persons living with HIV/AIDS, including health insurance and AIDS Drug Assistance Programs. Title III(b) supports early intervention in clinical settings such as community and migrant health centers, health care for the homeless programs, and Native Hawaiian health programs. Title IV supports services for women, children, adolescents, and families affected by the HIV epidemic. Part F of the Act supports Special Projects of National Significance (SPNS) and AIDS Education and Training Centers (AETCs). (AHSR-Del. and Fin. Terms)

safety net providers
Providers that historically have had large Medicaid and indigent care caseloads relative to other providers and are willing to provide services regardless of the patient's ability to pay. (AHSR-Del. and Fin. Terms)

screening
The use of 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. (AHSR-Del. and Fin. Terms)

secondary care
Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, 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. (AHSR-Del. and Fin. Terms)

secondary opinions
In cases involving non-emergency 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. (AHSR-Del. and Fin. Terms)

secondary payer
An insurer obligated to pay losses above or beyond losses that are assumed by a primary payer. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Section 1115 Medicaid Waiver
Section 1115 of the Social Security Act grants the secretary of Health and Human Services broad authority to waive certain laws relating to Medicaid for the purpose of conducting pilot, experimental or demonstration projects which are "likely to promote the objectives" of the program. Section 1115 demonstration waivers allow states to change provisions of their Medicaid programs, including: eligibility requirements, the scope of services available, the freedom to choose a provider, a provider's choice to participate in a plan, the method of reimbursing providers, and the statewide application of the program. (AHSR-Del. and Fin. Terms)

Section 1915(b) Medicaid Waiver
Section 1915(b) waivers allow states to require Medicaid recipients to enroll in HMOs or other managed care plans in an effort to control costs. The waivers allow states to: implement a primary care case-management system; require Medicaid recipients to choose from a number of competing health plans; provide additional benefits in exchange for savings resulting from recipients' use of cost-effective providers; and limit the providers from which beneficiaries can receive non-emergency treatment. The waivers are granted for two years, with two-year renewals. Often referred to as a "freedom-of-choice waiver." (AHSR-Del. and Fin. Terms)

self-funding / self-insurance
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. (AHSR-Del. and Fin. Terms)

Selective Serotonin Reuptake Inhibitor (SSRI)
A class of antidepressant medications. SSRIs can also be used to treat panic disorder, obsessive-compulsive behavior, alcoholism, obesity and bulimia. Common SSRIs include Prozac, Paxil, and Zoloft. (AHSR-Del. and Fin. Terms)

sentinel event
An unexpected occurrence or variation involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The event is called "sentinel" because it sends a signal or sounds a warning that requires immediate attention. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

SF-12
A shorter version of the SF-36 (1-page, 2-minute) survey form that has been shown to yield summary physical and mental health outcome scores that are interchangeable with those from the SF-36 in both general and specific populations. This shorter version of the SF-36 was published in early 1995 is already one of the most widely used surveys of health status. (AHSR-Del. and Fin. Terms)

SF-36
A comprehensive short-form health status questionnaire with only 36 questions that yields an 8-scale health profile as well as summary measures of health-related quality of life. As documented in more than 750 publications, the SF-36 has proven useful in monitoring general and specific populations, comparing the burden of different diseases, differentiating the health benefits produced by different treatments, and in screening individual patients. The SF-36 is a standard measure of health care quality used by health service researchers and others who monitor quality of care. The survey is produced by Quality Metric Inc.(AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

skilled nursing facility (SNF)
A nursing care facility participating in the Medicaid and Medicare programs which meets specified requirements for services, staffing and safety. (AHSR-Del. and Fin. Terms)

small-group market
The insurance market for products sold to groups that are smaller than a specified size, typically employer groups. The size of groups included usually depends on state insurance laws and thus varies from state to state, with 50 employees the most common size. (AHSR-Del. and Fin. Terms)

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 an 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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

specialist
A physician, dentist, or other health professional who is specially trained in a certain branch of medicine or dentistry related to specific services or procedures (e.g., surgery, radiology, pathology); certain age categories of patients (e.g., geriatrics); certain body systems (e.g., dermatology, orthopedics, cardiology); or certain types of diseases (e.g., allergy, periodontics). Specialists usually have advanced education and training related to their specialties. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

SSI: Supplemental Security Income (AHSR-Acronyms)

State Children's Health Insurance Program (SCHIP)
This program was enacted as part of the Balanced Budget Act of 1997, which established Title XXI of the Social Security Act to provide States with $24 billion in Federal funds for 1998-2002 targeting children in families with incomes up to 200 percent of the Federal Poverty Level. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

Supplemental Security Income (SSI)
A federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act. States may use SSI income limits to establish Medicaid eligibility. (AHSR-Del. and Fin. Terms)

systems approach
A school of thought evolving from earlier systems analysis theory, propounding that virtually all outcomes are the result of systems rather than individuals. In practice, the systems approach is characterized by attempts to improve the quality and/or efficiency of a process through improvements to the system. (AHSR-Del. and Fin. Terms)

telehealth
The use of telecommunications technologies and electronic information to support long-distance clinical health care, patient and professional health-related education, or public health and health administration. (AHSR-Del. and Fin. Terms)

telemedicine
The use of telecommunications (i.e., wire, radio, optical or electromagnetic channels transmitting voice, data and video) to facilitate medical diagnosis, patient care, and/or distance learning. (AHSR-Del. and Fin. Terms)

Temporary Assistance to Needy Families (TANF)
Title I of the Welfare Reform Act of 1996 converted Federal funding under the former AFDC program to a State block grant program called TANF. (AHSR-Del. and Fin. Terms)
See Aid to Families with Dependent Children

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. (AHSR-Del. and Fin. Terms)

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). (AHSR-Del. and Fin. Terms)

third-party administrator (TPA)
A fiscal intermediary, a person or an organization that serves as another's financial agent. A TPA processes claims, provides services, and issues payments on behalf of certain private, federal and state health benefit programs or other insurance organizations. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

TRICARE
The health care program for members of the military, eligible dependents, and military retirees. TRICARE was formerly called CHAMPUS (Civilian Health and Medical Program of the Uniformed Services). (AHSR-Del. and Fin. Terms)

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 possesses the attribute for which the test is conducted. (AHSR-Epid. and Stat. Terms)

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. (AHSR-Del. and Fin. Terms)

underinsured
People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay. (AHSR-Del. and Fin. Terms)

uninsurables
High-risk persons who do not have health care coverage through private insurance and who fall outside the parameters of risks of standard health underwriting practices. (AHSR-Del. and Fin. Terms)

uninsured
People who lack public or private health insurance. (AHSR-Del. and Fin. Terms)

underwriting
In insurance, the process of selecting, classifying, evaluating, and assuming risks according to their insurability. Its purpose is to make sure that the group or individual insured has the same probability of loss and probable amount of loss, within reasonable limits, as the universe on which premium rates were based. Since premium rates are based on an expectation of loss, the underwriting process must classify risks into groups with about the same expectation of loss. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

utilization review
Evaluation of the necessity, appropriateness, and efficiency of the use of health care 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. (AHSR-Del. and Fin. Terms)

Vaccine—A preparation of weakened microorganisms given to create resistance to a certain disease.(AHRQ-Glossary)

Vacuum extraction—A technique used to facilitate childbirth using a suction device to help move the baby through the birth canal.(AHRQ-Glossary)

Ventricle—A small cavity or chamber; there are four ventricles in the brain that circulate cerebrospinal fluid through it, and two in the heart that pump blood throughout the body.(AHRQ-Glossary)

vertical integration
Organization of production whereby one business entity controls or owns all stages of the production and distribution of goods or services. (AHSR-Del. and Fin. Terms)

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. (AHSR-Del. and Fin. Terms)

voluntary reporting
A medical error reporting system where the reporter chooses to report an error in order to prevent similar errors from occurring in the future. One theory of voluntary reporting systems is that they allow reporters to focus on a set of errors broader than just those that cause serious harm and that they help to detect system weaknesses before the occurrence of serious harm. (AHSR-Del. and Fin. Terms)

withhold
A form of compensation whereby a health plan withholds payment to a provider until the end of a period at which time the plan distributes any surplus based on some measure of provider efficiency or performance.(AHSR-Del. and Fin. Terms)

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