Comparative Health Policy

Fourth edition

by Robert H. Blank and Viola Burau

Glossary

Use the alphabetical list below to find words beginning with each letter.

A | C | D | E | F | G | H | I | L | M | O | P | Q | R | S | T | U | V | W


A

Acute Care: Medical treatment rendered to people whose illnesses or medical problems are short-term or don’t require long-term continuing care. Acute care facilities are hospitals that mainly treat people with short-term health problems.

Ambulatory Care: All health services delivered outside hospitals (that is, in primary care settings).

Amenable Mortality: A premature death from causes that should not occur in the presence of timely and effective health care.


C

Capitation Fee: A payment system based on a fixed pre-payment, per patient, paid to a health care provider to deliver medical services to a particular group of patients. The payment is the same no matter how many services or what type of services each patient actually gets.

Case Management: Intended to improve health outcomes or control costs by tailoring services to a patient’s needs.

Chronic Illnesses: Health problems that are long-term and continuing. Nursing homes, mental hospitals and rehabilitation facilities are examples of chronic care facilities.

Clinical Guidelines: Carefully developed information on diagnosing and treating specific medical conditions. Guidelines are usually based on clinical literature and expert consensus, are designed to help physicians make decisions and to help funding organizations evaluate appropriateness and medical neces­sity of care.

Coordinated Care: Delivery of systematic, responsive and supportive care to people with complex needs, for example chronic illness. Coordinated care typically spans across different sectors of health care delivery and involves different health professions.

Co-payments: Flat fees or payments that a patient pays for each doctor visit or prescription or other health care service.

Core Services: A package of health care services deemed basic for all citizens.

Cost Containment: The method of constraining health care costs from increasing beyond a set level by controlling or reducing inefficiency and waste in the health care system.

Cost Sharing: The requirement that the patient pay a portion of the costs of covered services. Deductibles, co-insurance and co-payments are cost sharing techniques.

Cost Shifting: When one group of patients does not pay the full cost for a service, health care providers pass on the costs for these services to other groups of patients.

Covered Services: Treatments or other services for which a health plan pays at least part of the charge.


D

Deductible: The amount of money, or value of certain services (such as one physician visit) a patient or family must pay before costs (or percentages of costs) are covered by the health plan or insurance company, usually per year.

Diagnostic-Related Groups (DRGs): A system for classifying hospital stays according to the diagnosis of the medical problem being treated for the purposes of payment.

Disease Management: Programmes for persons who have chronic illnesses such as asthma or diabetes that encourage them to live a healthy lifestyle and take medications as prescribed.


E

Effectiveness: A measure of the extent to which a specific intervention, proce­dure, regimen or service, when deployed in the field in routine circumstances, does what it is intended to do for a specified population.

Elective: A health care procedure that is not an emergency and that the patient and doctor plan in advance.

Electronic Health Record (EHR): Also electronic medical record (EMR). An evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across many health care settings.


F

Fee-for-Service: The traditional payment method where the insurer (patient, insurance plan or government) pays providers per services rendered. The doctor charges a fee for each service provided.


G

Gatekeeper: A primary care physician responsible for overseeing and coordinat­ing all aspects of a patient’s medical care. The gatekeeper usually has to pre-authorize other specialty care, diagnostic tests or hospital admission.

General Practitioners: Physicians without specialty training who provide a wide range of primary health care services to patients.

Global Budgets: Budgets set to contain health care costs. Common in national health systems that annually set the maximum amount of money that will be spent on health care.

Group Insurance: Health insurance offered through business, union trusts or other groups and associations. The most common system of health insurance in the USA is the one in which the cost of insurance is based on the age, sex, health status and occupation of the people in the group.


H

Halfway Technology: Focuses on alleviating problematic symptoms instead of the root causes of poor health.

Health Indicator: An indicator applicable to a health or health-related situation.

Health Inequalities: Differences in health among people and groups within and between countries that are the consequence of social injustice.

Health Inequities or Disparities: Systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically or geographically.

Health Information Technology (HIT): The umbrella term to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government and quality entities and insurers.

Health Insurance: Financial protection against the health care costs caused by treating disease or accidental injury. A system of risk sharing through pooled resources.

Health Maintenance Organization (HMO): A health plan providing compre­hensive medical services to its members for a fixed, prepaid premium. Members must use participating providers and are enrolled for a fixed period of time. HMOs can be either for-profit or not-for-profit. Most HMOs provide care through a network of doctors, hospitals and other medical professionals that their members must use in order to be covered for that care.

Health Outcomes: Measures of the effectiveness of particular kinds of medical treatment. This refers to research-based information that asks what difference a drug, procedure or other health care intervention really makes to a patient’s health.

Health Sector: Part of the economy dealing with health-related issues in society.

Health System: The people, institutions and resources, arranged together in accordance with established policies to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. The set of elements and their relations in a complex whole, designed to serve the health needs of the population.

Home Health Care: Skilled nurses and trained aides who provide nursing services and related care to someone in his or her home.


I

In-patient Care: Care for a person who has been admitted to a hospital or other health facility for a period of at least 24 hours.


L

Long-term Care: Health care, personal care and social services provided to people who have a chronic illness or disability and do not have full functional capacity. This care can take place in an institution or at home on a long-term basis.


M

Malpractice Insurance: Coverage for medical professionals which pays the costs of legal fees and/or any damages assessed by a court in a lawsuit brought against a professional who has been charged with negligence. Endemic in the USA.

Managed Care Organization: An umbrella term for HMOs and all health plans that provide health care in return for pre-set monthly payments and coordinate care through a defined network of primary care physicians and hospitals. Prepaid medical plans that attempt to control health care costs through a preven­tative health care approach.

Means Test: An assessment of a person’s or family’s income or assets so that it can be determined if they are eligible to receive public support.

Medical Home Model: An organizational and financing system that is meant to enhance primary care services through a financial mechanism (care management payments) and communications (information technology). It emphasizes continuity and coordination among specialists and first-contact practitioners without specifying who would coordinate the care.

Medical Tourism: Patient movement generally from highly developed nations to less developed ones to obtain medical treatment that is less expensive or unavailable in their home country. Medical tourism differs from the traditional model of international health travel where patients go from less developed countries to major medical centers in highly developed countries for medical treatment that is unavailable in their own communities.


O

Out-of-Pocket Payments: The amount of money that a person must pay directly for his or her health care, including: deductibles, co-payments, payments for services that are not covered, and/or in the US health insurance premiums that are not paid by his or her employer.

Out-patient Care: Health care services that do not require a patient to receive overnight care in a hospital (such as day surgery).


P

Preventive Health Care: An approach to medicine that attempts to promote and maintain the health of people by preventing disease or its consequences. It includes primary prevention to keep people from getting sick (such as immu­nizations), secondary prevention to detect early disease (such as Pap smears) and tertiary prevention to keep ill people or those at high risk of disease from getting sicker (such as helping someone with lung disease to quit smoking).

Primary Care: Preventive health care and routine medical care that is typically provided by a doctor trained in internal medicine, paediatrics or family practice, or by a nurse, nurse practitioner or physician’s assistant.

Primary Care Provider: The health professional who provides basic health care services and may control patients’ access to the rest of the health care system through referrals.

Private Insurance: Health insurance that is provided by commercial insurance companies and where insurance premiums are risk-based.


Q

Quality Assessment/Assurance: A systematic process to improve the quality of health care by monitoring quality, finding out what is not working and fixing the problems of health care delivery.


R

Rationing: The denial of a treatment to a particular patient who would benefit from it.

Referral System: The process through which a primary care provider authorizes a patient to see a specialist to receive additional care.


S

Single Payer System: A health care system in which costs are paid by taxes or compulsory contributions to sickness funds or social insurance plans rather than by the employer and employee.

Social Determinants of Health: The broad and complex array of social, political, economic, environmental and cultural factors that strongly impact on health status and equity between and within countries.


T

Third Party Payer: An organization other than the patient or health care provider involved in the financing of personal health services.


U

Universal Coverage: This refers to health systems that guarantee health care to all people regardless of the way that the system is financed.


W

Waiting List Time: The amount of time a person must wait from the date he or she is deemed to need a procedure to the date they actually receive it.