Chapter 1 - The US Healthcare Delivery System Flashcards
Accountable care organization (ACO)
A group of service providers that work together to manage and coordinate care to Medicare fee-for-service beneficiaries.
Accreditation
- A voluntary process of institutional or organizational review in which a quasi-independent body created for this purpose periodically evaluates the quality of the entity’s work against preestablished written criteria
- A determination by an accrediting body that an eligible organization, network, program, group, or individual complies with applicable standards
- The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency
Acute care
Medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and treat an injury or a short-term illness
Allied health professional
A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietician, social worker, or occupational therapist)
Ambulatory care
Preventative or corrective healthcare services provided on a nonresident basis in a provider’s office, clinic setting, or hospital outpatient setting
Biotechnology
The field devoted to applying the techniques of biochemistry, cellular biology, biophysics, and molecular biology to addressing practical issues related to human beings, agriculture, and the environment
Centers for Medicare and Medicaid Services (CMS)
The Department of Health and Human Services agency responsible for Medicare and parts of Medicaid. Maintains oversight of the survey and certification of nursing homes and continuing care providers and makes information about these activities available to beneficiaries, providers and suppliers, researchers, and state surveyors
Certification
- The process by which a duly authorized body evaluates and recognizes an individual, institution, or educational program as meeting predetermined requirements
- An evaluation performed to establish the extent to which a particular computer system, network design, or application implementation meets a prespecified set of requirements
Chief executive officer (CEO)
The senior manager appointed by a governing body to direct an organization’s overall long-term strategic management
Clinical Privileges
The authorization granted by a healthcare organization’s governing board to a member of the medical staff that enables the physician to provide patient services in the organization within specific practice limits
Continuum of care
Patients are provided care by different caregivers at several different levels of the healthcare system
Deemed status
An official designation indicating that a healthcare facility is in compliance with the Medicare Conditions of Participation
For-profit
Healthcare organizations are privately owned. Excess funds are paid back in to the managers, owners, and investors in the form of bonuses and dividends
Health maintenance organization (HMO)
Entity that combines the provision of healthcare insurance and the delivery of healthcare services, characterized by: 1. An organized healthcare delivery system to a geographic area, 2. A set of basic and supplemental health maintenance and treatment services, 3. Voluntarily enrolled members, and 4. Predetermined fixed, periodic prepayment for members’ coverage
Health savings account (HSA)
Savings accounts designated to help people save for future medical and retiree health costs on a tax-fee basis; part of 2003 Medicare bill; Also called medical savings account
Home healthcare
A wide-range of healthcare services that can be delivered in the home and it is the fastest-growing sector to offer services for Medicare recipients
Hospice care
An interdisciplinary program of palliative care and supportive services that addresses the physical, spiritual, social, and economic needs of terminally ill patients and their families
Hospital
A healthcare entity that has an organized medical staff and permanent facilities that include inpatient beds and continuous medical or nursing services and that provides diagnostic and therapeutic services for patients as well as overnight accommodations and nutritional services
Hospital outpatient
A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Inpatient
A patient who is provided with room, board, and continuous general nursing services in an area of an acute care facility where patients generally stay at least overnight
Integrated delivery system (IDS)
A system that combines the financial and clinical aspects of healthcare and uses a group of healthcare providers, selected on the basis of quality and cost management criteria, to furnish comprehensive health services across the continuum of care
Investor-owned hospital chain
Group of for-profit healthcare facilities owned by stockholders
Licensure
The legal authority or formal permission from authorities to carry on certain activities that by law or regulation require such permission (applicable to institutions as well as individuals)
Long-term care
A variety of services that help people with health or personal needs and activities of daily living over a period of time. Long-term care can be provided in the home, in the community, or in various types of facilities, including nursing homes and assisted living facilities.
Managed care
- Payment method in which the third-party payer has implemented some provisions to control the costs of healthcare while maintaining quality care
- Systematic merger of clinical, financial, and administrative processes to manage access, cost, and quality of healthcare
Managed care organization (MCO)
A type of healthcare organization that delivers medical care and manages all aspects of the care or the payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care; Also called coordinated care organization.
Medicaid
A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if a patient qualifies for both Medicare and Medicaid.
Medical device
An instrument, machine, implement or apparatus intended for use in the diagnosis of disease or for monitoring or treatment of a condition.
Medical staff bylaws
Standards governing the practice of medical staff members; typically voted upon by the organized medical staff and the medical staff executive committee and approved by the facility’s board; governs the business conduct, rights, and responsibilities of the medical staff; medical staff members must abide by these bylaws in order to continue practice in the healthcare facility.
Medical staff classification
The organization of physicians according to clinical assignment.
Medicare
A federally funded health program established in 1965 to assist with the medical care costs of Americans 65 years of age and older as well as the other individuals entitled to Social Security benefits owing to their disabilities.
Mission
A written statement that sets forth the core purpose and philosophies of an organization or group; defines the organization or group’s general purpose for existing; also known as a mission statement.
Multihospital system
A system that includes two or more hospitals owned, leased, sponsored, or contract managed by a central organization.
Network
- A type of information technology that connects different computers and computer systems so they can share information
- Physicians, hospitals, and other providers who provide healthcare services to members of a managed care organization; providers may be associated through formal or informal contracts and agreements
Not-for-profit
Healthcare organizations uses excess funds to improve their services and to finance educational programs and community services.
Organized healthcare delivery
Care providers have established relationships and mechanisms for communicating and working to coordinate patient care across health conditions, services, and care settings over time.
Patient-focused care
A concept developed to contain hospital inpatient costs and improve quality by restructuring services so that more of them take place in the nursing units (patient floors) and not in specialized units in dispersed hospital locations
Peer review
- Review by like professionals, or peers, established according to an organization’s medical staff bylaws, organizational policy and procedure, or the requirements of state law; the peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without fear of reprisal.
- The process by which experts in the field evaluate the quality of a manuscript for publication in a scientific or professional journal.
Point of service (POS) plan
A type of managed care plan in which enrollees are encouraged to select healthcare providers from a network of providers under contract with the plan but are also allowed to select providers outside the network and pay a larger share of the cost.
Post-acute care
Care that supports patients who require ongoing medical management or therapeutic, rehabilitative, or skilled nursing care
Preferred provider organization (PPO)
A managed care contract coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licenses or organized under state law as an HMO.
Retail clinics
Clinics that treat non-life-threatening acute illnesses and offer routine wellness services such as flu shots, sports physicals, and prescription refills.
Skilled nursing facility (SNF)
A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, rehabilitative services but does not provide the level of care or treatment available in a hospital.
Surgeon general
Appointed by the president of the United States, this individual provides leadership and authoritative, science-based recommendations about the public’s health; the surgeon general has responsibility for the public health service workforce.
Telehealth
A telecommunications system that links healthcare organizations and patients from diverse geographic locations and transmits text and images for (medical) consultation and treatment.
TRICARE
The federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities in which the federal government pays a percentage of the cost; formerly known as Civilian Health and Medical Program of the Uniformed Services.
Values
- The social and cultural belief system of a person or a healthcare organization
- A descriptive list of the organization’s fundamental principles or beliefs
Value-based purchasing
CMS incentive plan that links payments more directly to the quality of care provided and rewards providers for delivering high-quality and efficient clinical care
Vision
A picture of the desired future that sets a direction and rationale for change
Workers’ compensation
Insurance that employers are required to have to cover employees who get sick or injured on the job
