definitions Flashcards
Academic Medical Center
AMC/AHC (health center); preeminent institutions in US HCS; mission to provide undergrad/grad medical education and training, clinical research, state-of-the-art medical care, care for poor and medical indigent
Access
ability to obtain personal health services to achieve the best possible health outcomes; can be influenced by travel, distance, waiting time, resources, health status of population
accountability (corporate governance)
a set of processes, customs, policies, laws and institutions affecting the way a corporation is directed, administered, or controlled; includes the relationships among many stakeholders involved and the goals which govern the corporation
accounts receivable management
management of money that is owed to venture for goads and services that have been purchased for it or committed as a grand/donation; included on balance sheet under current assets
accreditation
evaluative process in which HC organization undergoes an examination of its policies, procedures, performance by external organization (on/off site surveys)
- Joint Commission
- CMS manual system
acute health care
short term medical treatment, hospital based, for acute illness
advance directive
written/spoken statement about person’s future medical care; living will vs power of attorney
adverse selection
tendency for only those who will benefit from insurance to buy it; unhealthy people more likely to buy because they anticipate large medical bills
agency principal theory
principal-agent problem treated the difficulties that arise under conditions of incomplete and asymmetric information when a principal hires an agent; found in most employer/employee relationships (stockholders hire top executives of corporations)
ambulatory care
outpatient care, no overnight stay in hospital
antitrust regulation
Sherman Antitrust Act 1890, first gov statute to limit cartels and monopolies; oldest federal antitrust laws
Sherman Antitrust Act
combination in form of trust or otherwise in restraint of trade or commerce among several states-illegal; felony to attempt to monopolize
Clayton Act: 1914; extended right to sue under antitrust law
arbitration
legal technique for the resolution of disputes outside the courts, wherein the parties to a dispute refer it to oe or more persons, by whose decision they agree to be bound; includes alternative dispute resolution/mediation
assisted living facility
multifamily housing with congregate and personal care services (personal care, residential care, congregate care, board and care
- healthcare only if component of continuing care or life-care
- does not have established standards
average length of stay (ALOS)
statistical calculation often used for health planning purposes; type of reimbursement system or health insurance plan now plays a significant role in patient LOS
- (total discharge days/total discharges)
- (total inpatient days of care/total admissions)
bad debt expense
portion of receivables that can no longer be collected; typically from accounts receivable or loans
-considered an expense
=direct write off method (non-GAAP): charged directly to the income statement
=allowance method (GAAP): estimate is made at the end of each fiscal year of the amt of bad debt
baldrige national quality award
created by public law, signed 1987; led to creation of new public-private partnership; named for Malcolm Baldrige
-leadership of US in product and process quality has been challenged strongly by foreign competition
-american industry began to understand that poor quality costs companies 20% in revenues
-strategic planning for quality and quality improvement programs
-improved management understanding of factory floor, worker involvement in quality and emphasis on statistical process
-concept of quality improvement is directly applicable to small companies
-quality improvement programs: management-led, customer-oriented
-sev major industrial nations coupled rigorous private-sector quality audits with national awards
=national quality award program would help improve quality and productivity
bargaining unit
group of employees with clear and identifiable community of interest who are represented by a single labor union in collective bargaining
“law enforcement professionals”
“blue-collar workers”
“non-management professors”
barriers to entry
obstacles in the path of a firm which wants to enter a given market
barriers to exit
obstacles in the path of a firm which wants to leave a given market or industrial sector
belmont report
1974-National Research Act, created National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research
-basic ethical principles that should underlie conduct of biomedical and behavioral research involving human subjects
benchmarking
process used in management and particularly strategic management; evaluate aspects of processes in relation to best practice
-compare their process with that of a better process and try to improve the standard of the process the organization follows to improve quality of system, product, services
beneficence
ethical principle discussed in Belmont Report; obligation to protect persons from harm
- do no harm
- protect from harm by maximizing possible benefits, minimizing possible risks of harm
biomedical ethics
examination of ethics of all biomedical research, medicine, health care
a. beneficence
b. non-malfeasance
c. autonomy
d. justice
e. dignity
f. truthfulness
g. honesty-informed consent
bonds
a formal written promise to pay interest every six months and the principal amount at maturity
break-even analysis
break-even point; cost or expenses and revenue are equal
-calculated in order for businesses to determine if it would be profitable to sell a proposed product vs modified existing product
budget variance
analyzing the difference btw the financial value of something as estimated in budget and actual financial value
capital budgeting
planning process used to determine whether firm’s long-term investments are worth pursuing
(new machinery, replacement machinery, new plants, new products, research/development)
capital expenditures
expenditures creating future benefits; incurred when business spends money either to buy fixed assets or to add to value of existing asset with a useful life that extends beyond taxable year
capitation
method of payment to provider of medical services according to # of member sin health benefit plan (cost per person, ex sponsor pays uniform periodic fee for each member)
case mix index
average diagnosis-related group weight for all of hospitals medicare volume
-adjust the avg cost per patient for a given hospital relative to adjusted avg cost by dividing avg cost per patient
cash flow
term that refers to the amount of cash being received and spent by a business during a defined period of time
catastrophic coverage
type of insurance designed to cover catastrophes
certification
refers to confirmation of certain characteristics of an object, person, or organization; provided by external review, education, assessment
charge master
comprehensive and hospital-specific listing of each item that could be billed to patient, payers, or health care provider
charitable care
services provided to patients who do not have the ability to pay for the care and hospital does not charge for services
(unpaid bills, unreimbursed care)
collective bargaining
process whereby workers organize collectively and bargain with employers regarding the workplace
community hospital
based on American Hospital Association definition
community rating (health insurance)
insurer using community rating to set insurance premiums ignores any diff in expected cost among insured groups or people
conflict management
refers to long-term management of intractable conflicts
-ongoing process that may never have resolution
co-optation
election where members of a committee vote in order to fill vacancy on committee or group
co-payment
copay, capped contribution defined by policy and paid by insured person each time a medical service is accessed
cost-benefit analysis
used to help appraise, assess the case for project/proposal (project appraisal); informal approach to make decisions
cost containment
occurs when an insurance company attempts to reduce the benefit payment or costs associated with health plan
cost sharing
insurance and medical costs not paid for by the insurance company
-can be shared btw an employee and their employer or btw insurance company and insured
cost shifting
allocation of unpaid costs of care delivered to one patient population through above-cost revenue collected from other patient populations
cost-to-charge ratio
rate setting methodology using a ratio of costs of service and procedures to charges of those services or procedures in the hospitals setting
covered lives
the number of individuals and dependents enrolled a health insurance plan
data warehousing
central warehouse or repository for data collected by a business or enterprise
debenture
certificate of acceptance of loans which is given under company’s stamp and carries an undertaking that debenture holder will get fixed return
deductible
portion of any claim that is not covered by the insurance provider
demand management
art or science of controlling economic demand to avoid a recession
designated funds
contributions which the donor has designated to a specific voluntary agency, federation, or general option
diagnostics-related group (DRG)
system to classify hospital cases into one of approx 500 groups, developed for medicare as part of prospective payment system
-determine how much medicare pays the hospital
disproportionate share hospital
special funding to hospitals who treat significant populations of indigent patients through the DSH programs
a. Medicare Disproportionate Share
b. Medicaid Disproportionate Share
c. 340B-pharmacy
diversity management
long-term strategy and process intended to create and maintain a positive work environment where similarities and diff of individuals are valued so that all can reach their potential and max their contributions to orgo strategic goals/objectives
DNR
type of advance directive that requests not to have cardiopulmonary resuscitation
efficiency (resource utilization)
production of max amount of health services output with a given amount of resources or production of a given amt of health services with min amount of resources
-no waste in use of resources to produce and delivery health services
EHR (electronic health record)
electronic version of patients medical history
employee assistance program (EAP)
employee benefit programs offered by many employers in conjunction with health insurance plan
-assessment, short-term counseling, referral services
employment-at-will
doctrine of American law-employment relationship in which employer or employee can break relationship with no liability provided there was no express contract for a definite term governing the employment relationship and employer doesn’t belong to collective bargain
endowment
resources or property donated to an institution, individual, or group as a source of income
equal employment opportunity commission (EEOC)
dedicated to uphold Title VII of the Civil Rights Act of 1964; prohibits discrimination in employment on basis of race, color, national origin, sex
equity (health care ethics)
absence of systematic disparities in health btw groups of diff levels of underlying social advantage/disadvantage
-inequities in health systematically put groups of people who are socially disadvantaged at further disadvantage with respect to their health
equity theory of pay (adams)
attempt to explain relational satisfaction in terms of perception of fair/unfair distributions of resources within interpersonal relationships
evidence-based practice
development, implementation, evaluation of effective programs and policies in PH through application of scientific reasoning
existence, relatedness, growth theory of motivation
ERG extension of Maslow’s hierarchy of needs
-needs classified in three categories (existence, relatedness, growth)
expectancy theory (Vroom)
explains processes that individual undergoes to make choices; motivation theory
- putting more effort will yield better job performance
- better job performance will lead to organizational rewards
- predicted organizational rewards are valued by employee in question
experience rating
statistical procedure used to calculate premium rate based on loss experience of an insured group
fee-for-service reimbursement
method of charging whereby a physician bills for each encounter or service rendered
filibuster
form of obstruction in legislature or other decision-making body
financial ratios
ratio of selected values on business financial statements
financial statements
objective of general purpose financial statements to provide info about financial position, financial performance, and cash flows of an entity that is used to wide range of users in making economic decisions
- assets
- liabilities
- equity
- income/expenses
5 P’s of strategy
plan, ploy, pattern, position, perspective
fixed assets (plant)
non-current asset; used in accountancy for assets and property which cannot easily be converted into cash
4 P’s of marketing
product
price
place
promotion
free rider
actors that consume more than their fair share of resource
gag rules
rule that limits or forbids the raising, consideration or discussion of a particular topic by members of legislative or decision making body
gatekeeper
variety of techniques intended to reduce the cost of providing health benefits and improve quality of care
globe rate (reimbursement)
a risk-adjusted rate given by insurance providers based on severe factors (age, sex, complications, comorbidities)
green facilities
design and construction of efficient, cost-effective, durable, and environmentally sound buildings and landscapes
grievance process
uniform process to address a grievance by an employee put in place by employer with escalating to litigation
GNP
total dollar value of all final goods and services produced for consumption in society during time period (calendar year)
health care rationing
denial or delay in treatment or procedure as a method to deter the increases in health care cost/utilization
health care systems
public and/or private organization used to deliver health care
health disparities
refer to gaps in quality of health and health care across racial, ethnic, and socioeconomic groups
health maintenance organizations (HMO)
health care system that assumes or shares both financial risks and delivery risks associated with providing comprehensive medical services to volunteer enrolled population in a particular geographic area; return for fixed, prepaid fee
health plan employer data and information set (HEDIS)
consists of 71 measures across eight domains of care developed and maintained by the NCQA
health policy triangle
cost, quality, accessibility of health care
hierarchy of needs (maslow)
depicted as a pyramid consisting of five levels
- physiological needs: survival needs, safety and security, love and belonging, self-esteem
- psychological needs: self-actualization
horizontal integration
microeconomics and strategic management; describes a type of ownership and control
-seeks to sell a type of product in numerous markets
hospice care
end-of-life care provided by health professionals and volunteers
indemnity insurance
fee-for-service insurance with high degree of choice for insurance; individual or through group
independent practice association (IPA)
association of independent physicians, organization that contracts with independent physicians, provides services to managed care organizations on negotiated per capita rate, flat retainer fe, fee-for-service basis
informed consent
process and form; information must be presented to personal to voluntarily decide whether or not to participate as research subject
-ensure respect
institutional review board
appropriately constituted group that has been formally designated to review and monitor biomedical research involving human subjects
-approve, require modifications, disapprove research
integrated health delivery system
network of health care providers and organizations which provides or arranges to provide a coordinated continuum of services to a defined population
interpersonal quality
measurement of quality of the interaction btw patient and provider on level of communication, courtesy, and respect for the patient by the provider
joint venture
entity formed btw two or more parties to undertake economic activity together
-share in revenues, expenses control of enterprise
leadership styles
task-oriented vs people-oriented
learning organizations
people continually expand their capacity to create the results they truly desire; learning to see the whole together
leverage (debt financing)
use given resources in a way that potential positive or negative outcome is magnified
-using borrowed funds, debt to attempt to increase returns to equity
linking pin theory of management
organization is represented as number of overlapping work units in which members of one unit are leaders of another
living will
type of advance directive that usually covers specific directives as course of treatment to be taken by caregivers/providers
long term debt
referencing assets owed
- means of using future purchasing power in present
- debt greater than one year
managed care organization (MCO)
manage managed care plans which are health insurance plans that contract with HCP and medical facilities to provide care for members at reduced costs
- Health Maintenance Organizations (HMO)
- Preferred Provider Organizations (PPO)
- Point of Service (POS): choose btw HMO/PPO each time you need care
market concentration
function of number of firms and their respective shares of the total production in market
market share
percentage or proportion of total available market or market segment that is serviced by a company
medicaid
Title XIX of Social Security Act
-pays for medical assistance for certain individuals and families with low income and resources; largest source of funding for medical and health-related services for america’s poorest people
medical saving account
special account owned by individual used to pay for current/future medical expenses usually used in conjunction with high deductible health plan
medicare
entitlement health insurance program that covers people 65 or older, individuals with disabilities, and those in ESRD
medicare part A
helps cover inpatient care in hospitals, hospice care, and some home health care
medicare part B
helps cover doctors services and outpatient care including PT/OT, home health
-pay monthly premium
medicare advantage (part C)
given option to receive medicare benefits through private health insurance plans
-charge addiitonal premiums
medicare part D
added prescription drug coverage that is considered insurance
-private companies provide the coverage, monthly premium
medigap insurance
health insurance sold by private insurance companies to fill gaps
merger and acquistion
aspect of corporate strategy, corporate finance, and management dealing with buying, selling and combining different companies to can aid, finance, and help a grow a company
monopolistic markets
competitive market; large number of independent firms which have very small proportion of market share
moral hazard
prospect that a party insulated from risk may behave differently from the way it would babur it if were fully exposed to risk
net assets
value of entity’s asset less the value of its liabilities
net income
equal to the income that firm has after subtracting costs and expenses from total revenue
non-operating revenue
include all types of income that an organization receives that are not part of its main line of business
-interest income, dividends, commissions
oligopolistic market
market form in which a market or industry is dominated by a small number of sellers
open system
system that is capable of self-maintenance on the basis of throughput of resources from the environment; continuously interacts with its environment
organic vs mechanistic models
organic: organization has very low degree of job specialization with broad knowledge of many diff jobs with very little top-level authority and high degree of self-control and coordination btw peers
mechanistic: extremely stable with high degree of specialization and imposition of rules with high level of authority
organizational culture
attitudes, experiences, beliefs, values of organization that are shared by people and groups in an organization that control the way they interact with each other and stakeholders outside the organization
organized interest group
organized collection of people who seek to influence decisions, political, or otherwise
outcome measures
method of assessing the extent to which a program has achieved its intended result
out-of-plan
service that is provided through a non-plan provider that is outside of health insurance plan’s network
path-goal theory of leadership
states that leader’s function is clear to path toward goal of the group, meets the needs of subordinates
patient advocate
person who speaks on behalf of patient in order to protect their rights and help them obtain needed information and services
patient safety
relatively recent initiative in healthcare, emphasized on reporting, analysis, prevention of medical error and adverse health events
patient satisfaction measure
quantitative measure used to gather data to assess patient satisfaction within an organization
patient service revenues
revenue recorded on accrual basis at full established charges regardless of amt providers expected to collect
patient’s bill of rights
1998; access to care to emergency services without prior authorization, out of network
pay-for-performance
quality-based purchasing; use of payment methods and other incentives to encourage quality improvement and patient-focused high-value care
perfect competition
economic model that describes a hypothetical market form in which no producer or consumer has the market power to influence prices
-completely efficient outcome
per member per month
method to express utilization in dollar amount for managed care orgo
physician hospital organization (PHO)
organization that includes hospitals and physicians contracting with one or more HMO, insurance plans, or directly with employers
point-of-service plan (POS)
plan that allows beneficiaries to choose a provider that is or not within a healthcare plan
political action committee
two distinct types of political committees registered with the FEC
a. separate segregated funds-established and admin by corporations, labor unions, membership orgo; only solicit contributions from individuals associated with connected or sponsoring organizations
b. non-connected committees-not sponsored; free to solicit contributions from general public
portability
HIPAA; offers protections for millions of American workers that improve portability and continuity of health insurance coverage
practice guidelines
clinical practice guidelines systematically developed statements and recommendations to assist clinicians and patient decisions about appropriate health care for specific clinical conditions
PPO
care plan that has network of providers that have agreed to contractually specified reimbursement for covered benefits; provided in-network/out-network
=more choices at greater cost
premium revenues
payments received by health insurance companies and health plans form individuals and groups who purchase a specified package of health insurance coverage benefits
price leadership
observation made of oligopic business behavior in which one company leads the way in determining prices
primary prevention
avoids the development of disease
prior approval
when health insurance providers and/or managed care organizations require advanced approval before reimbursement
professional bureaucracy
structural configuration that is common in universities and variety of other orgo
-professionals tend to exercise majors autonomy and carry out major activities of organizations
progressive discipline
system of discipline where penalties increase upon repeat occurrences
prospective payment system
method of reimbursement in which medicare payment is made based on predetermined, fixed amt based on DRG
protected health information, PHI
any info about health status, provision of health care, or payment for health care that can be linked to an individual
quality of health care
assures that medically necessary and appropriate care is being rendered in efficient and effective manner
quality adjusted life year (QALY)
unit of health care outcomes that adjusts gains/loses in years of life subsequent to health care intervention by quantity of life during those years
quality assurance
policy, procedures, systematic actions established in an enterprise for the purpose of providing and maintaining a specified degree of confidence in data integrity and accuracy throughout life cycle of data
quality improvement organization (QIO)
consist of national network responsible for each US state, territory, and district of columbia
- work with consumers, physicians, hospitals to refine care delivery systems
- safeguards integrity of trust fund by ensuring that payment is made only for medically necessary services
quality of life
public health and medical concept of health-related quality of life
reasonable accommodation
requires employee to provide reasonable accommodation to qualified individuals with disabilities who are employees or applicants for employment
resource-based relative value scale (RBRVS)
scale of national uniform relative values for all physicians services
-relative value of each service bus tbe the sum relative value units representing physicians work, practice net of malpractice, and cost of professional liability
resource utilization group (RUG)
measures staffing intensity and sued to categorize residents for medicare payment under skilled nursing facility prospective payment system
respect for persons
fundamental principle in research with human subjects
- individuals treated as autonomous agents
- diminished autonomy entitled to protection
restricted funds
donors to NGO may designate or restrict use of donation to particular purpose or project
revenue cycle
time btw organizations delivery services and receipt of payments for those services
risk adjustment
way that payments to health plans are changed to take into account a person’s health status
risk sharing
limits the unanticipated losses or unexpected gains by spreading risk throughout population
root cause analysis
method aimed at identifying the root causes of problems or events
-predicated on the belief the problems are best solved by attempting to correct or eliminate root causes
safe harbor requirement
important way for us companies to avoid experiencing interruption in business dealing with EU due to differences in privacy laws
safety net providers
providers that mandate or mission organize and deliver significant level of health care to uninsured, medicaid, and other vulnerable patients
- legal mandate adopted mission; “open door”
- substantial share of their patient mix is above
secondary prevention
activities are aimed at early disease detection; increasing opportunities for interventions to prevent progression of disease and emergence of symptoms
sentinel event
JCAHO; any unanticipated event in healthcare setting resulting in death or serious physical or psychological injury to a person or persons (loss of limb, gross motor function)
six sigma
measure of quality that strives for near perfection begun by Motorola corporation
small area variation
research analysis tool used by health services researchers to describe how rates of health care use and events very over well-defined geographic areas
social health maintenance organization (SHMO)
special type of health plan that provides the full range of medicare benefits offered by standard medicare HMO
standard of care
medical or psychological treatment guideline; specifies appropriate tx based on scientific evidence and collaboration btw medical and/or psychological professionals involved in treatment of given condition
State Children’s Health Insurance Program
(CHIP) free or low-cost health insurance available in all states for uninsured children <19 yrs
-too much for medicaid not enough to get private coverage
strategic business units
organizational unit within the overall organization hierarchy which is distinguishable from other business, services an outside market where management can conduct strategic planning in relation to products and markets
strategic planning
organizations process of defining its strategy, leadership and direction along with framework for allocating its capital and human resources
substitute products
products used as alternatives to the original (generic drugs)
strengths, weaknesses, opportinues, threats (SWOT)
strategic planning tool used to evaluate the SWOT involved in project or business venture
systems thinking
unique approach to problem solving
-further focusing on outcomes will only further develop the undesired element or problem
technical quality
clinical performance measures look at how well a health plan or hospital prevents and treats illnesses
tertiary prevention
reduces the negative impact of already established disease by restoring function and reducing disease-related complications
Theory X/Theory Y
theroies of human motivation used in human resource management, organizational behavior, and organizational development
X: assumes employees are inherently lazy and will avoid work (close supervision, comprehensive controls)
Y: employees are ambitious, self-motivated, anxious to accept greater responsibility (given chance employees have desire to be creative)
360 degree performance appraisal
employee development feedback that comes from all around employee (subordinates, peers, managers)
time value money
based on premise that investor prefers to receive payment of fixed amount of money today
present value PV: amount that will be received in future
present value of an annuity (PVA): present value of stream of future payments
present value fo perpetuity: value of regular stream of payments that last forever
future value: amount invested now at given rate of interest
future value over annuity: future value of a stream of payments
total quality management (TQM)
management strategy aimed at embedding awareness of quality in all organizational processes involving
a. total
b. quality
c. management: plan, organize, control, lead, staff, allocation
transactional leadership
uses conventional reward and punishment to gain compliance from constituents
a. contingent reward
b. management by expception
two factor theory
job satisfaction and job dissatisfaction acted independently of each other
union steward
title of official position within organizational hierarchy of labor union, held voluntarily
universal coverage
extended to all citizens and permanent residents of government region
up-coding
false diagnosis codes were assigned to patient records in order to increase reimbursement to hospitals by CMS, TRICARE, federal employees health benefits program
utilization review
reviews claims, services or procedures in HCO to ensure service was necessary and appropriate
vertical integration
organizations that are united through hierarchy and share a common owner
virtual organization
corporate, NGO, education, or productive organizational entity that uses telecommunication tools to enable, maintain, and sustain member relationships
waiver (medicaid)
autorizes multiple wavier and demonstration authors to allow states flexibility in operating medicaid programs
working capital management
decisions relating to working capital and short term financing that involve managing the relationship btw organizations short term assets and short term liabilities
