Healthcare Cost Flashcards
a method of reimbursing providers (usually primary care providers, such as physicians or nurse practitioners) in which the insurance company pays the provider a set payment each month to provide a devined set of health care services for the patient enrolled in the insurance company’s health plan…the payment is typically expressed as a per-member-per-month payment…the defiened healthcare services generally include preventitive, diagnostic, and treatment services
capitation
the federal government agency that administers MEdicare and Medicaid
Center of Medicare and Medicaid Services (CMS)
refers to reimbursement for health care services based ona predetermined fixed price-per-case or diagnosis
Diagnosis-Related Groups (DRG)
production of a desired outcome; takin ghte right action to acieve the expected result
effectiveness
the extent to which resources, such as energy, time, and money are used to produce the intended result
efficiency
the measure of the total value of goods and services produced within a country; the most comprehensive overall measure of economic output; provides key insight to the driving forces of the economy
Gross Domestic Product (GDP)
an economic term that erfers to a small or insignificant change in some variable (e.g. the number of tests performed)
marginal
a jointly sponsored state and federal programs that pays for medical services for persons who are elderly, poor, blind, or disables and for certain families with dependent children who meet specified income guidelines
Medicaid
a federally funded health insurance program for the disables, persons with end-stage renal disease, and persons 65 years of age and older who qualify for Social Security benefits
Medicare
a US federal statute enacted in 2010 that requires US citizens and legal residents to have health insurance through comprehensive healthcare reform; expands health care coverage access to millions of people who were previously uninsured (Kaiser Family Foundation, 2011)
Patient Protection and Affordable Care Act (PPACA)
a method for individuals to maintain insurance coverage for health care costs through a contract with a helath insurance company that agrees to pay all or a portion of the cost of a set of defined healthcare services such as routine, preventitive and emergency helathcare; hospitalizations; medical procedures; and/or Rx drugs…typically provided through an individual’s employer and a portion by the employee…can also be purchased by individuals but are generally much more expensive than when provided through an employer’s group plan
Private Health Insurance
a method of reimbursing health care providers (i.e physicians, hospitals) in which the total amount of payment for care is predetermined based on the patient’s diagnosis; provides for a “set price per diagnosis” payment system in contast to a “fee-for-service” system…encourages increased efficiency in the use of health care services b/c providers are reimbursed at a set level regardless of how many services are redered or procedures performed to treat a particular diagnostic category…the most common method of payment in today’s health care system
Prospective Payment System
an individual (such as a physician or nurse practitioner) or an orginzation (such as a hospital) that receives reimbursement for providing health care services
provider
a method of reimbursing health care providers in which professional services are rendered and charges are billed based on each individual service provided also known as the “fee-for-service” payment system…may encourage overuse of healthcare services b/c th more services rendered or procedures perfomed, the more revenue received by providers
Retrospective Payment System
a method of reimbursing in which one payer, usually the government, pays the health care expenses for citizens, funded by taxes…decisions about treatments, drugs, and services are made by the government
Single Payer System
care administered by many different groups offering all citizens health insurance coverage
Universal Healthcare
an organization other than the patient and provider, such as an insurance company, that assumed responsibility for payment of health care charges…an individual’s health insurance plan provided by his/her employer
Third Party Payer
financial plan for the allocation of the organization’s recources and a control for ensuring that results comply with the plan
budget
statements that reflect issues affecting the future performance of the organization; used as the gfraework for developing the budget; address questions such as the following: Are suppy prices lkikely to increase or decrease? What salaray range will ensure that the organization is able to recruit and retain quality employees? wWhat are the competitors offering in terms of new services? Is the patient census likely to increase or decrease over the next year?
budget assumptions
amount spent on items that will have long-term (greater than 1 year) value to an organization…typically includes property & equipment
capital expenditures
an event or iten that requires the outlay of money for purchase or the incurrence of aliability for future payment; major expenses for health care organizations include salraies, medical supplies and equipment, and facility maintenance
expense
a 12 month period used for calculating annual financial reports in business; does not have to constitute the calendar year but may be any 12 month period established and maintained by the business
fiscal year
the number of hours worked or paid that is equal to that expected of a full-time employee working a 40 hour workweek; annual work hours for 1 equals 2080 hours, and monthly work hours = 173.33 hours…one may be occupied by one employee working full time or shared by two or more employees working part-time
full-time equivalent
an approach to budget development that extrapolates from the piror period’s budget and adjusts for future growth or decline in revenues or expenses to determine the budget for the next period
incremental budgeting
