Healthcare System Terminology Quiz Flashcards
Adverse Selection
People in poor health are more likely to enroll in insurance and use healthcare services; if people are very sick, more likely to get health insurance
Capitated Provider Reimbursement:
A type of physician reimbursement in managed care where the physician is prepaid a set amount of money to take care of a group of insured patients
Co-insurance
A portion of healthcare charges that a person must pay that is determined by the insurance policy.
a percentage
Consultant Pharmacist
This type of pharmacist often works in a long-term care setting to review patient charts for appropriateness of patient drug therapy.
CMS requires a consultant pharmacist to visit a licensed nursing facility on a monthly basis to provide drug regimen reviews for all patients within the facility. Duties in the facility include documenting proper medication use, making recommendations to prescribers for optimal use, evaluating medication distribution by the nurses to the patients, serving on quality assurance committees and a number of special duties needed by the facility. In a sense any medication related activity at the nursing facility needs the consultant pharmacist to oversee.
Continuum-of-Care
Shift from fragmented care to continuum of care; the idea of healthcare providers following patients as they receive care at different times and locations (following patients through their healthcare journey); goal: better care and improved patient outcomes; Need communication and technology to make this happen
Copay
A portion of healthcare charges that a person must pay that is determined by the insurance policy
Discounted Fee-for-Service Reimbursement
A financial reimbursement system whereby a provider agrees to supply services on an FFS basis, but with the fees discounted by a certain percentage from the physician’s usual and customary charges. … This may be a fixed amount per service, or a percentage discount.
Fee-for-Service (FFS) Reimbursement/Insurance:
Fee for service (FFS) is the most traditional payment model of healthcare. In this model, the healthcare providers and physicians are reimbursed based on the number of services they provide or their procedures. (doesn’t include quality of care)
Formulary:
list of prescription drugs covered by a health insurance plan
Gatekeeping/Gatekeeper
A health care professional, typically a physician or nurse, who has the first encounter with a patient and who thus controls the patient’s entry into the health care system.
Gross Domestic Product (GDP)
The total value of goods produced and services provided in a country during one year.
Health Maintenance Organization (HMO)
A type of managed care organization where a patient can’t receive care outside of the provider network.
Healthcare Flexible Spending Account (FSA)
This type of account can help employees with private health insurance to set aside pre-tax dollars for eligible healthcare expenses that their health insurance doesn’t cover during a calendar year
Insured/Enrollee
person protected from risk of financial loss via insurance.
Integrated Healthcare Delivery System (IHDS)
Provide a coordinated continuum-of-services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced (different than continuum of care because it has that financial part); A network of organizations where there is a continuum of healthcare and providers are responsible for clinical outcomes and financial outcomes for the group of patients they are providing care.
Long-term Care Services
A range of health, personal care, social and housing services; For people who can’t care for themselves independently due to chronic illness, or mental or physical disability
Managed Healthcare Organization (MCO)
A type of healthcare organization that focuses on coordinating patient care to control costs, improve healthcare quality, andpatient wellness.
Moral Hazard:
refer to people with medical insurance getting more medical care, aside from whether they need it or not; If you have insurance, you are more likely to use healthcare good and services than if you had to pay price out-of-pocket
National Health Expenditures (NHE)
The total amount of money we spend yearly in the United States on healthcare.
Out-of-pocket maximum/limit
The dollar amount a person must pay before their insurer pays 100% of the person’s healthcare costs. Out-of-Pocket maximum is set for a calendar year: only applies for covered services, includes deductibles, copays and coinsurance, Out-of-network costs DONT apply to out-of-pocket maximum
Patient Protection & Affordable Care Act (ACA)
provides preventative care without cost sharing (for most plans); give people more access to healthcare; -insurance can’t deny coverage due to illness
-stay on parents until 26
Point of Service Plan (POS)
Patient can choose a doctor when they need to see a doctor. Patient can see a doctor out of network. Patients usually need to get a referral to see a specialist.
Preferred Provider
provider within network that the insurance covers
Preferred Provider Organization (PPO)
A type of managed care organization that allows patients to receive care outside of the provider network, but they will payless if they receive care in the network.
Premium:
The dollar amount a person pays for health insurance from an insurance plan
Provider/Physician (PCP):
In managed care, financial risk is shifted from the insurance company to this stakeholder in the healthcare system.
Private Health Insurance:
primarily employer based, self-insured via an individual health insurance policy
Provider Network:
List of healthcare providers covered by a health insurance plan, Patients typically have lower out-of-pocket costs “in network”, Networks include physicians, pharmacies, hospitals, clinics, etc.
Public Health Insurance:
This type of insurance is delivered and financed by the government.
Skilled Nursing Facility (SNF)
Facility where medical care is provided by a licensed nurse and other health care professionals; Residents have a variety of medical conditions; often with cognitive problems
Residents have both ADL and IADL issues
