Additional Material for Robert H. Blank and Viola Burau: Comparative Health Policy 2nd edition

Glossary

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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.

All-payer System: A health care system in which, no matter who is paying, prices for health services and payment methods are the same whether federal or state government, private insurance company, a self-insured employer plan, an individual, or any other payer. Also called multiple-payer system.

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

Capitation: A payment system based on a fixed pre-payment, per patient covered 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, services and education are tailored to a patient's needs, which are designed to improve health outcomes and/or control costs

Catastrophic Health Insurance: Health insurance that provides coverage for treating severe or lengthy illnesses or disability.

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

Clinical Care 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.

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

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.

Coverage: A person's health care costs are paid by their insurance or by the government.

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

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

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

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 healthcare procedure that is not an emergency and that the patient and doctor plan in advance.

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.

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 healthcare 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 in which the cost of insurance is based on the age, sex, health status and occupation of the people in the group.

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

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 in 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.
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 at their home.

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.

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.

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 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.

Out-of-Pocket Costs or Expenditures: The amount of money that a person must pay 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).

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 healthcare system through referrals.

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

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

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.

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.

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

Uncompensated Care: Health care provided to people who cannot pay for it and who are not covered by any insurance. This includes both charity care which is not billed and the cost of services that were billed but never paid.

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

Waiting List: 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.