Chapter 1 - Major Characteristics of U.S. HC Delivery System

Access

The ability of persons needing health services to obtain appropriate care in a timely manner. Can you get medical care when you need it? If yes, you have access to medical care. Access is not the same as health insurance coverage, although insurance coverage is a strong predictor of access to primary care services.

Capitation

A reimbursement mechanism under which the provider is paid a set monthly fee per enrollee (sometimes referred to as the per member per month, or PMPM, rate), regardless of whether or not an enrollee sees the provider and regardless of how often.

Enrollee

A person enrolled in a health plan, especially in a managed care plan.

Integrated delivery system (IDS)

A network of organizations that provides or arranges to 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.

Item-based pricing

Refers to the costs of ancillary services that often accompany major procedures such as surgery.

Package pricing

Bundling of fees for an entire package of related services.

Long-term care

A variety of individualized, well-coordinated services that are designed to promote the maximum possible independence for people with functional limitations. These services are provided over an extended period to meet the patients' physical, mental, social, and spiritual needs, while maximizing quality of life.

Managed care

A system that integrates the functions of financing, insurance, delivery, and payment and uses mechanisms to control costs and utilization of services.

Market justice

A distributional principle according to which health care is most equitably distributed through the market forces of supply and demand, rather than government interventions. See social justice.

Medicaid

A joint federal-state program of health insurance for the poor.

Medicare

A federal program of health insurance for the elderly, certain disabled individuals, and people with end-stage renal disease.

Need

The amount of medical care that medical experts believe a person should have to remain or become healthy.

Social justice

A distribution principle, according to which health care is most equitably distributed by a government-run national health care program. See market justice.

Socialized medicine

Any large-scale government-sponsored expansion of health insurance or intrusion in the private practice of medicine.

Children's Health Insurance Program (CHIP)

Provides health insurance to low-income families with children that covers access to health care services.

TRICARE

A program that is financed by the military. This insurance plan permits the beneficiaries to receive care from both private and military medical care facilities.

Veterans Integrated Service Networks (VISNs)

Responsible for coordinating the activities of the hospitals, outpatient clinics, nursing homes, and other facilities located within its jurisdiction.