Healthcare System Terminology Quiz

adverse selection

people in poor health are more likely to enroll in insurance and use healthcare services

capitated provider reimbursement

-healthcare providers are prepaid for providing care to a group of patients

-if patients are high utilizers of healthcare good & services that exceed the prepaid amount the provider receives, then the provider loses money and is at risk for financial loss

co-insurance

percentage of healthcare charges a person must pay determined by insurance policy

consultant pharmacist

a highly experienced clinical pharmacist who provides expert advice to healthcare providers and facilities on medication use, safety, and compliance to improve patient outcomes and control costs

continuum-of-care

-coordinated care + communication

-depending on their needs, patients receive care at different places in the healthcare system over their lifetime

copay

fixed portion of healthcare charges person must pay determined by insurance policy

discounted fee-for-service reimbursement

healthcare provider paid a discounted amount (negotiated) each time a service is provided

fee-for-service reimbursement/insurance

-greater number of services provided, more reimbursement

-patient who uses more healthcare services can cost insurance more than they are getting in premiums

formulary

list of prescription drugs covered by health insurance plan

gatekeeping/gatekeepers

a person or entity, most often a primary care provider (PCP) , who controls access to other healthcare services or resources.

gross domestic product

a measure of the total market value of all final goods and services produced in a country, which includes healthcare expenditures

health maintenance organization (HMO)

-provider at risk with capitation

-no out of network coverage

-includes gatekeepers

-low copays and premiums

healthcare flexible spending account (FSA)

-pre-tax dollars you set aside for health care expenses with your employer

-reimbursement regulated by federal government

-funds must be spent in 1 year or you lose them

insured/enrollee

person protected from risk of financial loss via insurance

integrated healthcare delivery system (IHDS)

-network of organizations, coordinated continuum-of-services, defined population, clinically and fiscally accountable

long-term care services

range of health, personal care, social, and housing services for people who cannot take care of themselves independently

managed healthcare organization (MCO)

-puts scarce resources to best use in optimizing patient care

-goals to improve healthcare quality, coordinate medical care, increase focus on wellness, control costs

moral hazard

if you have insurance you are more likely to use healthcare goods and services

national health expenditures (NHE)

total cost of annual healthcare services nationally

out-of-pocket max/limit

dollar amount a person must pay before their insurer pays 100% of the person’s healthcare costs

patient protection & Affordable Care Act (ACA)

used to increase access and make drugs more affordable

point-of-service plan (POS)

-allows patient to select providers at the time the service is needed rather than when the patient joins the plan

-some coverage out of network

-captiated/gatekeeping

preferred provider

A preferred provider is a doctor, hospital, or other healthcare professional who has a contract with a health insurance plan to offer medical services to members at a discounted rate. These providers are part of the insurance plan's "network," + offer more discounted services than in-network

preferred provider organization (PPO)

-discounted fee-for-service

-patients have coverage out of network

-high copays/premiums

premium

monthly subscription to insurance plan

primary care provider/physician

provides basic medical services to patients

private health insurance

-primarily employer based

-self-insured via individual health insurance policy

provider network

A provider network is a group of healthcare providers, such as doctors, hospitals, and pharmacies, that have an agreement with a health insurance plan or employer to provide services to its members at negotiated, often discounted, rates

public health insurance

government health (medicare, medicaid)

skilled nursing facility (SNF)

facility where medical care is provided by a licensed nurse and other health care professionals