Healthcare Delivery, Prevention Levels, and Insurance Systems

Flashcards covering key terms and concepts related to levels of prevention, private and public health insurance systems, regulatory standards, nursing roles, and inpatient care models.

Primary Prevention

Healthcare practices and services focused on illness prevention and health promotion prior to the onset of disease, including vaccines, healthy diet, adequate hydration, hand hygiene, and regular exercise.

Secondary Prevention

Healthcare services aimed at the early detection and screening of disease (such as CAT scans, blood tests, throat cultures, mammograms, and ultrasounds) to stop disease progression and reduce complications.

Tertiary Prevention

Care and education provided to manage long-term chronic conditions, post-surgical recovery, or traumatic injuries (such as teaching proper inhaler technique for asthma) to reduce symptoms, complications, and disability.

Health Maintenance Organization (HMO)

A private managed care insurance plan that requires members to designate an in-network primary care provider and obtain official referrals before seeing a specialist.

Exclusive Provider Organization (EPO)

A private insurance plan that exclusively covers services rendered within its designated network, offering freedom from specialist referrals and primary care designations at a higher premium than an HMO.

Preferred Provider Organization (PPO)

The most flexible and costly private insurance plan that allows enrollees to visit any provider without designated primary care doctors or referrals, commonly paying a set percentage (such as $80\%$) of allowable costs.

Deductible

The fixed annual monetary threshold (such as $3{,}000$ dollars) an enrollee must pay out of pocket toward covered healthcare costs before insurance coverage begins paying.

Copayment (Co-pay)

A predetermined flat fee paid out of pocket by the patient at each provider visit or medical encounter, separate from the deductible.

Annual Benefit Limit (Out-of-Pocket Maximum)

The maximum financial ceiling an individual is required to pay out of pocket for medical care in a given calendar year (such as $10{,}000$ dollars).

Fee-for-Service

A traditional reimbursement model in which healthcare providers submit individual billing claims to insurance companies for every specific test, procedure, or service administered.

Capitation

A prospective healthcare payment model in which an insurer pays a clinical practice a fixed annual sum per patient (such as $2{,}000$ dollars) regardless of the number or intensity of services rendered.

Medicare

A federal single-payer insurance program funded by payroll taxes and trust funds that provides standardized healthcare benefits to individuals aged $65$ and older, as well as younger people with severe permanent disabilities such as end-stage renal disease on dialysis.

Medicare Part A

The hospital insurance portion of Medicare that automatically covers inpatient hospital stays, skilled nursing facility care, and hospice care without requiring premium payments from qualifying beneficiaries.

Medicare Part B

The outpatient medical insurance branch of Medicare, paid through monthly premiums deducted directly from Social Security checks, that covers physician fees, outpatient hospital visits, and physical therapy.

Medicare Part C (Medicare Advantage)

Commercial managed care plans (such as HMOs and PPOs administered by companies like Humana or UnitedHealthcare) paid out of pocket to supplement Parts A and B, often adding coverage for dental, vision, and hearing.

Medicare Part D

A voluntary prescription drug benefit under Medicare that requires beneficiaries to enroll in and pay separate monthly premiums for an approved commercial plan.

Medicaid

A jointly funded federal, state, and local insurance program administered individually by each state to cover healthcare costs for qualifying low-income individuals, with children constituting the largest demographic of recipients.

State Children's Health Insurance Program (SCHIP)

A state-administered program supplementing Medicaid that extends medical, dental, vision, and inpatient/outpatient coverage to uninsured children whose families earn too much to qualify for standard Medicaid.

Affordable Care Act (ACA / Obamacare)

Federal legislation enacted in $2010$ establishing health insurance exchanges and requiring all compliant individual insurance plans to cover $10$ essential benefit categories without opt-out provisions.

Care Coordinator

A healthcare professional who organizes interdisciplinary team services (including physical, occupational, and speech therapy) and initiates comprehensive discharge planning starting from the time of patient admission.

Case Manager

An agency-wide or outpatient healthcare professional responsible for navigating specific patient populations or complex diagnoses through the appropriate clinical services and follow-up care pathways.

Certification

A formal public regulatory inspection conducted by state government agencies or Medicare/Medicaid authorities to verify that a healthcare facility meets official operational standards.

Accreditation

A voluntary evaluation performed by an independent, private organization to inspect and verify that all departments within a healthcare facility meet rigorous predetermined quality and safety standards.

The Joint Commission

A private accrediting organization that conducts evaluations of healthcare facilities across clinical and support departments, including dietary, pharmacy, housekeeping, engineering, and nursing.

Five Rights of Medication Administration

A core nursing safety standard ensuring accurate drug delivery: right medication, right route, right time and frequency, right patient, and right dose.

Dedicated Unit Approach

A specialized inpatient hospital unit structured entirely around a specific medical condition (such as stroke or pediatrics) with dedicated multidisciplinary teams, clinical protocols, and customized physical environments.

Transitional Care Model

A specialized post-discharge care coordination framework where a nurse specialist visits and monitors a discharged patient in their home environment (such as every $48\text{ hours}$) to verify adherence to the prescribed plan.