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Comprehensive vocabulary flashcards covering health care financing, outpatient and primary care, hospital administration, managed care organizations, and long-term care services.

Financing

Any mechanism that gives people the ability to pay for health care services, functioning as a necessary condition for accessing medical care.

Moral Hazard

Consumer behavior that leads to a higher utilization of health care services because the services are covered by insurance.

Provider-Induced Demand

The artificial creation of demand by health care providers that increases the use of health care services and contributes to rising costs.

Underwriting

The formal process by which an insurance agency evaluates, selects or rejects, classifies, and rates financial risks.

Premium

The fee charged by an insurer to provide coverage, typically shared between employers and employees in employment-based health insurance.

Deductible

The specific out-of-pocket amount an insured individual must pay annually before health plan benefits begin paying for care.

Copayment

A flat fee paid out of pocket by the insured each time a specific medical service is received.

Coinsurance

A cost-sharing mechanism in which the enrollee pays a set percentage of the costs of health care services provided (such as an $80:20$ ratio).

Stop Loss

An insurance provision that sets a maximum ceiling on the total out-of-pocket expenses an insured person must pay in a given year.

Self-Insurance

An arrangement in which large employers assume their own risk and pay employee medical claims directly rather than purchasing insurance from an outside insurer.

Reinsurance

Stop-loss coverage purchased by self-insured employers or insurance carriers to protect against catastrophic or exceptionally high medical claims.

Medicare Part A

The hospital insurance portion of Medicare, financed by mandatory payroll taxes paid equally by employers and employees, covering inpatient hospital stays, skilled nursing care, home health, and hospice.

Benefit Period

A timing metric under Medicare Part A that begins on the day a beneficiary enters a hospital and ends when the beneficiary has been out of a hospital or skilled nursing facility for $60$ consecutive days.

Medicare Part B

The Supplementary Medical Insurance (SMI) component of Medicare covering physician services, hospital outpatient visits, diagnostics, and annual wellness exams, requiring an annual deductible and $80:20$ coinsurance.

Medicare Part C (Medicare Advantage)

A voluntary option permitting Medicare beneficiaries to receive Part A, B, and D benefits through private managed care organizations (MCOs), eliminating the need for Medigap.

Medicare Part D

Prescription drug coverage enacted under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, requiring a monthly premium and an annual deductible across tiered spending levels.

Medicaid

A means-tested public insurance program established under Title 19 of the Social Security Act, jointly funded by federal and state governments to finance care for indigent populations.

Children's Health Insurance Program (CHIP)

A federal-state insurance initiative enacted under Title 21 of the Social Security Act to provide health coverage for children in low-income families up to age 19.

Fee-for-Service

A traditional reimbursement method where providers set prices and bill separately for each distinct medical service delivered.

Balance Billing

The practice where health care providers bill the patient for the remaining balance between their original charge and the actual amount reimbursed by insurance.

Bundled Payments

A package reimbursement method that combines payments for related services across an entire clinical episode of care into a single pre-set price.

Resource-Based Relative Value Scale (RBRVS)

A Medicare prospective payment system that reimburses physician services based on a calculated relative value reflecting physician time, skill, and intensity.

Capitation

A provider reimbursement mechanism used heavily by HMOs paying a fixed per member per month ($\text{PMPM}$) sum to cover all required care, transferring financial risk to the provider.

Diagnosis-Related Groups (DRGs)

A prospective reimbursement system for acute hospital inpatient care that sets a predetermined, bundled reimbursement rate based on the patient's principal diagnosis at admission.

Ambulatory Payment Classifications (APCs)

Medicare's Outpatient Prospective Payment System (OPPS) dividing hospital outpatient services into categories based on clinical and cost similarities.

Ambulatory Care

Diagnostic, therapeutic, and preventive clinical services provided to non-bedridden, walking patients who travel to a clinic or physician office.

Outpatient Service

Any health care service delivered to an individual that does not require an overnight stay in an inpatient institution.

Surgicenter

A freestanding, hospital-independent medical facility providing a full range of ambulatory surgical procedures without overnight hospital stays.

Hospice Care

A specialized approach offering comprehensive palliative and psychosocial support to terminally ill individuals with a life expectancy of $6$ months or less.

Palliation

Medical care focused on the relief of pain, symptoms, and stress associated with serious illness rather than providing curative therapies.

Primary Care

Basic, routine, accessible, and continuous health care serving as the initial point of entry and organizing hub for comprehensive patient needs across the lifespan.

Gatekeeping

An operational model in managed care where a primary care physician (PCP) must authorize referrals before an enrollee can see a specialist or enter a hospital.

Secondary Care

Short-term health services that typically include sporadic specialist consultation, routine surgical intervention, acute hospitalization, or short-term rehabilitation.

Tertiary Care

The most complex and technology-driven level of clinical care, provided primarily in large teaching institutions for uncommon or intensive conditions (e.g., burn care, trauma, transplants).

Community-Oriented Primary Care (COPC)

A delivery model applying a biopsychosocial paradigm to blend conventional primary care medicine with a population-based public health focus to address community-level health needs.

Patient-Centered Medical Home (PCMH)

An interdisciplinary, team-based primary care practice model designed to deliver continuous, comprehensive, and coordinated care for chronic illnesses.

Coordination Role of Primary Care in Health Delivery

The healthcare organizational model that places primary care at the central core, ensuring continuity and comprehensiveness while coordinating specialist care, inpatient care, surgery, and diagnostic services.

Inpatient

A patient classification requiring an overnight stay in a health care facility following formal admission under a physician's order.

Hospital

An institution with at least 6 beds licensed to deliver diagnostic and therapeutic medical care, providing continuous registered nurse (RN) care and an organized medical staff.

Medical Center

A specialized, high-capacity hospital offering a broad scope of advanced services that frequently engages in medical research and physician education.

Hill-Burton Act (1946)

Federal legislation providing federal grants to states to build and modernize hospital facilities, recognized as the single largest contributor to U.S. hospital expansion.

Average Length of Stay (ALOS)

A metric of hospital utilization representing the average number of days an inpatient remains hospitalized during a specific care episode.

Days of Care

The total number of inpatient bed days utilized by a specified population over a set period, calculated as $\text{Discharges} \times \text{ALOS}$.

Occupancy Rate

The percentage of a hospital's available inpatient beds occupied over a given timeframe, calculated by dividing the average daily census by total capacity.

Community Hospital

A nonfederal, short-stay hospital whose services and facilities are accessible to the general public, constituting approximately 85% of all U.S. hospitals.

Critical Access Hospital (CAH)

A Medicare designation for a rural hospital with no more than 25 inpatient beds and 24-hour emergency services, reimbursed under a cost-plus formula rather than prospective payment.

Beneficence

The ethical and moral imperative requiring healthcare providers to act in a manner that alleviates patient suffering and promotes their well-being.

Nonmaleficence

The foundational medical ethics principle dictating that healthcare practitioners have an explicit obligation to not inflict harm or injury on patients.

Patient Self-Determination Act of 1990

Federal legislation mandating that all healthcare institutions participating in Medicare or Medicaid inform newly admitted patients of their rights to accept or refuse medical care and formulate advance directives.

Advance Directives

Legally documented written preferences outlining an individual's explicit instructions concerning medical interventions or life-support withdrawal should they lose decision-making capacity.

Types of Hospitals (2019 AHA Distribution)

The proportional breakdown of the 6,090 U.S. hospitals in 2019: Private nonprofit (48%), Private for profit (20%), State and local government (16%), Nonfederal psychiatric (10%), Federal (3%), and Other nonfederal (2%).

Managed Care

A mechanism of healthcare delivery that systematically integrates financing, insurance, healthcare delivery, and provider payment under a single organization to control utilization and costs.

Prospective Utilization Review

A utilization management process that reviews and determines the clinical necessity of a procedure or institutionalization before the treatment is actually performed (such as precertification).

Concurrent Utilization Review

The clinical monitoring and evaluation of appropriateness conducted during the active course of medical care, including monitoring length of hospital stay and discharge planning.

Retrospective Utilization Review

A post-treatment examination of patient medical records and claims data to assess the appropriateness of care and uncover overutilization or underutilization trends.

Health Maintenance Organization (HMO)

A managed care organization focusing heavily on preventative care that restricts coverage to in-network providers, uses primary care gatekeepers, and compensates providers predominantly via capitation.

Preferred Provider Organization (PPO)

A managed care plan contracting with a selected network of providers using discounted fee-for-service arrangements (typically 25% to 35% below retail) that allows out-of-network access at higher out-of-pocket costs.

Point-of-Service Plan (POS)

A managed care hybrid model incorporating HMO-style utilization management and gatekeeping with PPO-style flexibility to choose out-of-network providers.

Staff Model HMO

An HMO organizational structure that directly employs its own salaried physicians and operates its own clinical facilities, maintaining maximum control over physician practice habits.

Independent Practice Association (IPA) Model

An HMO structure that contracts with an intermediary legal corporation, which in turn contracts with multiple independent solo and group practices to provide patient care.

Horizontal Integration

A geographic growth strategy where a health care organization acquires or merges with identical or similar operating organizations (such as multiple acute care hospitals).

Vertical Integration

An organizational alignment linking distinct, successive stages of health care production (such as outpatient clinics, hospitals, and long-term care) to provide a continuum of care.

Accountable Care Organization (ACO)

An integrated network of physicians, hospitals, and healthcare professionals that voluntarily partner to assume shared clinical and financial responsibility for coordinating care for a defined group of Medicare patients.

Long-Term Care (LTC)

A coordinated set of individualized therapeutic, custodial, and supportive health services provided over an extended period to promote maximum possible functional independence.

Activities of Daily Living (ADLs)

A functional assessment scale measuring essential self-care abilities—such as bathing, dressing, toileting, transferring, eating, and continence—used to determine the need for institutionalization.

Instrumental Activities of Daily Living (IADLs)

A scale evaluating complex tasks necessary for self-reliant community living, such as cooking, grocery shopping, housekeeping, managing money, and handling medications.

Progressive Steps Toward the Need for Long-Term Care Among the Elderly

The sequential functional trajectory of aging: Chronic conditions and comorbidity lead to functional impairment (disability), progressing to ADL limitations (dependency), and culminating in the need for long-term care.

Continuing Care Retirement Community (CCRC)

An institutional campus offering an integrated continuum of living arrangements—ranging from independent retirement living to personal care and skilled nursing—supporting an aging-in-place concept.

Assisted Living Facility (ALF)

A residential long-term care setting providing 24-hour supervision, scheduled and unscheduled ADL assistance, social programming, and medication administration in a non-hospital environment.

Skilled Nursing Facility (SNF)

A licensed inpatient long-term care facility offering medically oriented skilled nursing, therapeutic diets, and rehabilitation delivered by licensed nurses under physician authorization.

Subacute Care

Technically complex, post-acute clinical and rehabilitation care delivered in long-term care hospitals or specialized SNF units as an affordable alternative to continued acute hospitalization.

Respite Care

Short-term temporary relief services—such as adult day care or brief institutional stays—provided to alleviate the physical and emotional burden experienced by informal family caregivers.

Restorative Care

Therapeutic care focused on helping an individual regain or improve physical functioning after an illness or trauma, including maintenance and adaptive rehabilitation.