Health Care Delivery Systems Chapter 1

major characteristics of U.S. Health Care Delivery

health care delivery system

the provision of medical care or illness care

universal coverage

health insurance coverage for all citizens

access

ability of persons needing health services to obtain appropriate care in a timely manner

osteopathic medicine

medical philosophy based on a holistic approach to treatment that also emphasizes correction of the position of the joints or tissues and diet and environment as factors that might destroy natural resistance

managed care

system of health care delivery that seeks to achieve efficiencies by integrating the four functions of health care delivery, employs mechanisms to control utilization of medical services, determines how much the providers get paid

enrollee

person covered by a health plan, especially a managed care plan

health plan

contractual arrangement between the managed care organization and the enrollee, including the collective array of covered health services to which the enrollee is entitled

public health

wide variety of activities undertaken by state and local governments to ensure conditions that promote optimal health for society as a whole

capitation

a reimbursement mechanism under which the provider is paid a set monthly fee per enrollee regardless of whether the enrollee actually sees the provider and regardless of how often an enrollee sees the provider

underwriting

systematic technique used by an insurer for evaluating, selecting, classifying, and rating risks

risk

possibility of a substantial financial loss from an event whose probability of occurence is relatively small

Medicaid

joint federal-state program of health insurance for the poor

Medicare

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

tricare

an insurance program financed by the U.S. department of defense in which beneficiaries can recieve care from both private and military medical care facilities

medical model

delivery of health care that places it primary emphasis on the treatment of disease and relief of symptoms instead of prevention of disease and promotion of optimal health

special populations

persons with health needs but with inadequate resources to address those needs

include individuals who are poor and uninsured, belong to certain minority groups, certain immigration status, live in geographically or economically disadvataged communitities, usually receive care through public health insurance such as medicare and medicaid, community health centers, free clincs, ERs public hospitals

integrated delivery systems

network of health care providers and orgs that provide coordinated health care to a population and is responsible for health outcomes and health status of that population; by owning or partnering with hospitals, physicians and insurers, they aim to deliver a range of services; ids with largest number of health care facilities is Ascension Health

quality

degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current profesional knowledge

integrated care

embodies the concepts of comprehensive, coordinated, and continuous services that provide a seamless process of care

long-term care

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 spirtual needs while maximizing quality of life

national public health performance standards 10 esential services:

1. monitor health status to identify and solve community health problems

2. diagnose and investigate health problems and hazards

3. inform, educate, and empower people about health problems and hazards

4. mobilize the community to identify and solve health problems

5. develop policies and plans to support individual and community health efforts

6. enforce laws and regulations to protect health and safety

7. provide people with access to necessary care

8. ensure a competent, professional health workforce

9. evaluate the effectiveness, accessibility, and quality of personal and population-based health services

10. perform research to discover innovative solutions to health problems

Prevention and Public health fund

provides expanded, sustained national investments in prevention and public health, improve health outcomes, and enhance quality of health care

patient advocacy organizations

entities (typically nonprofit) whose primary mission is to educate the general public about diseases so that people will be informed about ways to avoid risks and identify early signs of disease before they develop a severe health problem

health care reform

systemic changes in how medical care is financed or delivered

cost sharing

sharing the cost of health insurance premiums by those persons enrolled in the plan and/or payment of certain medical costs out of pocket, such as copayments and deductibles

health care system

organizations, personnel, and activities associated with promoting, restoring, and maintaining health

reimbursement

amount insurers pay to a provider

certification

conferred by the U.S. Department of Health and Human Services, a status that entitles an organization to participate in Medicare and Medicaid. organization must comply with the conditions of participation

medical technology

practical application of the scientific body of knowledge for the purpose of imporving health and creating efficiencies in the delivery of health care

item-based pricing

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

specialist

physician who specializes in specific health care problems such as cardiologists and oncologists

package pricing

bundling of fees for an entire package of related services

moral hazard

consumer behavior that leads to a higher utilization of health care services solely because people are covered by insurance

provider-induced demand

artificial creation of demand by providers that enables them to deliver undeeded services to boost their incomes

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

social justice

distribution principle according to which health care is most equitably distrubuted by a government-run national health care program

defensive medicine

prescribing additional diagnostic tests, scheduling checkup appointments, maintaining abundant case documentation

alliance

joint agreement between 2 organizations to share their resources without joint ownership of assets

E-health

health care information and services offered over the internet by professionals and nonprofessionals alike

universal acess

ability of all citizens to obtain health care when needed. misnomer because timely access to certain services may still be a problem because of supply-side rationing