Chapter 11 – The Health Care Delivery System

Vocabulary flashcards summarizing key terms, concepts, systems, payment models, settings, roles, and trends from Chapter 11 on the U.S. Health Care Delivery System.

Institute of Medicine (IOM) Six Outcomes

The Institute of Medicine (IOM) outlined six crucial outcomes for a high-performing 21st-century U.S. health system: Safe (avoiding injuries from care), Effective (providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit), Efficient (avoiding waste), Patient-centered (providing care that is respectful of and responsive to individual patient preferences, needs, and values), Timely (reducing waits and harmful delays), and Equitable (providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status).

Access to Health Care

The ability of individuals to obtain necessary medical services when needed. This is influenced by multiple factors including an individual's insurance coverage (financial access), the geographic availability of healthcare providers and facilities (physical access), and legislative policies like the Patient Protection and Affordable Care Act (PPACA) which aimed to expand coverage.

Patient Protection and Affordable Care Act (PPACA)

Enacted in 2010, this comprehensive U.S. federal statute aimed to reform the healthcare system by: expanding health insurance coverage to millions of uninsured Americans through employer mandates and individual subsidies; implementing measures to control healthcare costs; and improving the quality and delivery of healthcare services through various initiatives, including the creation of health insurance marketplaces.

Health Insurance Marketplace

Online platforms established by the PPACA where individuals and small businesses can compare and purchase private health insurance plans. These marketplaces offer various tiers of plans (bronze, silver, gold, platinum) with different levels of coverage and cost-sharing, often providing subsidies in the form of tax credits to eligible individuals to make coverage more affordable.

Medicaid Expansion (PPACA)

A key component of the PPACA that allowed states to expand Medicaid eligibility to cover nearly all non-elderly adults with incomes up to 138% of the federal poverty level. The law also offered subsidized plans through the Health Insurance Marketplace for people with incomes up to 400% of the federal poverty level, significantly increasing access to affordable health coverage for low-income populations.

Provider Shortage

A situation where there are an insufficient number of qualified healthcare clinicians (such as physicians, nurses, and specialists) to meet the healthcare needs of a population. This shortage can lead to longer wait times for appointments, reduced access to specialized care, and poorer health outcomes, particularly in rural or underserved areas.

Quality and Safety

Fundamental dimensions of healthcare delivery focused on ensuring services are reliable (consistent outcomes), error-free (preventing medical errors and adverse events), evidence-based (utilizing the best available research and clinical expertise), and ultimately patient-centered (responsive to patient values and preferences). It encompasses continuous improvement efforts to optimize patient outcomes and safety.

Accountability Matrix

A structured organizational tool used to assign and delineate specific responsibilities and accountabilities for tasks, processes, or quality metrics within a healthcare setting. It helps organizations track and improve performance by clearly defining who is responsible for what, leading to better accountability for quality and safety outcomes.

Pay for Performance (Value-Based Purchasing)

A reimbursement model that shifts away from the traditional fee-for-service approach by linking provider payments directly to the quality of care provided and the efficiency with which it is delivered. Providers receive financial incentives for achieving specific quality outcomes, improving patient satisfaction, and reducing costs, encouraging a focus on value over volume.

Penalty for Excess Readmissions

A provision under Medicare's Hospital Readmissions Reduction Program (HRRP) that imposes financial reductions in payments to hospitals that have higher-than-expected rates of patients being readmitted within 30 days of discharge. This penalty aims to incentivize hospitals to improve care coordination, discharge planning, and post-discharge support to prevent avoidable readmissions.

Affordability

The degree to which healthcare costs, including premiums, deductibles, copayments, and coinsurance, are manageable and sustainable for individuals, families, insurers, and society as a whole. It addresses whether people can access and pay for necessary healthcare services without incurring significant financial hardship.

Multi-payer System

A health financing system characterized by the presence of multiple public and private entities that pay healthcare providers for services delivered. In the U.S., this includes a mix of government programs (like Medicare and Medicaid) and private insurance companies, leading to a complex administrative landscape with varying payment rules and benefit structures.

Single-payer System

A national health financing model where a single public or governmental agency is primarily responsible for collecting healthcare revenues and handling payments for all healthcare services for the entire population. This system often simplifies administration and can provide greater leverage for cost control, as seen in countries like Canada or the UK.

Diagnosis-Related Groups (DRGs)

A patient classification system used by Medicare for prospective payment to hospitals. Patients with similar clinical characteristics and expected resource utilization are grouped together. DRGs determine a fixed reimbursement amount for a hospital stay, incentivizing hospitals to manage patient care efficiently to remain profitable.

Resource Utilization Groups (RUGs)

A patient classification system used for prospective payment to skilled-nursing facilities (SNFs) under Medicare. Residents are grouped based on their clinical condition, functional status, and resource needs, which then determines the daily reimbursement rate for their care, encouraging efficient provision of necessary services.

Bundled Payments

A healthcare payment model where a single, comprehensive payment is made to providers for all medical services related to a specific condition, treatment, or episode of care (e.g., a hip replacement). This encourages providers to coordinate care efficiently across different settings and disciplines, reducing fragmentation and overall costs.

Rate Setting

A mechanism where a government agency or a major insurer determines the maximum prices or rates that healthcare providers can charge for specific medical services, procedures, or commodities. This approach is used to control healthcare costs and ensure fair pricing, influencing provider revenues and service availability.

Comparative Effectiveness Analysis

A systematic research approach that compares the benefits and harms of different medical interventions (e.g., drugs, devices, surgical procedures) and strategies for preventing, diagnosing, or treating health conditions. The goal is to provide evidence to help patients, clinicians, and policymakers make informed decisions about healthcare choices, focusing on what works best for whom.

Patient Cost Sharing

The portion of healthcare costs that patients are directly responsible for paying out-of-pocket, even when they have health insurance. Common forms include: Deductibles (the amount paid before insurance begins to cover costs); Copayments (fixed amounts paid for specific services like doctor's visits or prescriptions); and Coinsurance (a percentage of the cost of a service paid after the deductible is met).

Primary Health Care

The initial and most common point of contact for individuals within the healthcare system, focusing on prevention, health promotion, routine care for common illnesses, and management of chronic conditions. Services typically include family medicine, general internal medicine, pediatrics, and sometimes obstetrics/gynecology, emphasizing continuity of care.

Secondary Health Care

Healthcare services that require the specialized clinical expertise of specialists for more complex or acute conditions that cannot be managed solely by primary care. This level of care typically involves referrals from primary care providers to specialists (e.g., cardiologists, dermatologists) or hospital-based services for diagnosis and treatment.

Tertiary Health Care

Highly specialized medical care often provided in large teaching hospitals or academic medical centers for the management of rare, complex, or unusually complicated disorders. It involves advanced diagnostic tools, complex surgical procedures, and intensive care, typically following a referral from a secondary care provider.

Health Maintenance Organization (HMO)

A type of managed care plan that offers comprehensive healthcare services to members through a network of contracted providers for a fixed monthly fee (prepayment). Members typically choose a primary care physician (PCP) within the HMO network who acts as a 'gatekeeper,' requiring referrals for specialist visits and out-of-network care is generally not covered, aiming to control costs and coordinate care.

Preferred Provider Organization (PPO)

A type of managed care health insurance plan that provides more flexibility than an HMO. Members can choose providers from a preferred network at a lower cost, but also have the option to see out-of-network providers for a higher out-of-pocket expense (larger copayments, coinsurance, or deductibles). Referrals for specialists are typically not required, offering greater choice.

Accountable Care Organization (ACO)

A group of healthcare providers (including doctors, hospitals, and other clinicians) who come together voluntarily to provide coordinated, high-quality care to their Medicare patients. The goal is to ensure patients receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. If they meet quality metrics and reduce costs, they share in the savings.

Medical Home

A team-based primary-care model focused on delivering coordinated, comprehensive, patient-centered, accessible, and continuous healthcare. The patient's primary care provider leads a team that integrates physical and mental health care, promotes communication, and uses technology to manage chronic conditions, improve preventive care, and coordinate with other healthcare providers.

Medical Neighborhood

An extended network of specialists, community organizations, and healthcare facilities that collaborate with a primary care-centered medical home to provide comprehensive and integrated care. This model ensures seamless information exchange and coordinated patient journeys across various healthcare settings and providers, enhancing the medical home's ability to manage diverse patient needs.

Out-of-Pocket Payment

Payments made directly by patients for healthcare services or products at the time of service, without any reimbursement from an insurance company or other third-party payer. This includes costs like deductibles, copayments, coinsurance, or the full cost of services for uninsured individuals.

Individual Private Insurance

Health insurance coverage purchased directly by an individual from an insurance company, rather than through an employer, union, or government program. This type of insurance is typically chosen by self-employed individuals, those whose employers do not offer health benefits, or those who prefer to select their own plan outside of employer-sponsored options.

Employer-Based Private Insurance

Health coverage provided to employees and their dependents by an employer as a benefit. It is the most common form of health insurance in the U.S. and often involves the employer covering a significant portion of the premium costs, making it a valuable benefit for attracting and retaining talent.

Medicare

A federal health insurance program in the United States primarily for: individuals aged \ge65 years; certain younger people with disabilities (after a waiting period); and people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). It consists of several parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage, managed care plans), and Part D (prescription drug coverage). Hospital payments often utilize Diagnosis-Related Groups (DRGs).

Medicaid

A joint federal and state government program in the United States that provides health coverage to low-income individuals and families, including eligible pregnant women, children, parents, and people with disabilities. Eligibility criteria and covered services can vary by state, as it is administered by states within federal guidelines.

Children’s Health Insurance Program (CHIP)

A United States federal-state program that provides low-cost health coverage for children in families who earn too much money to qualify for Medicaid but cannot afford private insurance. CHIP aims to bridge the gap for children from working families who fall into this income bracket.

Veterans Health Administration (VHA)

A federal agency within the U.S. Department of Veterans Affairs (VA) that delivers integrated healthcare services to eligible military veterans. It operates a nationwide system of hospitals, clinics, and long-term care facilities, providing comprehensive medical, surgical, and rehabilitative care.

Quality-Improvement Tools

Systematic methodologies and techniques used within healthcare organizations to identify and address deficiencies, reduce waste, and enhance the safety and quality of patient care. Examples include Lean, which focuses on eliminating waste and streamlining processes, and Six Sigma, which aims to reduce variation and errors to near perfection by identifying and removing the causes of defects.

Home Health Care

Skilled nursing care, therapy services (physical, occupational, speech), and aide services provided to patients in their own homes. This type of care is crucial for continuity of care, allows patients to recover in a familiar environment, can prevent hospital readmissions, and often supports early discharge from hospitals by providing necessary medical support at home.

Hospital at Home

An innovative care delivery model that allows patients to receive acute, hospital-level medical care, monitoring, and services in the comfort and familiarity of their own home environment, rather than in a traditional hospital setting. This model often utilizes remote monitoring technology, regular home visits from healthcare professionals, and virtual consultations, offering potential benefits such as reduced risk of hospital-acquired infections and improved patient satisfaction.

Extended-Care Facility

A facility that provides various levels of care, including transitional care (e.g., after a hospital stay), assisted living, or long-term care, for individuals who need ongoing medical or personal support due to chronic illness, disability, or age. Examples include skilled nursing facilities, rehabilitation centers, and nursing homes.

Assisted-Living Facility

A residential setting that provides housing, personal care services (such as assistance with activities of daily living like bathing, dressing, and eating), and limited medical services for adults, primarily seniors, who need some support but do not require the constant medical supervision of a nursing home. It aims to promote independence while providing necessary assistance.

Respite Care

Short-term relief services provided for primary caregivers of individuals who are chronically ill, disabled, or elderly. This care can be delivered in various settings (home, healthcare facility) and allows caregivers to take a break from their demanding responsibilities, preventing burnout and supporting their own well-being.

Hospice Services

A comprehensive philosophy and program of care specifically for terminally ill patients, typically with a prognosis of six months or less to live. Hospice focuses on providing comfort, pain management, and emotional and spiritual support, rather than curative treatment, aiming to enhance the patient's quality of life during their final stages and supporting their families.

Palliative Care

An interdisciplinary approach to care for individuals with serious illnesses, focusing on relieving symptoms, pain, and stress associated with the illness at any stage, alongside curative treatment. Unlike hospice, palliative care can be introduced at the time of diagnosis and continue through the course of the illness, regardless of prognosis, aiming to improve quality of life for both the patient and their family.

Voluntary Agency

A non-profit organization that typically provides health-related services, education, advocacy, or support to specific populations or for particular health conditions. These organizations often rely on donations and volunteers, playing a significant role in public health alongside government and private entities (e.g., American Heart Association, Susan G. Komen).

Centers for Disease Control and Prevention (CDC)

The leading national public health agency of the United States, headquartered in Atlanta, Georgia. The CDC is responsible for protecting public health and safety through the control and prevention of disease, injury, and disability. Its work involves disease surveillance, public health research, developing health policies, emergency preparedness, and promoting healthy behaviors.

Collaborative Care Team

A group of healthcare professionals from various disciplines who work together to provide comprehensive and coordinated patient care. This team often includes physicians, nurses, therapists (physical, occupational, speech), dietitians, pharmacists, social workers, and chaplains, collaborating to address all aspects of a patient's physical, mental, and social health needs, ensuring holistic and integrated care.

Advanced Practice Registered Nurse (APRN)

A registered nurse who has attained graduate education (Master's or Doctoral degree) and specialized clinical training, enabling them to provide advanced clinical care in various settings. APRNs include Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Certified Nurse-Midwives (CNMs), and Certified Registered Nurse Anesthetists (CRNAs), each having distinct scopes of practice and responsibilities.

Nurse Practitioner (NP)

An Advanced Practice Registered Nurse (APRN) who has completed advanced education and clinical training, allowing them to diagnose and treat acute and chronic conditions, order and interpret diagnostic tests, prescribe medications, and provide preventive care. NPs often serve as primary-care providers, delivering comprehensive care with a focus on health promotion and disease prevention across the lifespan.

Clinical Nurse Specialist (CNS)

An Advanced Practice Registered Nurse (APRN) who is an expert in a specific specialty area of nursing practice (e.g., critical care, oncology, pediatrics, geriatrics). CNSs provide direct patient care, but also focus on improving nursing practice through consultation, education for patients and staff, research, and by implementing evidence-based practice within their specialty.

Trends in Health-Care Delivery

Significant shifts and evolving patterns influencing how healthcare services are organized, delivered, and financed. Key trends include: changing demographics (aging population, increasing chronic diseases); increasing diversity (cultural competence in care); technology explosion (telehealth, AI, data analytics); globalization (cross-border care, disease spread); and persistent cost pressures (rising expenditures, affordability challenges).

Pay-for-Performance Penalty

A financial reduction or penalty applied to healthcare providers (e.g., hospitals, physicians) for failing to meet predetermined quality, safety, or cost-efficiency benchmarks as part of a value-based purchasing or pay-for-performance program. These penalties incentivize providers to improve performance and adhere to best practices to avoid financial losses.

Comparative Effectiveness

Research that systematically compares the effectiveness, benefits, and harms of different medical interventions (e.g., treatments, procedures, diagnostic tests) when used in real-world settings. This research helps inform clinical guidelines, personal medical decisions, and healthcare policy by identifying which interventions work best for specific patient populations and conditions.

Globalization of Health Care

The increasing interconnectedness and cross-border exchange within the healthcare sector. This includes the movement of patients (medical tourism), healthcare professionals (international workforce recruitment), medical knowledge and technology, and the global spread of diseases or health issues, significantly impacting care delivery, health policy, and public health worldwide.