| Term |
Definition |
|---|
| Allied Health
Professional (AHP) |
AHPs are individuals trained to support, complement, or supplement the
professional functions of physicians, dentists, and other health professionals in
the delivery of health care to patients. They include physician assistants,
dental hygienists, medical technicians, nurse midwives, nurse practitioners,
physical therapists, psychologists, and nurse anesthetists. |
| Ambulatory Care |
Health care services provided to patients on an ambulatory basis, rather than by
admission to a hospital or other health care facility. The services may provided
at a hospital or a free-standing facility. |
| Ambulatory
Payment
Classification
(APC) |
This is the method used by CMS to implement prospective payment for
ambulatory procedures. APC clusters many different ambulatory procedures
into groups for purposes of payment. |
| Ambulatory Surgery
Center (ASC) |
Surgery performed on an outpatient basis, either hospital-based or performed in
an office or surgicenter. |
| Any Willing
Provider Laws |
Any willing provider laws take many different forms, but they typically restrict
the ability of managed-care organizations to use a closed panel of physicians,
hospitals, or other providers. |
| Average Wholesale
Price (AWP) |
Average Wholesale Price of brand-name pharmaceuticals, as stated by the
manufacturer, is used as a basis for determining discounts and rebates. |
| Capitation |
Capitation pays the provider a fixed amount for each of the patients for whom
he agrees to provide care, regardless of whether those patients seek care or not.
Payment is typically based on a set number of dollars "per member-per
month." |
| Care Management
Protocols (CMPs) |
Care Management Protocols specify utilization and treatment standards for
various diagnoses. |
| Certificate of Need
(CON) |
A certificate issued by a governmental body to an individual or organization
proposing to construct or modify a health facility, or to offer a new or different
service. The process of obtaining the certificate is included in the term. |
| Certification |
Certification is a voluntary system of standards that practitioners can choose to
meet to demonstrate accomplishment or ability in their profession.
Certification standards are generally set by non-governmental agencies or
associations. |
| Chronic Illness |
Diseases which have one or more of the following characteristics: they are
permanent, leave residual disability, are caused by nonreversible pathological
alteration, require special training of the patient for rehabilitation, or may be
expected to require a long period of supervision, observation, or care. |
| CMS |
Centers for Medicare and Medicaid Services. |
| COBRA |
Consolidated Omnibus Budget Reconciliation Act of 1986. |
| Collective
Bargaining |
Collective bargaining refers to bargaining by union members, which is
authorized by the NLRA, or non-unionized physicians' attempts to obtain the
right to bargain collectively. |
| Computerized
Physician Order
Entry (CPOE) |
Computer physician order entry (CPOE) is an electronic prescribing system.
With CPOE, physicians enter orders into a computer rather than on paper.
Orders are integrated with patient information, including laboratory and
prescription data. The order is then automatically checked for potential errors
or problems. |
| Coronary Artery
Bypass Graft
(CABG) |
Surgical therapy of ischemic coronary artery disease, achieved by grafting a
section of saphenous vein, internal mammary artery, or other substitute
between the aorta and the obstructed coronary artery distal to the obstructive
lesion. |
| Critical Loss
Analysis |
A two step analysis is used to perform a critical loss analysis. The first step
identifies, for any given price increase, the amount of sales that can be lost
before the price increase becomes unprofitable. The second step considers
whether or not the actual level of sales lost due to the price increase will
exceed this amount. |
| Diagnosis Related
Group (DRG) |
DRGs form the cornerstone of the prospective payment system. A DRG is a
cluster of diagnoses that are expected to require comparable hospital resources
and lengths of stay. |
| Durable Medical
Equipment (DME) |
Devices which are very resistant to wear and may be used over a long period of
time. DME includes items such as wheelchairs, hospital beds, artificial limbs,
etc. |
| EMTALA |
Emergency Medical Treatment and Active Labor Act of 1986. |
| End-Stage Renal
Disease (ESRD) |
An irreversible and usually progressive reduction in renal function in which
both kidneys have been damaged by a variety of diseases to the extent that they
are unable to adequately remove the metabolic products from the blood and
regulate the body's electrolyte composition and acid-base balance. Chronic
kidney failure requires hemodialysis or kidney transplantation. |
| ERISA |
Employee Retirement Income Security Act. |
| Fee-for-Service
(FFS) |
In FFS, a provider is paid based on the number and type of services that are
performed. |
| Formulary |
A list of approved drugs for treating various diseases and conditions. |
| Group Purchasing
Organization (GPO) |
A shared service which combines the purchasing power of individual
organizations or facilities in order to obtain lower prices for equipment and
supplies. |
| HIPAA |
Health Insurance Portability and Accountability Act of 1996 . |
| Health Plan
Employer Data and
Information Set
(HEDIS) |
A set of standardized performance measures designed to ensure that purchasers
and consumers have reliable information with which to compare the
performance of MCOs. |
| Herfindahl-
Hirschman Index
(HHI) |
The Herfindahl-Hirschman Index is a commonly accepted measure of market
concentration. It is calculated by squaring the market share of each firm
competing in the market and then summing the resulting numbers. The HHI
takes into account the relative size and distribution of the firms in a market.
The HHI increases both as the number of firms in the market decreases and as
the disparity in size between those firms increases. |
| Independent
Practice Association
(IPA) |
IPAs are networks of independent physicians that contract with MCOs and
employers. IPAs may be organized as sole proprietorships, partnerships, or
professional corporations. |
| Inpatient
Prospective
Payment System
(IPPS) |
Medicare's payment system for inpatient hospitals and facilities. The specific
amount that is paid is based on the DRG for the hospital admission. |
| Licensure |
A mandatory system of state-imposed standards that practitioners must meet to
practice a given profession. |
| MMA |
Medicare Prescription Drug, Improvement, and Modernization Act of 2003. |
| Managed Care
Organization
(MCO) |
MCOs integrate, to varying degrees, the financing and delivery of health care
services. |
| Maximum
Allowable Cost
(MAC) |
Maximum Allowable Cost, or Charge. The maximum that a vendor may
charge for something. This term is often used in pharmaceutical contracting. |
| Medicare + Choice
(M+C) |
Also known as Medicare Part C. The Balanced Budget Act of 1997 (BBA)
established the Medicare+Choice program. Under this program, an eligible
individual may elect to receive Medicare benefits through enrollment in a
Medicare+Choice plan, which generally takes the form of a MCO. |
| Medicare
Advantage (MA) |
As of 2003, the new name for Medicare+Choice (M+C). |
| Medicare Payment
Advisory
Commission
(MedPAC) |
The Commission was created by the BBA through a merger of the Prospective
Payment Assessment Commission and the Physician Payment Review
Commission. MedPAC reviews payment policies under Medicare Parts A and
B and the effects of Medicare Part C. MedPAC also evaluates the effect of
prospective payment policies and their impact on health care delivery in the
US. |
| Medigap |
A supplemental health insurance policy sold by private insurance companies
that is designed to pay for health care costs and services that are not paid for by
Medicare and any private health insurance benefits. |
| Metropolitan
Statistical Areas
(MSA) |
Standard metropolitan statistical areas are defined by the U.S. Census so that
institutions and individuals gathering statistics on urban areas can use a
common definition. |
| Most Favored
Nation (MFN) |
A "Most Favored Nation" (MFN) clause is a contractual agreement between a
supplier and a customer that requires the supplier to sell to the customer on
pricing terms at least as favorable as the pricing terms on which that supplier
sells to other customers. These clauses are sometimes found in the contracts
health insurers enter into with providers. |
| Outpatient
Prospective
Payment System
(OPPS) |
Medicare's system for payment to outpatient departments of hospitals and
other outpatient facilities. The specific amount that is paid is determined by
the relevant APC. |
| Patient Flow Data |
Patient flow data identifies the zip code of each patient discharged from a
hospital. |
| Payment for
Performance (P4P) |
Payment for Performance pays providers based on their success in meeting
specific performance measures. |
| Pharmacy Benefit
Manager (PBM) |
A company under contract with managed care organizations, self-insured
companies, and government programs to manage pharmacy network
management, drug utilization review, outcomes management, and disease
management. |
| Physician-Hospital
Organization (PHO) |
A PHO is a joint venture between a hospital and some or all of the physicians
who have admitting privileges at the hospital. |
| Point of Service
(POS) |
A health insurance plan in which members do not have to choose how to
receive services until they need them. The most common use of the term
applies to a plan that enrolls each member in both an HMO (or HMO-like)
system and an indemnity plan. These plans provide different benefits,
depending on whether the member chooses to use plan providers or go outside
the plan for services. |
| Preferred Provider
Organization (PPO) |
A health insurance plan with an established provider network ("preferred
providers) that provides maximum benefits when members use a preferred
provider. |
| Quality
Improvement
Organization (QIO) |
Organizations that contract with CMS to review care provided to Medicare
beneficiaries. |
| Resource-Based
Relative Value
Scale (RBRVS) |
The RBRVS determines the rate at which Medicare reimburses physicians on
an FFS basis. The RBRVS is calculated based on the cost of physician labor,
practice overheads, materials, and liability insurance. The resulting figures are
adjusted for geographical differences and are updated annually. |
| Single Specialty
Hospital (SSH) |
Specialized hospitals that provide treatment relating to a single specialty (e.g.,
cardiac or orthopedic services). Many of the physicians who refer patients to
an SSH have an ownership interest in the facility. |
| State Action
Doctrine |
First articulated in Parker v. Brown, the state action doctrine shields certain
anticompetitive conduct from federal antitrust scrutiny. |
| State Board of
Medical Examiners |
State Boards of Medical Examiners are typically responsible for licensure and
promulgate regulations governing physicians and AHPs. |
| State Children's
Health Insurance
Program (SCHIP) |
Also referred to as Children's Health Insurance Program (CHIP). A program
created by the federal government to encourage states to provide insurance
coverage for children. SCHIP is funded through a combination of federal and
state funds, and administered by the states in conformity with federal
requirements. |
| Telemedicine |
Telemedicine involves the use of electronic communication and information
technologies to provide or support clinical care at a distance. |
| Third-Party
Administrator
(TPA) |
A firm that performs administrative functions (e.g., claims processing,
membership) for a self-funded plan or a start-up MCO. |
| Utilization Review |
An organized procedure carried out through committees to review admissions,
duration of stay, professional services furnished, and to evaluate the medical
necessity of those services and promote their most efficient use. |