AHS vocab
Biosimilar Drug
A biosimilar product is a biologic product that is approved based on demonstrating that it is highly similar to an already Food and Drug Administration (FDA) ‐ approved biologic drug.
Reference-based pricing
A cap is set on the price that is paid for a drug or service based on the price of a similar or "reference" product.
Medicaid Expansion
A centerpiece of the Patient Protection and Affordable Care Act is the expansion of Medicaid eligibility to people with annual incomes below 138 percent of the federal poverty level, or $26,347 for a family of three and $15,417 for an individual. (June 2012: Supreme Court ruled that states could not be forced to expand their Medicaid programs; now left to each state to determine participation)
Formulary ("tiered" formulary)
A list of prescription drugs that an insurer will cover. These days it will be organized into tiers or levels of copays for drugs. These are typically generic and brand, both preferred and nonpreferred, and specialty tiers. Co-payments are structured to incentivize using certain drugs (i.e. preferred generics) over the others.
Over-the-counter
A medication or supplement that is available for direct purchase by a consumer without the need for a prescription. Many drugs that were formerly prescription-only drugs are now available over- the-counter, and insurance companies commonly stop covering them unless a special dose, quantity, or indication is prescribed.
Co-payment
A patient's share of the costs for a covered service, as a fixed amount. An example is a $15 co-payment you are required to pay for a primary care doctor's visit. The amount can vary by the type of covered health care. For example, a generic drug may require a $10 co-pay, while a brand-name may require a $25 co-pay. A "preferred" generic may require a $5 co-pay, whereas a non-preferred generic may require $15.
Co-insurance
A patient's share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service.
Biologic Drug
A pharmaceutical agent that is derived from or developed in living things. Examples are monoclonal antibody drugs and v accines that may be the by products of cellular processes or developed in cells.
Cost-Benefit Analysis
A precursor to cost-effectiveness analysis. Refers to comparison between costs (direct and indirect) and benefits associated with a project/intervention; both are traditionally measured in monetary terms. Direct costs involved in building a new hospital wing, for example, would include materials, labor, etc. Indirect costs might include traffic delays or rerouting caused by construction or the effects of noise and dust from the construction site on patient wellbeing. Benefits and costs may be compared by taking the difference between the two, or by taking a ratio.
Medical Errors
A preventable adverse effect of medical care; medical errors constitute a significant cause of death in the US (per a 2016 BMJ study, it is the third leading cause).
Accountable Care Organization (ACO)
A provider-led, contract-based integration of various providers (usually at least a hospital system, physician groups, and other services) who join together to manage the full continuum of care for a fixed population. They contract with a particular payer, such as Medicare or private insurer like Blue Cross Blue Shield Illinois, who assigns them this population.
Group Model HMO
A single multi-specialty medical group is contracted to provide care to the HMO's membership. The group practice may work exclusively with the HMO, or it may provide services to non-HMO patients as well. The HMO pays the medical group a negotiated, per capita rate, which the group distributes among its physicians, usually on a salaried basis.
Adverse Selection
A situation in which people with higher risk of adverse events (e.g. sickness, car accident, house fire, etc.) are more likely to buy insurance than people with lower risk of adverse events. This may result from asymmetry of information, when buyers have more information about themselves than sellers of insurance do. Example: A person with a family history of heart disease is not required to disclose this history to an insurer and yet they purchase insurance at the same price as others with no family history.
Fentanyl
A synthetic opioid. Fentanyl is 50-100x more potent than heroin: in other words, a tiny quantity of fentanyl can produce the same effect as a "regular" dose of heroin.
cost-sharing
A term encompassing patients' share of paying for healthcare services, also referred to as "out-of-pocket" payment (e.g., co-payment, co-insurance, deductible). This is not the same as "self-pay."
health maintenance organization
A type of health insurer that is a Managed Care health insurance company that either directly employs or pays a network of providers to provide health services to its customer or "members." and generally employs a capitation payment model
Civil Commitment
Also known as involuntary commitment. Refers to institutionalization of patients based on the recommendation of a mental health professional. Institutionalization may occur without the patient's consent (hence the alternative term, involuntary commitment). Civil commitment typically stems from concern that patients may pose a threat to themselves or others.
Chargemaster
Also known as the "charge description master." A list of the price of each service provided by a hospital. The ACA required hospitals to publish their chargemasters.
ACHA
American Health Care Act of 2017 was a Republican- supported health plan that would have partially repealed the Patient Protection and Affordable Care Act (ACA). It ultimately did not pass the Senate. It removed the employer mandate for providing health insurance and relaxed minimum coverage requirements for health insurance plans, among a number of other changes.
Negligence
An act or omission by a medical professional that is at variance with accepted medical practice (i.e., the standard of care). Negligence and medical malpractice are not synonymous.
Patient Satisfaction
An important feature of discussions of quality within healthcare. The HCAHPS survey (see above) represents one of the ways in which satisfaction is gauged. However, assessing satisfaction is inherently challenging. The HCAHPS is lengthy, resulting in a low response rate (approximately 1 survey is returned for every 10 mailed out). In addition, there is the question of attribution : if a patient is cared for by multiple physicians, which one is most responsible for the patient's perception of the quality of their care?
Preferred Provider Organization (PPO)
An indemnity plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers
Experience Rating
An insurer uses "experience rating" when it predicts a group's future medical costs based on its past experience (i.e., the actual cost of providing health care coverage to the group during a given period of time; the group's claim history). Thus, the insurer calculates the group's insurance premium based on its own, not the overall community's, experience.
Patent
An intellectual property right that is granted by the U.S. Patent and Tradmark Office to the inventor, developer, or discoverer of a specific intellectual property, like a chemical formulary, a particular innovation, or a different way of delivering a particular compound (one drug can also carry many patents). It can be granted at any time during the development of a drug. This is contrasted with market exclusivity , which is granted at the time of approval the New Drug Application to protect a drug from competition for a specific market.
Adverse Event
An unexpected event that results in injury to the patient or patient/family dissatisfaction with care.
Recovery Model
Approach to caring for patients with mental illness; focus is on recovery and inclusion in society, rather than on stigmatizing and segregating patients. The recovery model incorporates both internal conditions (hope, healing, empowerment, connection) and external conditions (creating a more accepting and inclusive culture, reducing the stigma around mental illness, fostering a healing culture, and providing recovery-oriented services).
Episode-Based Payment
As the name suggests, providers are reimbursed per episode, which may be defined as a particular diagnosis-related group (e.g., pneumonia), a procedure (cesarean section), or a span of time (e.g., a lump sum payment for 30 days of care).
Near-Miss Event
Case in which a medical error occurred but the patient did not suffer an injury (e.g., an incorrect dose of a medication was administered, but the patient experienced no adverse effects).
Quality-Adjusted Life Years (QALYs)
Commonly used to gauge effectiveness of an intervention in cost-effectiveness research. QALYs = years of life added by a particular intervention x health-related quality-of-life weight ("HRQoL weight"). The number of life-years can be calculated via various simulation techniques, including the Markov model simulation. HRQoL weight is a means of quantifying the quality of life associated with each added life-year. This weight can be calculated via "direct" approaches (visual analogue scale, time trade-off, or "standard gamble") or via surveys (e.g., EuroQoL 5- Domain survey).
80/20 Rule
Concept that the majority of healthcare spending in the United States (~80%) goes toward the care of a small but highly complex group of patients (~20% of the patient population).
Cost
Defined as price x quantity. For instance, price might refer to the charge per day for a hospital room or the charge associated with a flu shot. Quantity could refer to the number of days that a patient is admitted or the number of flu shots administered in a year. Costs can be divided into revenue costs (income, salaries, facility and equipment maintenance, etc.) and capital costs (investment in infrastructure/equipment). A variety of factors contribute to cost, including price inflation (rising prices in healthcare across the board), ineffective/inappropriate care (unnecessary testing; admitting a patient to the hospital when outpatient management would have been more appropriate), and administrative waste (excess printouts, redundant office equipment). Costs may be controlled "painlessly" (seeking discounts on new medical equipment; offering a more limited array of medications at the hospital pharmacy) or "painfully" (cutting salaries; laying off staff).
Value
Defined as quality divided by costs. Value can be improved by increasing quality and/or decreasing costs (e.g., reducing salaries, contracting with less expensive suppliers, decreasing capital costs (infrastructure), reducing staff numbers, etc.).
Prospective Payment System
Developed by Medicare in 1983, this system introduced the diagnosis-related group (DRGs). Each diagnosis/type of illness is assigned a DRG (e.g., appendicitis, pneumonia); for each DRG, Medicare offers a fixed amount in reimbursement. This is a prospective system in that if the care for a patient with, say, community-acquired pneumonia costs more than the mandated reimbursement for this particular DRG, the hospital must bear the difference. Conversely, if a patient's care costs less than the set reimbursement rate, the hospital gets to keep the difference.
Comparative Effectiveness Research
Direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest harms. Examples include comparing two different proton pump inhibitors (PPIs), Nexium and Prilosec, in the treatment of Gastroesophageal Reflux Disorder or comparing coronary angioplasty vs. optimal medication therapy and lifestyle change for stable coronary artery disease (CAD).
Orphan drugs
Drugs developed for diseases with small numbers of patients. In US, these are usually diseases with less than 200,000 patients
Prescription Drug Monitoring Program
Electronic database that charts all prescriptions issued for controlled substances, such as opioids or benzodiazepines. Evidence suggests that PDMPs are associated with a reduction in the number of opioid overdose deaths.
Hatch-Waxman Act of 1984
Established government regulations for generic drugs in the United States and made it easier for generic drugs to enter the market.
Monopoly
Exclusive possession or control of the supply or trade in a commodity or service.
Defensive Medicine
Medical care, including laboratory tests, imaging, referrals to specialists, and procedures (e.g., biopsies), actuated by a desire to avoid potential litigation (malpractice suits, etc.), rather than by a high degree of clinical suspicion. Defensive medicine is often cited in discussions of rising health care expenses. The defense may argue, among other things, that there was no duty or no breach; that the patient assumed the risk (e.g., failure to take prescribed medications); that the injury was a known complication of the procedure performed.
Market exclusivity
Exclusivity rights granted by the FDA to a drug manufacturer upon approval of a drug to protect it from competition from other drugs for the same market (i.e. disease or indications). This is contrasted from a patent , which is a protection granted over a specific intellectual property, like a chemical formula or a particular innovation; a patent does not protect a product from competitors that are different chemicals but may serve a similar purpose in the market. (For example, TUMS and Nexium are different chemicals but both may be used for heartburn/acid reflux). The exclusivity period is set differently for different reasons (from 6 months to 7 years) and can run concurrently with a patent or not. Granting market exclusivity incentivizes drug companies to bring certain special drugs to the market that may not be profitable without such a temporary monopoly in that market.
Drug Label (Package Insert)
FDA-approved label or package insert that provides prescribing information, including indications, dosing, side effects, safety information
Supervised Injection Facilities
Facility where patients may use drugs in a safe, hygienic environment, without fear of arrest. These facilities are associated with a reduction in overdose deaths, increased enrollment in addiction treatment programs, and reductions in syringe-sharing. This model has been adopted by 11 countries; the US is not one of them.
Pay-for-Performance
Financial reward system for employees in which monetary compensation is tied to their performance, as determined by pre-specified criteria. In healthcare, providers may be paid bonuses or penalized based on the quality of their care or the outcomes of their patients. Example: A physician is paid a bonus if more than 80% of her patients are vaccinated for influenza or if more than 80% of their patients with hypertension achieve good blood pressure control.
National Institute for Health and Care Excellence (NICE)
Founded in the UK in 1999, NICE was established to perform cost-effectiveness research for the National Health Service (NHS). NICE's recommendations often drive practice guidelines for the NHS. For instance, a new medication on the market might be evaluated by NICE in order to determine the cost per quality-associated life year associated with the drug. If that cost is deemed acceptable (i.e., perhaps this is a very expensive cancer treatment, but it is associated with a marked increase in symptom-free survival), NICE would endorse its incorporation into NHS protocols. Interestingly, CEA has a more complex history in the US: in the 1990s, Oregon's Medicaid program did attempt to use CEA to pare down the number of services it covered (using the savings to insure a larger number of people). However, this effort was relatively short-lived, and no other states have attempted similar measures. Of note, the ACA has forbidden the PCORI (Patient- Centered Outcomes Research Institute, an entity created by the ACA for the purpose of conducting CEA) from assigning a dollar value to QALYs.
Managed Care Organization (MCO)
Health insurance company that controls the cost of treatment through various tools. They encourage/incentivize patients to visit only certain doctors and hospitals in a network because they have negotiated discounted rates with them and require these providers to undergo utilization review. Types of MCOs include HMOs and PPOs.
Pay-For-Reporting
In 2003, Medicare began encouraging hospitals to publish their quality metrics for certain conditions (e.g., pneumonia, heart failure). Hospitals that do not share their data are penalized. There is some evidence that pay-for-reporting is associated with improved quality measures, though there is also concern that hospitals may focus their attention disproportionately on reported metrics, at the expense of other (unreported) aspects of care.
Capitation/Capitated Payments
In this healthcare payment model, healthcare providers are paid a fixed amount for each patient that they choose to care for or are assigned - i.e., they are paid "per head" ("per capita"). The amount is fixed, usually per month, regardless of how often the patient sees the doctor. This is in contrast to fee for service. Often the capitated payment (per member per month or "PMPM") is adjusted for risk, based on age, sex, lifestyle, and medical history, in order to avoid cherry-picking the healthiest/least complex patients. As with bundled payment models, healthcare providers have an incentive to help patients avoid high-cost procedures and tests in order to maximize their compensation.
Cost-Effectiveness Analysis
Introduced in the 1970s, cost-effectiveness analysis (CEA) examines the incremental costs and outcomes/effects of a particular healthcare policy/intervention. Costs are typically monetary, but effectiveness is often measured in quality-adjusted life years (QALYs). (Contrast this with cost-benefit analysis, in which both costs and benefits are measured in monetary terms.) The results are reported in incremental cost-effectiveness ratios (ICERs). A dominant strategy is an intervention that increases QALYs while also reducing costs. For instance, if a new lung cancer treatment is developed that costs far more than the current standard of care and yields relatively little benefit to the patient (e.g., prolongation of life by only a few weeks, with no improvement in quality of life), we might say that the treatment is not very cost-effective.
Moral Hazard
Lack of incentive to guard against risk when one is protected from its costs. In insurance, moral hazard results when someone engages in risky behavior or uses more healthcare services after being insured. This happens because individuals may seek care even if their value is lower than the true costs (Example: using the emergency department for a minor issue such as a cold). This can also be reversed: care be under-used if a person has to bear the full costs (be uninsured), when the value of that care meets or exceeds those costs. (Example: avoiding cancer treatment due to cost even though it is life-saving).
Allowed Amount/Allowed Charge/Plan Allowance
Maximum amount an insurance plan will base their payment for a covered health care service. This may be called "eligible expense," "payment allowance" and is negotiated between the insurer and provider. It is almost always less than what a provider charges. If your provider charges more than the allowed amount, the insurer will not pay amount above the allowance. Depending on the rules or state law, the patient may or may not have to pay the difference. (see balance-billing).
Naloxone
Medication used to reverse opioid overdoses. Shown to be cost-effective and associated with reductions in overdose deaths. In Illinois, providers can prescribe naloxone to laypeople, and pharmacies can dispense standing orders.
Pharmaceutical Benefits Manager (PBM)
Middle-men in the drug delivery chain. Primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims.
Rebates
Money that is paid back by manufacturers to certain buyers of their drugs, such as Medicaid, or as part of price negotiations.
Network Model HMO
Multiple physician groups are contracted to provide services to HMO members. The physician groups may provide services to both HMO and non-HMO plan participants
Medical Malpractice
Occurs when a provider's negligence results in harm (damages) to the patient. To plead a medical malpractice case, a plaintiff must make the case that there was a breach of duty (in this case, the duty is the doctor-patient relationship) and that this breach directly caused (hence the notion of proximate cause) a compensable injury to the patient (damages). Damages include economic damages (e.g., lost income because the patient was unable to work) and noneconomic damages (e.g., pain and suffering; loss of companionship when a partner dies).
Medicare Part D
Oral prescription drug benefit under Medicare
ACA
Patient Protection and Affordable Care Act; often called "Obamacare." It was passed in 2010. The law addresses health insurance coverage, health care costs, and preventive care. Notably, it expanded Medicaid, mandated the establishment of insurance exchanges, and created the individual mandate requiring all individuals to buy insurance or pay a penalty (notably, the individual mandate was challenged in the Supreme Court and was upheld; however in 2017 Congress removed the tax penalty, essentially repealing the individual mandate).
Fee-for-service payment
Payment model in which each healthcare service is paid for separately. Example services may be a surgery, a lab test, or a doctor's visit. More services (i.e. higher volume) therefore leads to higher reimbursement, and the fee is not tied to the outcome of the service.
Global Budget
Payment system in which a fixed dollar amount is budgeted annually for all care delivered. Hospitals or organizations that use this often are both the payer and the provider. They have to determine how dollars are allocated to various services they provide.
Quality
Per the Institute of Medicine, quality healthcare is safe, timely, effective, efficient, equitable, and patient-centered ("STEEEP"). of receiving care ( unsafe care: e.g., amputating the wrong limb, hospital-acquired infections), when patients are subjected to long wait-times or harmful delays (care that is not timely ), when care is based on unsound science/reasoning ( ineffective ), is wasteful ( inefficient ), or is influenced by patient characteristics such as income or race (lack of equity ), or when patient preferences are not taken into account (not patient-centered ). Quality is commonly assessed via the structure-process- outcomes model, known as the "Donabedian framework." (See individual definitions below.) Of the three, structure and process are typically easiest to measure; ultimately, outcomes are the most important. Structure and process are largely controlled by healthcare providers. Achieving desired outcomes typically requires both provider and patient involvement.
staff-model HMO
Physicians are salaried employees of the HMO and have offices in HMO buildings. Contracted physicians can only see HMO patients.
Pay-for-delay
Practice whereby a drug company with a branded product pays a generic competitor to stay out of the market after the patent for that brand expires.
Off-label prescribing
Prescribing drugs for indications for which they are not approved by the FDA and therefore not listed in their FDA drug label.
Specialty drugs
Prescription drugs that are classified as high cost, high complexity, and/or need a high level of service. Examples include Humira for Crohn's disease (requires injection and carries severe side effects), or Sovaldi for Hepatitis C (very high price, requires selection of appropriate patients)
Indications-based pricing
Pricing system in which drug manufacturers are paid more when treatments are used for indications for they have higher value ("high-value indications") and less for indications for which they confer less benefit ("low-value indications).
Value-Based Design/Value-Based Reimbursement
Promotion of value (= quality divided by cost; see additional definitions below) within the healthcare system, often by means of financial incentives/penalties. For instance, substantial evidence supports the use of certain classes of relatively inexpensive medications (e.g., beta- blockers) in patients with congestive heart failure (CHF). Thus, beta-blockers in this context represent high-value care (evidence- based and effective medication at low cost). A value-based reimbursement model might offer a reduced copay for CHF patients taking a beta-blocker, incentivizing this high-value care. To take another example, Medicare might penalize a hospital for having a large number of patients with hospital-acquired infections (= poor-quality, low-value care). Conversely, if the hospital institutes a quality improvement project and successfully reduces the number of hospital-acquired infections the following year, it might be eligible for a financial reward from Medicare.
Good Samaritan law
Protection afforded to providers who happen to be present at an emergency and provide assistance in good faith, e.g. at the scene of a car accident or a patient experiencing chest pain on a flight. In such cases, providers are protected against any harm that may occur as they attempt to help (unless they are deemed to have engaged in "willful and wanton misconduct").
RVU Scale Update Committee
RVUs are reevaluated every 5 years by the RVU Scale Update Committee (RUC).
Tort
Refers to a civil wrong (as opposed to a criminal wrong). In tort cases, the burden is on the injured party (the plaintiff) to show that the alleged perpetrator (the defendant) caused harm. In a medical setting, the plaintiff is a patient and the defendant is usually a provider.
Per-Diem Payment
Reimbursement for each day of hospitalization; rates typically decrease as the length of stay increases.
Screening, Brief Intervention, and Referral to Treatment
SBIRT involves providers identifying (screening) patients with opioid risk disorder (e.g., through a series of standardized questions during an ED visit); providing brief, preliminary counseling (brief intervention); and referring the patient for further treatment.
Diagnosis-Related Group
See "Prospective Payment System." [Developed by Medicare in 1983, this system introduced the diagnosis-related group (DRGs). Each diagnosis/type of illness is assigned a DRG (e.g., appendicitis, pneumonia); for each DRG, Medicare offers a fixed amount in reimbursement. This is a prospective system in that if the care for a patient with, say, community-acquired pneumonia costs more than the mandated reimbursement for this particular DRG, the hospital must bear the difference. Conversely, if a patient's care costs less than the set reimbursement rate, the hospital gets to keep the difference.]
Value-based pricing
Setting a price for a drug based on the value or outcome it provides
Retail drug spending
Spending on drugs at retail pharmacies, like Walgreen's or CVS. This contrasts with spending on drugs administered by physicians in their offices or given in the hospital
HCAHPS
Stands for hospital consumer assessment of healthcare providers and systems. This mail-out survey, administered by a third-party vendor, assesses patient satisfaction with their care following a hospital admission. Individual attribution (see below) presents a significant challenge in interpreting the HCAHPS.
Ever-greening
Strategy to extend patents over products that are about to expire
Single Payer
System in which a single public or quasi-public agency organizes health care financing (note: delivery of care can remain private)
Product hopping
Tactic by which brand name pharmaceutical companies can try to obstruct generic competitors and preserve monopoly profits on a patented drug by making modest reformulations that offer little or no therapeutic advantages (a type of ever-greening)
Opioid Crisis
Term that describes high rates of abuse of opioids (includes prescription pain medication, heroin, and synthetic opioids , such as fentanyl). Rates of abuse began to rise in the late 1990s, in conjunction with a surge in promotional campaigns for pain medications on the part of the pharmaceutical industry (though this is not the only reason for the current crisis - see below). Several key contributors to the current crisis include: - Pharmaceutical marketing campaigns - A push within the medical profession to treat pain more aggressively/effectively - Economic decline (opioid crisis is most severe in areas struggling economically) - Changing heroin markets (drug cartels have begun to favor highly-potent synthetic opioids, such as fentanyl, since these have the same effect as heroin but at a fraction of the volume).
Sustainable Growth Rate
The Balanced Budget Act of 1997 introduced the concept of an acceptable ("sustainable") annual rate of increase in Medicare Part B expenditures, known as the sustainable growth rate (SGR) . The idea was that each year, physician fees under Medicare Part B would be adjusted in order to ensure that increases in spending did not exceed the SGR. Expenditures above-goal would result in fees being scaled back the following year. Implementation of these cuts was repeatedly postponed and costs continued to rise, leading many policy-makers to question the efficacy of the SGR. The SGR was ultimately repealed in 2015.
Deductible
The amount a patient owes for health care services your health insurance plan covers before the plan even begins to pay. For example, a plan's deductible is $1,000. A patient undergoes surgery for which a provider charges the plan won't pay anything until the patient has met their $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Marginal Benefit
The benefit of an additional unit of good or service. Usually, there is a diminishing return, a point at which it's not worth the marginal cost (additional cost of a service)
Flat-of-the-Curve Medicine
The concept that at some point along the "supply-outcome" curve, additional health care expenditure (laboratory tests, imaging, referrals, etc.) no longer provides any benefit to the patient. In other words, the curve reaches a plateau. This represents one of the ways in which supply drives up health care costs.
Utilization Review/Management
The evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of a given health benefits plan. Utilization review has traditionally been a hallmark of HMO care: the HMO's utilization review board would review a physician's orders (e.g., for an MRI) and determine whether or not the decision was appropriate (and, by extension, whether or not to approve reimbursement).
Maximum Out-of-Pocket Expense
The maximum dollar amount a group member is required to pay out of pocket during a year. Until this maximum is met, the plan and group member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.
Detailing
The practice of marketing to prescribers by having sales representatives make presentations to them about the 'details' of their products. They may also target prescribers based on their past prescribing patterns; the data for which can be obtained by drug companies from pharmacies
Triple Aim
The term "Triple Aim" refers to the simultaneous pursuit of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care.
Covered Services
These are the healthcare services for which an insurance plan explicitly says it will provide at least some payment. It may seem obvious, but all other services are considered "uncovered" or "excluded" and may not receive any payment or reimbursement by the insurer.
Individual Attribution
This refers to the challenge of accurately attributing various quality/satisfaction metrics when multiple physicians are involved in a patient's care during a hospital admission. In other words, if a patient has seen multiple providers, which of them should be held "responsible" for a patient's good/bad outcomes or level of satisfaction? This question is critical because satisfaction data are used to identify outliers (providers with very high and very low ratings). Ideally, struggling providers will be identified and given assistance, while those with high ratings are encouraged to share their successful strategies with their peers.
Resource-Based Relative Value Scale
This system, introduced by Medicare, assigns each physician-performed procedure/service a number of relative value units (RVUs), which reflect the number of resources involved. RVUs are multiplied by a conversion factor to generate a dollar value for physician reimbursement. Adjustments are made for geography and variance in practicing costs. RVUs are reevaluated every 5 years by the RVU Scale Update Committee (RUC).
Charges
This term refers to the prices that the provider asks for particular services. It is almost always more than the "allowed" amount that was negotiated between the provider and insurer.
Medication-Associated Treatment
Treatment strategy for patients with opioid use Disorder, combining medication and counseling. Commonly- used medications include methadone and buprenorphine, both of which act (at least partially) at opioid receptors in the brain, but have substantially reduced addictive potential. Both are associated with reduced risk of death from overdose.
Community Rating
Under "community rating," an insurer charges all people covered by the same type of health insurance policy the same premium without regard to age, gender, health status, occupation, or other factors. The insurer determines the premium based on the health and demographic profile of the geographic region or the total population covered under a particular policy that it insures.
Deinstitutionalization
Until the mid-20 th century, individuals with mental illness were largely institutionalized (in "poorhouses," asylums, sanatoriums, etc.). The goal was to segregate these patients from the rest of the community. In the 1960s, many patients were transitioned to community-based treatment centers, a process known as deinstitutionalization. This shift was driven by multiple factors, including a growing awareness of the alarmingly poor conditions within many inpatient psychiatric facilities; the advent of antipsychotic medications; and concerns about the financial cost of institutionalization.
Value-Based Design
Value-based insurance design aims to increase health care quality and decrease costs by using financial incentives to promote cost efficient health care services and consumer choices. Pay-for-performance at the individual provider level is one example; similarly, hospitals may be rewarded/penalized if they meet/fail to meet certain nationally mandated standards (they may be penalized for an excessive number of nosocomial infections or preventable patient falls, for instance).
Standard of Care
What a reasonably well-trained physician would do in the same or similar circumstances. Providers are compared to others at the same level of training - e.g., a first-year resident would be compared to other junior residents.
Price Transparency
When the factors that influence the price of a drug are made public, such as the costs of research, development, marketing, and advertising
