Healthcare

diagnostic related groups

(DRGs) Providers of care for Medicare patients receive a predetermined amount, the typical expected hospital costs of all common diagnosis, regardless of the actual cost of care.

in-patient care

services provided to a patient within a hospital

government agency

An individual unit of the government responsible for carrying out tasks delegated to it by Congress or the president in accordance with the law

telemedicine

A cutting edge medical technology in which telecommunications equipment transmits the image or and general information about a client at a distant site.

preferred provider organization

A managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.

for-profit agency

A portion of earned income is returned to the investors or shareholders or used to increase organizational fund balances. Have expanded their market share in the Social Service delivery network.

Deductible vs. Premiums.

A premium is a figure or amount, that the insurance company charges for your own particular risk. Example 2000 a year to insure your car. A deductible is the un-insured portion of any potential loss. So if you have for example a collision deductible of $1000 and you get in an accident- this is the portion that you would pay before they would repair your vehicle. Insurance companies work on deductibles to basically eliminate small losses. Check out http://www.insuranceria.com/.

private insurance

A private insurance program which insures the lender for loan amounts in excess of 80% of value.

medicare

A program added to the Social Security system in 1965 that provides hospitalization insurance for the elderly and permits older Americans to purchase inexpensive coverage for doctor fees and other health expenses.

Fee for service with bonus payments for quality and efficiency

Advantages: 1) Has some incentives to increase efficiency and quality Disadvantages: 1) May lead to misaligned incentives; can reward organizations that were previously inefficient and punish cost-efficient providers. 2) If an individual provider's share of pool is small relatives to its FFS (fees for service) reimbursement, financial incentive to improve efficiency may be weak.

Per episode (bundled payments)

Advantages: 1) Encourages coordination among multiple caregivers 2) Supports flexibility in care delivery 3) Creates incentive to efficiently manage episodes 4) Establishes clear accountability of care for single episodes Disadvantages: 1) Defining boundaries of an episode can be difficult. 2)May increase barriers to patients' choice of provider and/or geographic availability 3) Does not have incentives to reduce unnecessary episodes 4) Requires a certain number of cases/episodes to become viable and may not be applicable to all hospitals

Alternative Quality Contracting

Advantages: 1) Has similar advantages in terms of cost controls and overutilization of as global payments and capitation. 2) May promote better patient outcomes and health care quality. Disadvantages: 1) Solvency is also a risk.

Global payments/partial capitation

Advantages: 1) Includes incentives to avoid overutilization and coordinate care among multiple providers or replace inappropriate care settings. 2) Includes incentives for providers to try new and nontraditional methods Disadvantages: 1) Solvency is a real risk.

Catastrophic Plan

Catastrophic Plan: If you are under the age of 30, you can purchase a catastrophic health plan. With a catastrophic health you may have: 1) Lower premium 2) 3 primary care visits before the deductible applies 3) Free preventive care, even if you haven't met the deductible What you pay: Premium, Deductible ( A catastrophic health plan) has a deductibley of $7,150 for an individual and $14,300 for a family in 2017. After you reach that deductible, the plan will pay 100% of your medical costs for covered benefits. Paperwork Involved: You will want to keep track of your medical expenses before you meet the deductible.

reimbursement

Compensation or repayment for healthcare services

EPO

Exclusive Provider Organization (EPO): With an EPO you have: 1) A moderate amount of freedom to choose your health care providers-- more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist. 2) No coverage for out-of-network providers; if you see a provider that is not in your plan's network-- other than in an emergency-- you will have to pay the full cost yourself. What you pay: Premium, Deductible (Some EPOs may have a deductible), Copay or coinsurance, Other Costs (other costs= if you see an out-of-network provider you will have to pay the full bill)

HMO

Health Maintenance Organization (HMO): delivers all health services through a network of healthcare providers and facilities. With an HMO you have: 1) The least freedom to choose your health care providers 2) The least amount of paperwork compared to other plans 3) A primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist. What you pay: Premium, Deductible (your plan may require you to pay the amount of a deductible before it covers care beyond your essential benefits. When you have reached those amounts, your health plan will pay 100% of charges), Copays and/or co-insurance for each type of care.

group plan

One insurance policy that covers a group of people

medigap

a specialized supplemental insurance policy designed to cover the deductible and coinsurance amount left over after medicare pays

POS

Point of Service Plan (POS): 1) More freedom to choose your health care providers than you would in an HMO 2) A moderate amount of paperwork if you see out of-network providers 3) A primary care doctor who coordinates your care and who refers you to specialists. What you pay: Premium, Deductible (Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services. You may pay higher deductible if you see an out-of-network provider), Copays or Coinsurance. Paperwork Involved: If you go out-of-network, you have to pay your medical bill. Then you submit a claim to your POS plan to pay you back.

PPO

Preferred Provider Organization (PPO): With a PPO, you may have: 1) A moderate amount of freedom to choose your health care providers-- more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist. 2) Higher out-of-pocket costs if you see out-of-network doctors vs. in-network providers. 3) More paperwork than with other plans if you see out-of-network providers. What you pay: Premium, Deductible (some PPOs may have a deductible. You will likely have to pay a higher deductbiel if you see an out-of-network doctor), Copay or Coinsurace, Other Costs (Other Costs= if your out-of-network doctor chargers more than others in the area do, you may have to pay the balance after your insurance pays its share).

Premium:

This is the cost you pay each month for insurance.

cost containment

Trying to control the rising cost of health care and achieving the maximum health benefit for every dollar spent

Deductible

Your plan may require you to pay the amount of a deductible before it covers care beyond your essentiall benefits (For HMO at least).

deductible

a clause in an insurance policy that relieves the insurer of responsibility to pay the initial loss up to a stated amount

medicaid

a federally aided, state operated program that provides medical benefits for low-income persons in need of medical care

workers compensation

a form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment.

co-payment

a small fixed fee paid by the patient at the time of an office visit

tricare

a three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and fees implemented nationwide by the federal government

managed care

a type of insurance in which the carrier is responsible for both the financing and the delivery of health care.

outpatient care

care usually provided for less than 24 hours for persons who have had treatments or surgery requiring short-term skilled care. .

health maintenance organization

group insurance that entitles members to services of participating hospitals and clinics and physicians

individual heathcare plan

healthcare plan that provides coverage for only one person

indemnity plan

insurance company's agreement to reimburse a policy holder a predetermined amount for covered losses

co-insurance

insurance issued jointly by two or more underwriters

health information management systems

management of personal healthcare information by the healthcare agency

out-of-pocket

medical bill that is not covered by insurance and must be paid by the patient

preventative care

more disease oriented and focuses on reducing and controlling risk factors for disease

insurance premium

payments made by customers to secure a policy written by an insurance company

veterans health administration

provides healthcare services to anyone who served in the military