Access. The timely use of personal health services to achieve the best possible health outcomes.

Accountable Care Organizations (ACOs). Groups of doctors, hospitals, and other healthcare providers who partner voluntarily to give coordinated, high-quality care to the Medicare patients they serve.

Accreditation. A review process that determines if an agency meets the defined standards of quality determined by the accrediting body.

Adult day care. A group program designed to meet the needs of functionally and/or cognitively impaired adults and provide respite for family caregivers.

Adverse selection. A problem in the health insurance industry caused by asymmetry in information before insurance is purchased, such as when individuals/patients who know they are more likely to require care tend to choose more generous insurance plans.

Aides. Individuals that provide routine care and assistance to patients under the direct supervision of other health care professionals and/or perform routine maintenance and general assistance in health care facilities and laboratories.

Ambulatory Payment Classification (APC). A method of paying facilities prospectively for outpatient services.

Ambulatory surgical center. An outpatient facility that operates primarily to provide surgical services to patients who do not require overnight hospital care.

Artificial intelligence (AI). A machine-based system that can, for a given set of human-defined objectives, make predictions, recommendations or decisions influencing real or virtual environments.

Assisted living. A living environment focused on maintaining independence in a supervised setting.

Blockchain. A database technology (or digital ledger) that enables the secure storing and sharing of information.

Brand-name drugs. Drugs that once were or still are under patents.

Bundled Payment Care Initiative (BPCI). A form of reimbursement that links various providers together for one single payment.

Capitation. A fixed sum of money paid to the provider per time unit (usually monthly) for each patient being treated by the provider.

Children’s Health Insurance Program (CHIP). A cooperative federal/state public health insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

Clinical care. The prevention, treatment, and management of illness and preservation of mental and physical well-being through services offered by medical and allied health professions, also known as healthcare.

Clinical privileges. Permissions to provide medical and other patient care services in the granting institution, within defined limits, based on the individual’s education, professional license, experience, competence, ability, health, and judgment.

Cloud computing. A layered architecture composed of the hardware, storage infrastructure, platform composed of the software framework, and web service applications.

Coinsurance. A form of medical cost-sharing requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, is paid. 

Concurrent utilization review. A form of utilization review conducted while the medical services are ongoing.

Conventional indemnity plan. An indemnity that allows the participant the choice of any provider without effect on reimbursement. These plans reimburse the patient and/or provider as expenses are incurred.

Copayments. The fixed dollar amount that an insured person must pay when a service is received before the insurer pays any remaining charges.

Core measures. National standards of care and treatment processes for common conditions.

Coverage limits. Insurance payment limits set in terms of a dollar or per-day ceiling on benefits.

Covered entities. Any entity (health plans, health care clearinghouses, or health care providers) that provides, bills, or receives payments for healthcare services as part of its normal business activities.

Current Procedural Terminology (CPT). A uniform coding system primarily used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient.

Custodial care. Non-medical care that can be safely provided by non-licensed caregivers. It can take place at home or in a nursing home and involves help with daily activities like bathing and dressing. In some cases where care is received at home, care can also include help with household duties such as cooking and laundry. It may be covered by Medicaid if care is provided in a nursing home setting and not at home.

Cybersecurity. The art of protecting networks, devices, and data from unauthorized access or criminal use and the practice of ensuring confidentiality, integrity, and availability of information.

Deductible. The deductible is a dollar amount that an insured person pays during the benefit period–usually a year–before the insurer starts to make payments for covered medical services.

Determinant. A factor that contributes to the generation of a trait.

Diagnostic-related group (DRG). A method of paying hospitals prospectively for inpatient services by relating the type of patients a hospital treats to the resource demands and associated costs incurred by the hospital.

Digital healthcare. The delivery of patient and personalized medicine using digital channels to collect the patient’s medical data, helping the patient to self-manage his health conditions using digital platforms or tools.

Disease management. A comprehensive, integrated approach to care and  reimbursement based on a disease’s natural course.

Dually eligible. People who are eligible for both Medicare and Medicaid.

eHealth. The use of information technology and/or systems and electronic devices for healthcare service delivery (electronic health).

Encryption. A method of converting an original message of regular text into encoded text.

Electronic clinical decision support (CDS). Tools integrated into some electronic health records (EHR) to provide accurate and timely information to help advise clinical decision-making within the patient encounter.

Electronic health record (EHR). A digital system that provides the most up-to-date documented information on the patient’s medical status.

Emergency department. Hospital facilities that are staffed 24 hours a day, 7 days a week, and provide unscheduled outpatient services to patients whose condition requires immediate care.

Emergency Medical Treatment and Labor Act (EMTALA). Legislation that requires hospitals to treat patients in emergency situations whether or not they have insurance.

Epidemic. An increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.

Episode of illness. A specific medical condition or problem of expected limited duration.

Exclusive Provider Organization (EPO) plan. A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage.

Exergaming. Technology-driven physical activities, such as video game play, that requires participants to be physically active or exercise in order to play the game.

Facility-based long-term care services. Residential care facilities, assisted living facilities, nursing homes, and continuing care retirement communities.

Fee-for-service. A method of insurance payment in which doctors and other healthcare providers are paid for each service performed. Examples of services include tests and office visits.

Formulary drugs. Generic and brand-name drugs approved by the healthcare provider.

Game technology. The application of game design elements to traditionally nongame contexts.

Gatekeeping. The requirement to visit a general practitioner, family practitioner, general internal medicine physician, or general pediatrician in an ambulatory setting and to obtain a referral prior to accessing specialist care.

Generic drugs. Drugs that are not under any patents.

Geriatrics. The branch of medicine dealing with the care of patients 65 and older.

Group health maintenance organization. A model in which the health maintenance organization contracts with a single, multispecialty entity for providers to provide care to its members.

Health. A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Health disparities. Preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups and communities.

Health indicators. Summary measures that capture relevant information on different attributes and dimensions of health status and performance of a health system.

Health information exchange (HIE). The sharing of electronic health data between two or more healthcare organizations or providers.

Health information networks (HIN). Standards, policies, and services that secure health information exchange over the Internet.

Health information technology (HIT). The field of information and communication technology mainly focusing on process automation and medical data processing to support healthcare service delivery, patient self-management, and any other related processes.

Health Information Technology for Economic and Clinical Health Act (HITECH). Part of the American Recovery and Reinvestment Act of 2009 that provided the Department of Health and Human Services the authority to create programs that would improve quality, safety, and efficiency in the exchange of health information. 

Health Insurance Portability and Accountability Act (HIPAA). A federal law requiring the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.

Health maintenance organization (HMO). A healthcare system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for healthcare delivery to HMO members in a particular geographic area, usually in return for a fixed, prepaid fee.

Health outcome. The result of a medical condition that directly affects the length or quality of a person’s life.

Healthy People 2030. Launched in August 2020, this initiative is the fifth and most current iteration of the Healthy People initiative. It builds on knowledge gained over the last 4 decades and has an increased focus on health equity, social determinants of health, and health literacy with a new focus on well-being

High deductible health plan (HDHP). This type of plan typically features a higher deductible and lower insurance premiums than traditional health plans.

Hippocratic oath. A Greek medical text that requires a new physician to swear upon a number of healing gods that he will uphold a number of professional ethical standards.

Home and community-based services (HCBS). Person-centered care that allows people with significant physical and cognitive limitations to live in their home or a home-like setting and remain integrated with the community.

Home healthcare. A formal, regulated program of care delivered in the home that can include a range of services provided by skilled medical professionals.

Hospice care. Care focused on providing comfort and pain control versus extending one’s life for patients expected to live six months or less.

Hospitals. Licensed institutions with at least six beds whose primary function is to provide diagnostic and therapeutic patient services for medical conditions; they have an organized physician staff, and they provide continuous nursing services under the supervision of registered nurses.

In-network providers. Healthcare providers (e.g., specialists, hospitals, laboratories) that have accepted contracted rates with the insurer. As a result, the insured person typically pays a lower price for using services within the network.

Indemnification. The payment for losses actually incurred.

Independent Practice Association (IPA). A health maintenance organization model in which a group of independent practitioners and group providers who decide to form a legal contract with a separate legal entity.

Infant mortality. The death of an infant before his or her first birthday. 

Inpatient rehabilitation facility. A specialized hospital or unit focused on delivering intensive rehabilitative services to patients with medically complex diagnoses.

Internet of Medical Things (IoMT). The use of mobile computing, medical sensors, and cloud computing to monitor patients’ vital signs in real-time and the use of communication technologies to relay data to a Cloud computing framework.

Internet of Things (IoT). User or industrial devices that are connected to the internet including sensors, controllers, and household appliances.

Interoperability. The ability of two or more systems to exchange health information and use the information once it is received.

Intervention. An action or ministration that produces an effect or is intended to alter the course of a pathologic process.

Iron triangle. A population health management model focused on three key aims of healthcare delivery: access, quality, and cost.

Lean. A set of management practices to improve efficiency and effectiveness by eliminating waste.

Lean six sigma. A philosophy of improvement that values defect prevention over defect detection.

Life expectancy. The average number of years that a person could expect to live if he or she experienced the age-specific mortality rates prevalent in a given country in a particular year.

Long-term care. A type of care traditionally provided in nursing homes, providing patients who can no longer be cared for at home or in assisted living with support for both daily living activities and complex medical problems.

Long-term care hospital. An inpatient facility for those demonstrating a great deal of medical complexity and requiring an extended period of medical care and hospitalization.

Long-term services and supports (LTSS). Home and community-based services and facility-based settings.

Magnet Recognition Program. An American Nurses Credentialing Center award that recognizes organizational commitment to nursing excellence.

Mail-order drugs. Drugs that can be ordered through the mail.

Managed care plans. Managed care plans generally provide comprehensive health services to their members and offer financial incentives for patients to use the providers who belong to the plan.

Managed care organizations (MCOs). Integrated and coordinated organizations designed to provide care to a specific patient population.

Maximum out-of-pocket expense. The annual dollar amount limit a participant or family is required to pay out-of-pocket in addition to the plan deductible.

Meaningful use. The use of certified electronic health record by healthcare providers to improve the safety, efficiency, and  quality of care.

Medicaid. A cooperative federal/state public health insurance program that provides access to comprehensive health coverage that may not be affordable otherwise for eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities.

Medical loss ratio. The percentage of insurance premium dollars that a health plan spends on medical care for policyholders and quality improvement efforts, rather than on administrative costs. The Affordable Care Act set minimum MLR standards between 80-85% for insurers in the United States.

Medicare. A federal public health insurance program that provides health insurance coverage to nearly all Americans aged 65 and older and people who have received federal disability payments for two or more years, those with end-stage renal disease, and amyotrophic lateral sclerosis.

Medicare Part A. A program within Medicare that provides hospital coverage to all Medicare recipients receive at no cost.

Medicare Part B. Also known as Supplementary Medical Insurance (SMI), this helps cover doctors’ services and outpatient care.

Medicare Part C.  A voluntary program within Medicare that is an alternative to Parts A and B and provides coverage through private organizations, such as health maintenance organizations, for the same services.

Medicare Part D. A program within Medicare that provides prescription drug coverage.

Medical tourism. A patient intentionally crosses a border to seek medical care that will typically require out-of-pocket payment for services.

mHealth. Medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (mobile health).

Moral hazard. A problem in the health insurance industry caused by asymmetry in actions after insurance is purchased, such as when a buyer of insurance is incentivized to use more services because they will bear a smaller share of their medical care costs.

Network management. The process of identifying and contracting with preferred providers who offer either lower fees or lower utilization of services and steering patients to them, through benefit design or by requiring referrals.

Network model – A model in which the health maintenance organization contracts with multiple provider groups, either single or multispecialty, to provide services to its members.

Organizational health literacy. The degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Out-of-network providers. Healthcare providers who have not accepted contracted rates with the insurer. As a result, services received outside the network of healthcare providers with contracted rates typically carry a higher cost to the insured person.

Overall limits. Restrictions that apply to all or most insurance benefits under the plan, as opposed to selected individual benefits.

Palliative care. A type of care that focuses on managing the chronic conditions of a patient with the goal of providing comfort and the highest quality of life possible.

Pandemic. Denoting a disease affecting or attacking the population of an extensive region, country, or continent.

Patient-centered. Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

Patient-centered medical home (PCMH). A multidisciplinary approach to primary care delivery focused on providing meaningful, holistic care of the patient, both physical and mental, via an interdisciplinary team of providers under one roof.

Patient Protection and Affordable Care Act (PPACA). Legislation aimed to increase consumers’ access to healthcare coverage and protect them from insurance practices that restricted care or significantly increased the cost of care.

Patient safety goals. Guidelines specifically for organizations accredited by The Joint Commission that focus on healthcare safety problems and ways to solve them.

Personal health literacy. The degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Physician-hospital organization (PHO). Alliances between physicians and hospitals for the purpose of helping providers attain market share, improve bargaining power and reduce administrative costs.

Plan-do-study-act (PDSA). A commonly used quality improvement method that allows for refinement of the change to implementation on a broader scale after successful changes have been identified.

Point-of-service (POS) plan. A POS plan is an “HMO/PPO” hybrid, sometimes referred to as an “open-ended” HMO when offered by an HMO. POS plans resemble HMOs for in-network services. 

Population health (PopH). The health outcomes of a group of individuals, including the distribution of such outcomes within the group.

Population health management (PHM). The process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.

Post-acute care. Care provided to patients recently released from the hospital and can take place in many settings, including nursing homes and rehabilitation centers.

Prevention. An action to avoid, forestall, or circumvent a happening, conclusion, or phenomenon (e.g., disease).

Pre-authorization. A decision by a health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary.

Preferred provider organization (PPO). An indemnity plan where coverage is provided to participants through a network of selected healthcare providers (such as hospitals and physicians).

Premium. Agreed upon fees paid for coverage of medical benefits for a defined benefit period.

Primary care. The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Prior authorization. A decision by a health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary.

Prospective utilization review. A form of utilization review done prior to the medical services or procedures being delivered.

Protected health information (PHI). Individually identifiable health information that is transmitted or maintained in any form or medium (electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records.

Public health. The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities, and individuals.

Quality. The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Reinsurance. The acceptance by one or more insurers called reinsurers or assuming companies, of a portion of the risk underwritten by another insurer contracted with an employer for the entire coverage.

Retrospective utilization review. A form of utilization review done after the services are provided and the bill is delivered.

Risk. The chance of loss or the perils to the subject matter of an insurance contract; also: the degree of probability of such loss.

Robotic process automation (RPA). The use of automation technologies to mimic back-office tasks of human workers, such as extracting data, filling in forms, moving files, et cetera.

Robotic surgery. A method of performing surgery using very small tools attached to a robotic arm.

Self-insured plan. A plan offered by employers who directly assume the major cost of health insurance for their employees.

Six Sigma. A model for quality improvement that uses a measurement-based strategy for process improvement and problem reduction applied to improvement projects.

Skilled nursing facility care. Care ordered by a physician, delivered by skilled nursing or therapy staff, and paid for by Medicare Part A for a fixed period of time (up to 100 days).

Social determinants of health. The conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.

Staff model. A model in which the health maintenance organization directly employs providers on a salary basis.

Stop-loss coverage. A form of reinsurance for self-insured employers that limits the amount the employers will have to pay for each person’s healthcare (individual limit) or the employers’ total expenses (group limit).

Telehealth. The provision of non-clinical services such as provider training and medical education.

Telemedicine. The use of electronic communications and software to provide clinical services without the need for an in-person visit to the doctor’s office.

Triple aim. A population health management model focused on simultaneously improving the patient experience of  care, improving population health, and reducing the per capita costs of care.

Usability. The extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.

Usual, customary, and reasonable (UCR) charges. The charge that is the provider’s usual fee for a service that does not exceed the customary fee in that geographic area and is reasonable based on the circumstances.

Utilization review (UR). The evaluation of the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the provisions of the applicable health benefits plan, also known as utilization management.

Value-based reimbursement models. Reimbursement models used by Medicare, Medicaid, and private insurance companies that use financial incentives to reward quality healthcare and positive patient outcomes.

Value stream mapping. A lean tool that employs a flowchart documenting every step in the process.

Veterans Affairs Healthcare System (VAHS). A national system of clinics and hospitals that provides healthcare services for military veterans.

Wearable technology. Small devices using computers and other advanced technology designed to be worn in clothing or directly against the body for the purpose entertainment and other tasks like monitoring physical activity.

Wellness. The optimal state of health of individuals and groups, expressed as a positive approach to living.


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Exploring the U.S. Healthcare System Copyright © 2023 by Karen Valaitis is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

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