A health system, also sometimes referred to as health care system or healthcare system, is the organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations.
There is a wide variety of health systems around the world, with as many histories and organizational structures as there are nations. In some countries, health system planning is distributed among market participants. In others, there is a concerted effort among governments, trade unions, charities, religious organizations, or other co-ordinated bodies to deliver planned health care services targeted to the populations they serve. However, health care planning has been described as often evolutionary rather than revolutionary.
Goals[edit | edit source]
According to the World Health Organization, health care systems' goals are good health for the citizens, responsiveness to the expectations of the population, and fair means of funding operations. Progress towards them depends on how systems carry out four vital functions: provision of health care services, resource generation, financing, and stewardship. Other dimensions for the evaluation of health systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness. Also, continuity of health care is a major goal.
Definitions[edit | edit source]
Often health system has been defined with a reductionist perspective, for example reducing it to health care system. In many publications, for example, both expressions are used interchangeably. Some authors have developed arguments to expand the concept of health systems, indicating additional dimensions that should be considered:
- Health systems should not be expressed in terms of their components only, but also of their interrelationships;
- Health systems should include not only the institutional or supply side of the health system, but also the population;
- Health systems must be seen in terms of their goals, which include not only health improvement, but also equity, responsiveness to legitimate expectations, respect of dignity, and fair financing, among others;
- Health systems must also be defined in terms of their functions, including the direct provision of services, whether they are medical or public health services, but also "other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce." -
- World Health Organization definition
The World Health Organization defines health systems as follows:
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes, for example, a mother caring for a sick child at home; private providers; behaviour change programmes; vector-control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well known determinant of better health.
Providers[edit | edit source]
Health care providers are institutions or individuals providing health care services. Individuals including health professionals and allied health professions can be self-employed or working as an employee in a hospital, clinic, or other health care institution, whether government operated, private for-profit, or private not-for-profit (e.g. non-governmental organization). They may also work outside of direct patient care such as in a government health department or other agency, medical laboratory, or health training institution. Examples of health workers are doctors, nurses, midwives, dietitians, paramedics, dentists, medical laboratory technologists, therapists, psychologists, pharmacists, chiropractors, optometrists, community health workers, traditional medicine practitioners, and others.
There are generally five primary methods of funding health systems:
- general taxation to the state, county or municipality
- social health insurance
- voluntary or private health insurance
- out-of-pocket payments
- donations to charities
[edit | edit source]
- accreditation: an evaluative process in which a health care organization undergoes an examination of its policies, procedures and performance by an external organization (accrediting body) to ensure that it is meeting predetermined criteria. It usually involves both on- and off-site surveys.
- accrued payments: The charges for services less the sum of government allowances, non-government contractual allowances, uncompensated care and allowance for employee self insurance.
- acute care: a type of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel, using complex and sophisticated technical equipment and materials. Unlike chronic care, acute care is often necessary for only a short time.
- affiliation: an agreement (usually formal) between two or more otherwise independent entities or individuals that defines how they will relate to each other. Affiliation agreements between hospitals may specify procedures for referring or transferring patients from one facility to another, joint faculty and/or medical staff appointments, teaching relationships, sharing of records or services, or provision of consultation between programs. HSP may or may not regulate an affiliation, depending on its nature.
- ambulatory care: all types of health services which are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to receive services that do not require an overnight stay.
- ambulatory setting: a type of organized healthcare setting in which health services are provided on an outpatient basis. Ambulatory care settings may be either mobile (when the facility is capable of being moved to different locations) or fixed (when the person seeking care must travel to a fixed service site).
- ambulatory surgery: surgical procedures that do not require an overnight hospital stay. Procedures can be performed in a hospital or licensed surgical center. Also called outpatient surgery.
- appeals process: the process used by health care consumers to request that their health plan re-consider a previous decision. There may be different appeal processes for members, providers, types of products, or state of issue. In Connecticut, The Office of the Managed Care Ombudsman and/or the Department of Insurance oversees the health insurance appeals process.
- average daily census: a term to measure hospital utilization. The formula is the number of total patient days in a year divided by 365.
- average length of stay: a term to measure hospital utilization. Average Length of Stay (ALOS) refers to the average number of days a patient stays at the facility. The formula is the total number of patient days in a given period divided by the number of total discharges in that same period.
- bad debt: income lost to a provider because of failure of patients to pay amounts owed. Bad debts are distinguished from free care, which is care for which the hospital did not expect to receive full reimbursement when it provided the service. Bad debts, net of recoveries, can be accounted for as deductions from revenue if, after reasonable collection efforts, it is determined that the accounts are uncollectible.
- balance billing: in Medicare and private fee-for-service health insurance, the practice of billing patients for charges that exceed the amount that the health plan will pay. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.
- benchmark: a level of care set as a goal to be attained. Internal benchmarks are derived from similar processes or services within an organization. Competitive benchmarks are comparisons with the best external competitors in the field. Generic benchmarks are drawn from the best performance of similar processes in other industries.
- capital expenditure: an expenditure for the acquisition, replacement, modernization, or expansion of facilities or equipment which, under generally accepted accounting principles, is not properly chargeable as an expense of operation and maintenance.
- carve out: regarding health insurance, an arrangement whereby an employer eliminates coverage for a specific category of services (e.g., vision care, mental health/psychological services and prescription drugs), and contracts with a separate set of providers for those services according to a predetermined fee schedule or capitation arrangement. Carve out may also refer to a method of coordinating dual coverage for an individual.
- case-mix: a measure of the mix of cases being treated by a particular health care provider that is intended to reflect the patients' different needs for resources. Case-mix is generally established by estimating the relative frequency of various types of patients seen by the provider in during a given time period, and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.
- Centers for Medicare and Medicaid Services (CMS): the government agency within the federal Department of Health and Human Services responsible for directing the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act), and conducting research to support those programs, ( Formerly the Health Care Financing Administration, HCFA.).
- Certificate of Need (CON): a certificate issued by a governmental body to an individual or organization proposing to construct or modify a health facility, acquire major new medical equipment, modify a health facility, offer a new or different healthcare service or terminated services. Such issuance recognizes that a facility or service, when available, will meet the needs of those for whom it is intended. CON is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. In Connecticut, the Office of Health Care Access is the state agency designated to issue Certificates of Need.
- charity care: a term that generally refers to physician and hospital services provided to persons who are unable to pay for the cost of services, especially those who are low-income, uninsured and underinsured. A high proportion of the costs of charity care is derived from services for children and pregnant women (e.g., neonatal intensive care).
- Consolidated Omnibus Budget Reconciliation Act (COBRA): a law that requires employers to continue allowing employees to remain covered under the employerâs group health plan for a period of time after: the death of a spouse, job loss, work schedule reduction, or divorce. The employee or former employee normally assumes payment for both his share and the employerâs share of the plan premium.
- conversion: a transaction where all or part of the assets of a health care organization undergo a shift in profit status (non-profit, public or for-profit) through sale, lease, joint venture, or operating/management agreements. In Connecticut, conversions are regulated under Public Act 19a-486.
- copayment: in health plans, the amount a consumer pays for each medical service, such as a doctorâs visit. The copayment is usually a set amount.
- costs: expenses incurred in the provision of services or goods. Many different kinds of costs are defined and used (see allowable, direct, indirect, and operating costs). Charges, (the price of a service or amount billed an individual or third party), may or may not be equal to service costs.
- cost sharing: any provision of a health insurance policy that requires the insured individual to pay some portion of medical expenses. The general term includes deductibles, copayments, and coinsurance.
- cost-shifting: refers to a providerâs recouping the cost of providing uncompensated care by increasing revenues from some payers to offset losses and lower net payments from other payers.
- crowd-out: a phenomenon whereby new public healthcare programs or expansions of existing public programs designed to extend coverage to the uninsured prompt some privately insured persons to drop their private coverage and take advantage of the expanded public subsidy.
- current cost: cost stated in terms of current values rather than in terms of actual acquisition cost.
- Current Population Survey (CPS): a national survey conducted annually by the U.S. Department of Commerce, Bureau of the Census. The CPS gathers information on the noninstitutionalized population of the United States. The CPS is the most commonly reported source for the number of persons without health insurance and other information about this population.
- Current Procedural Terminology, fourth edition (CPT-4): a manual that assigns five-digit âCPTâ codes to medical services and procedures in order to standardize claims processing and data analysis.
- customary charge: one of the factors determining a physician's payment for a service under Medicare. It is calculated as the physician's median charge for that service over a prior 12-month period.
- Customary, Prevailing, and Reasonable (CPR): the current method of paying physicians under Medicare. Payment for a service is limited to the lowest of (1) the physician's billed charge for the service, (2) the physician's customary charge for the service, or (3) the prevailing charge for that service in the community. Similar to the Usual, Customary, and Reasonable system used by private insurers.
- deductible: the annual amount payable by the beneficiary for covered services before their health plan will make payment to a provider.
- Diagnosis Related Grouping (DRG): an inpatient hospital classification system used to pay a hospital or other provider for its services and to categorize illness by diagnosis and treatment. DRGs are intended to categorize patients into groups that are clinically meaningful and homogeneous with respect to resource use.
- direct cost: a cost which is identifiable directly with a particular activity, service, or product of the program experiencing the costs. These costs do not include the allocation of costs to a cost center which are not specifically attributable to that activity, service or product. For example, in the case of a surgery, the cost of the sutures would be a direct cost, the cost of the lighting used in the surgical suite would not be a direct cost.
- Disproportionate Share (DSH) Adjustment: a payment adjustment under Medicare's prospective payment system or under Medicaid for hospitals that serve a relatively large volume of low-income patients. In Connecticut, the Office of Health Care Access calculates these payment adjustments based on hospital budget filings.
- durable medical equipment: medical equipment, including ventilators, wheelchairs, hospital beds, oxygen systems, and home dialysis systems - that may be prescribed by a physician for a patient's use at home for an extended period of time.
- exclusive provider arrangement: an indemnity or service health care plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with some exceptions for emergency and out-of-area services).
- Federal Poverty Level (FPL): the amount of income determined by the federal Department of Health and Human Services to provide a bare minimum for food, clothing, transportation, shelter, and other necessities. FPL is reported annually and varies according to family size (e.g., for a family of three in 1999, the FPL was $13,880, or $1,157 per month). Public assistance programs such as Medicaid define eligibility using some percentage of the FPL as income limits.
- Federally Qualified Health Center (FQHC): health centers that have been approved by the federal government for a program to give low cost health care. Medicare pays for some health services in FQHCs that are not usually covered, including preventive care. FQHCs can include community health centers, tribal health clinics, migrant health services, and health centers for the homeless.
- fee-for-service: The method of billing for health services whereby a physician or other practitioner charges the payer (whether it be the patient or his health insurance plan) separately for each patient encounter or service rendered. It is the method of billing used by the majority of U.S. doctors. Health plans often avoid engaging in fee-for-service payment contracts, since expenditures increase if the doctorsâ fees increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. This system contrasts with salary, per capita, or other prepayment systems, where the payment to the physician is not changed with the number of services actually used.
- fee schedule: an exhaustive list of physician services, in which each entry is associated with a specific monetary amount that represents the approved payment level for a given insurance plan.
- formulary: a list of drugs, usually by their generic names, and indications for their use. A drug formulary is intended to include a sufficient range of medicines to enable physicians, dentists, and, as appropriate, other practitioners to prescribe all medically appropriate treatment for all reasonably common illnesses. In some health plans, providers are limited to prescribing only drugs listed on the plan's formulary.
- free care: a term which represents the difference between the amount of expected reimbursement from charity patients (as defined by a hospital boardâs approved free care policy approved by HSP) for hospital services rendered, and the amount of the hospital's published charges for such services. Courtesy discounts, contractual allowances, and charges for health care services provided to employees are not included under the definition of free care.
- Freedom of Information Act: A law that requires the State agencies in Connecticut to provide certain information on written request to members of the public.
- Graduate Medical Education (GME): the period of medical training that follows graduation from medical school; commonly referred to as internship, residency, and fellowship training. The Centers for Medicare and Medicaid Services partly finances GME through Medicare direct and indirect payments.
- group practice: a formal association of three or more physicians or other health professionals providing health services. Income from the practice is pooled and redistributed to the members of the group according to some prearranged plan (often, but not necessarily, through partnership). Groups vary in size, composition, and financial arrangements.
- Health Insurance Portability and Accountability Act of 1996 (HIPAA): sometimes referred to as the Kennedy-Kassebaum bill, this federal law allows persons to qualify immediately for comparable health insurance coverage after losing a job or moving to another job. HIPPA requirements protect persons and their families who have existing medical conditions and/or problems getting health coverage. HIPAA also gives the federal government the authority to mandate and determine appropriate standards for the electronic exchange of health care data among insurers and providers.
- health insurance purchasing cooperatives: public or private organizations which purchase health insurance coverage on behalf of the workers of all member employers. The goal of these organizations is to consolidate purchasing to gain greater bargaining power with health insurers, plans and providers, and to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations.
- health planning: planning concerned with improving health, whether undertaken comprehensively for a whole community or for a particular population, type of health service, institution, or health program. The components of health planning include: data assembly and analysis, goal determination, action recommendation, and implementation strategy.
- Health Plan Employer Data and Information Set (HEDIS): a set of performance measures for health plans developed for the National Committee for Quality Assurance (NCQA) that provides purchasers with information on effectiveness of care, plan finances and costs, and other measures of plan performance and quality.
- Health Resources and Services Administration (HRSA): one of the eight agencies of the U.S. Public Health Service, HRSA has responsibility for addressing resource issues relating to access, equity and quality of health care, particularly to the disadvantaged and underserved. HRSA provides leadership to assure the support and delivery of primary health care services, particularly in underserved areas, and the development of qualified primary care health professionals and facilities to meet the health needs of the nation.
- high-risk pool: a subsidized health insurance pool organized by some states as an alternative for individuals who have been denied health insurance because of a medical condition, or whose premiums are rated significantly higher than the average due to health status or claims experience. Commonly operated through an association composed of all health insurers in a state. HIPAA allows States to use high- risk pools as an "acceptable alternative mechanism" that satisfies the statutory requirements for assuring access to health insurance coverage for certain individuals. In Connecticut, the pool is known as the Health Reinsurance Association.
- Hill-Burton Act: a program that provided federal support for the construction and modernization of hospitals and other health facilities in the 1950âs-1970âs. Hospitals that received Hill-Burton funds have an ongoing obligation to provide a certain amount of charity care.
- horizontal integration: a term describing the merging of two or more businesses at the same level of production in some formal, legal relationship. Also see vertical integration.
- hospice: a program that provides comfort and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or another community agency. The whole family is considered the unit of care, and care extends through their period of mourning.
- HUSKY (Healthcare for Uninsured Kids): Connecticutâs HUSKY Plan is designed to help all children who donât have health insurance. It includes services under the traditional Medicaid program (now known as HUSKY Part A). Through HUSKY Part B, it also provides health services for children in higher-income families (185% â 300% of poverty level). Even children in families with incomes above 300% of the federal poverty level can get most HUSKY services at a group rate. For more information: http: //www.huskyhealth.com/
- ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification): this coding classification system consists of two sections; diseases and procedures. Each diagnosis and each procedure is represented by a code. This system is established to be used in the United States, and is used as a basis for determining Diagnosis Related Groupings.
- indirect cost: a cost which cannot be identified directly with a specific activity, service, or product of the provider that incurs the cost. Indirect costs are usually apportioned among an entity's services in proportion to each service's share of direct costs. For example, in the case of a surgery, the cost of the sutures would be a direct cost, the cost of the lighting used in the surgical suite would be an indirect cost.
- inpatient discharge: refers to any patient who was discharged from the hospital on a date after the date he or she was admitted for treatment as an inpatient. This term also applies to a patient that was admitted and discharged on the same day, if the patient died or left against medical advice.
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO): a national private, nonprofit organization whose purpose is to encourage the attainment of uniformly high standards of institutional medical care. The commission establishes guidelines for the operation of hospitals and other health facilities and conducts survey and accreditation programs.
- magnetic resonance imaging (MRI): a this form of diagnostic radiology is a method of imaging body tissues that uses the response or resonance of the nuclei of the atoms of one of the bodily elements, typically hydrogen or phosphorus, to externally applied magnetic fields.
- Major Diagnostic Category (MDC): A clinically coherent grouping of ICD-9-CM diagnoses by major organ system or etiology that is used as the first step in assignment of most diagnosis related groups (DRGs). MDCs are commonly used for aggregated DRG reporting.
- managed care: a term that refers to the body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner. Managed care techniques are most often practiced by organizations and professionals that assume risk for a defined population (e.g., health maintenance organizations).
- management services organization (MSO): an entity that provides administrative and practice management services to physicians. An MSO may typically be owned by a hospital, hospitals, or investors. Large physician group practices may also establish MSOs to sell management services to other physician groups.
- mandatory reporting: a system under which physicians or other health professionals are required by law to inform health authorities when a specified event occurs, i.e. a medical error or the diagnosis of a certain disease. (See also voluntary reporting).
- Medicaid (Title XIX): a federally aided, state-operated and administered program which provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad federal guidelines, states determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program.
- medically necessary: a treatment or service that is appropriate and consistent with a patient's diagnosis and which, in accordance with locally accepted standards of practice, cannot be omitted without adversely affecting the patent's condition or the quality of care.
- Medicare (Title XVIII): a U.S. health insurance program for people aged 65 and over, for persons eligible for Social Security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured. It consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B).
- Medicare-approved charge: the amount Medicare approves for payment to a physician. Typically, Medicare pays 80 percent of the approved charge and the beneficiary (patient) pays the remaining 20 percent. Physicians may bill beneficiaries for an additional amount (the balance) not to exceed 15 percent of the Medicare approved charge.
- National Committee for Quality Assurance (NCQA): a national organization founded in 1979 composed of 14 directors representing consumers, purchasers, and providers of managed health care. It accredits quality assurance programs in prepaid managed health care organizations and develops and coordinates programs for assessing the quality of care and service in the managed care industry.
- Net Revenue from Operations: a financial indicator used by hospitals. The formula is: Accrued Payments + Uncompensated Care Program Tax Adjustment + Other Operating Revenue.
- network: an affiliation of doctors, hospitals, pharmacies and/or other health care providers, through formal and informal contracts and agreements. A health care plans contract with provider networks to provide services to its members. Provider networks may also contract externally to obtain administrative and financial services.
- occupancy % staffed beds: a measure of inpatient health facility use, determined by dividing the average daily census by the number of staffed beds.
- occupancy rate: a measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
- ombudsman: an individual who assists and often mediates disagreements for persons having problems with their health care plan. In Connecticut, the Office of the Managed Care Ombudsman can be reached at (860) 297-3989.
- operating cost: in the health field, the financial requirements necessary to operate an activity which provides health services. This cost normally includes the costs of personnel, materials, overhead, depreciation, and interest.
- operating margin: this ratio indicates the percentage of net patient service revenue that remains as income after operating expenses, except interest expense have been deducted. Calculation: Operating income (loss)/ (total operating revenue and non-operating margin).
- other operating revenues: includes revenues from non-patient goods and services. Such revenue is normal to the operation of a hospital but should be accounted for separately from patient revenues. Revenue from gifts, grants or subsidies specified by the donor for research, educational or other programs, and therefore, restricted by the donor or grantor for operating purposes, are considered other operating revenue.
- outcomes research: research on measures of changes in patient outcomes (patient health status and satisfaction), resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of the many other factors that influence patients' health and satisfaction.
- outlier: a hospital admission requiring either substantially more expense or a much longer length of stay than average. Under DRG reimbursement, outliers are given exceptional treatment (subject to peer review and organization review).
- outpatient: a patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. This definition does not include persons receiving services from a physician's office or as an inpatient program that also does not provide inpatient care.
- payer: in health care, an entity that assumes the risk of paying for health care services. This can be an uninsured (self-pay) patient, a self-insured employer, a health plan or an HMO.
- pharmaceutical assistance program: a public program to provide pharmaceutical coverage to those who cannot afford or have difficulty obtaining prescription drugs. Several states, including Connecticut, operate these programs, which primarily provide benefits to low-income elderly or persons with disabilities who do not qualify for Medicaid. The CONNPace program for seniors is an example of a pharmaceutical program operated in Connecticut.
- physician-hospital organization (PHO): a legal entity formed by a hospital and a group of physicians to further their mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices and agree to accept managed care patients according to the terms of a professional services agreement with the PHO. The PHO serves as a collective negotiating and contracting unit. It is typically owned and governed jointly by the hospital and its shareholder physicians.
- Public Act: a bill passed by both chambers of the legislature that amends the Connecticut General Statutes.
- quality of care: the degree to which delivered health services meet established professional standards and judgments of value to the consumer. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources (certification and/or training of providers); quality of the process of services delivery (the use of appropriate procedures for a given condition); and quality of outcome (actual improvement in a patients condition or reduction of harmful effects).
- reinsurance: the resale of insurance products to a secondary market thereby spreading the costs associated with underwriting.
- safety net: the network of providers and institutions which provide low cost or free medical care to medically needy, low income, or uninsured populations. The health care safety net can include (but is not limited to) individual practitioners, public and private hospitals, academic medical centers, and smaller clinics or ambulatory care facilities.
- safety net providers: providers that historically have had large Medicaid and indigent care caseloads relative to other providers and are willing to provide services regardless of the patient's ability to pay.
- sentinel event: an unexpected occurrence at a health care facility involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The event is called "sentinel" because it sends a signal or sounds a warning that requires immediate attention.
- small-group market: the insurance market for products sold to groups that are smaller than a specified size, typically employer groups. The size of groups included usually depends on state insurance laws and thus varies from state to state, with 50 employees the most common size.
- Special Act: a law that has a limited application or is of limited duration not incorporated into the Connecticut General Statutes.
- State Children's Health Insurance Program (SCHIP): a program enacted as part of the Balanced Budget Act of 1997, which established Title XXI of the Social Security Act to provide States with $24 billion in federal funds for 1998-2002, targeting children in families with incomes up to 200 percent of the Federal Poverty Level. Connecticutâs HUSKY plan is an example of a SCHIP-sponsored program.
- tertiary care: services provided by highly specialized providers (e.g., neurologists, neurosurgeons, thoracic surgeons, intensive care units). Such services frequently require highly sophisticated equipment and support facilities. The development of these services has largely been a function of diagnostic and therapeutic advances attained through basic and clinical biomedical research.
- Title XIX (Medicaid): the title of the Social Security Act that contains the principal legislative authority for the Medicaid program.
- Title XVIII (Medicare): the title of the Social Security Act that contains the principal legislative authority for the Medicare program.
- Total Emergency Room Visits: a hospital utilization measurement. It is simply the number of visits to a hospitalâs emergency unit in a given timeframe.
- Total Hospital Operating Expenses: a hospital financial measurement. It reflects the expenses necessary to maintain the functions of the hospital net of any expense recoveries.
- Total Inpatient Charges: a hospital financial term. This refers torevenue from services provided to inpatients at full-established rates (also known as âgross patient revenueâ).
- Total Licensed and Staffed beds: a hospital measurement tool. Hospitals are licensed for a specific number of beds by the state Department of Public Health. But due to lower inpatient volumes, the hospitals are often staffed to provide services for fewer beds. This measure relates only to a hospitalâs inpatient service.
- Total Margin: a measure that compares total hospital revenue and expenses for inpatient, outpatient, and non-patient care activities. Calculation: Net income/(total operating revenue and non-operating margin).
- Total Other Outpatient Visits: a hospital utilization measure. Each visit an outpatient makes to a discrete unit (even on the same day) constitutes one visit regardless of the number of diagnostic and/or therapeutic treatments that the patient receives. This measure should include all clinic visits, referred visits, observation services, and outpatient surgeries â but should exclude emergency room visits.
- Total Patient Days: a hospital utilization measure. The total number of days that hospital inpatients (excluding newborns in the nursery) are hospitalized in a given time period, e.g., per year. The day of admission, but not the day of discharge, is counted as a patient day. If both admission and discharge occur the same day, the day is counted as one patient day.
- TRICARE: Operated by the US Department of Defense, this program (formerly known as CHAMPUS) provides medical care to active duty members of the military, military retirees, and their eligible dependents.
- uncompensated care: service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs for these services may be covered through cost-shifting. Uncompensated care includes charity care and bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bill. HSPâs formula for computing a hospitalâs level of uncompensated care is to add together the hospitalâs reported amount of free care and bad debts.
- underinsured: persons with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay.
- uninsured: people who lack public or private health insurance.
- usual, customary and reasonable (UCR) fees: a term often used by the managed care industry, it involves the use of fee screens to determine the lowest value of physician reimbursement based on: (1) the physician's usual charge for a given procedure, (2) the amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and (3) the reasonable cost of services for a given patient after medical review of the case.
- utilization: a term that is often defined in patterns or rates of use of a single service or type of service, e.g., hospital care, physician visits, prescription drugs.
- utilization review: evaluation of the need, appropriateness, and efficiency of the use of health care services, procedures, and facilities. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, length of stay, and discharge practices, both on a concurrent and retrospective basis. Utilization review can be done by a peer review group or a public agency.
- vertical integration: organizational term whereby one business entity controls or owns all stages of the production and distribution of goods or services. (See also horizontal integration).
- voluntary reporting: a medical error reporting system where the reporter chooses to report an error in order to prevent similar errors from occurring in the future. One theory of voluntary reporting systems is that they allow reporters to focus on a set of errors broader than just those that cause serious harm and that they help to detect system weaknesses before the occurrence of serious harm. (See also mandatory reporting).
- working capital: the sum of an institution's short-term or current assets including cash, marketable (short-term) securities, accounts receivable, and inventories. Net working capital is defined as the excess of total current assets over total current liabilities.
Portions of content adapted from Wikipedia's article on Health system which is released under the CC BY-SA 3.0.
- â 1.0 1.1 "Health care system". Liverpool-ha.org.uk. Retrieved 2011-08-06.
- â New Yorker magazine article: "Getting there from here." 26 Jan 2009
- â World Health Organization. (2000). World Health Report 2000 â Health systems: improving performance. Geneva, WHO http://www.who.int/whr/2000/en/index.html
- â Remarks by Johns Hopkins University President William Brody: "Health Care '08: What's Promised/What's Possible?" 7 Sept 2007
- â 6.0 6.1 Frenk J, The Global Health System : strengthening national health systems as the next step for global progress, Plos Medicine, January 2010, Vol 7, issue 1, 3pp., available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797599/
- â "Regional Overview of Social Health Insurance in South-East Asia, World Health Organization. And Overview of Health Care Financing". Retrieved August 18, 2006.
Navigation: Wellness - Encyclopedia - Health topics - Disease Indexââ - Drugs - Rare diseases - Gray's Anatomy - USMLE - Hospitals
Ad: Tired of being Overweight? Try W8MD's insurance physician weight loss
Philadelphia medical weight loss & NYC medical weight loss.
Contributors: Prab R. Tumpati, MD