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Glossary
Glossary

 

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The following two glossaries define some terms frequently used in discussions of health policies. The first contains words and issues directly raised in Money-Driven Medicine. Beneath it is a second list of terms which can help you follow the wider debate about reforming our healthcare delivery system.

These two glossaries have been adapted from more comprehensive lists prepared by Web MD, the Kaiser Family Foundations and Families USA.


 

GLOSSARY: MONEY-DRIVEN MEDICINE

 

  • Case management: A method for coordinating the care of people with multiple, often complex healthcare needs where a single healthcare professional is responsible for arranging, coordinating and monitoring all needed treatments and care.

  • Chronic care management: The coordination of both healthcare and supportive services to improve the health and quality of life of patients with chronic conditions, such as diabetes and asthma. These programs focus on evidence-based interventions and rely on patient education to improve patients’ skills managing their condition.

  • Cost containment: A set of strategies aimed at controlling the level or rate of growth of healthcare costs. These measures encompass a myriad of strategies focused on moving away from fee-for-service payment, eliminating waste and inefficiency, avoiding unnecessary treatments and promoting preventive care.

  • Dartmouth Studies: More than twenty-five years of scientific research conducted at the Dartmouth Institute for Health Policy and Clinical Practice and compiled in the Dartmouth Atlas of Health Care comparing how aggressively patients are treated in different parts of the country, adjusting for race, income, age and underlying health of the population. Researchers found that in some hospital patients receive far more intensive and expensive care, yet outcomes are no better and sometimes worse; patients exposed to unnecessary treatment are, by definition, exposed to risk without benefit.

  • Doctor-patient partnership: A model of healthcare delivery based on collaboration between health professionals and patients in the choice and management of treatments and care. It emphasizes fully-informed, shared decision-making as central to the doctor-patient relationship.

  • Evidence-based treatment: Treatment based on the best available medical studies, sometimes referred to as “comparative effectiveness research”, assessing the efficacy of various medical treatments, drugs and devices. A key component of many healthcare reform proposals, this research aims to improve quality of care while controlling costs. (cf. Dartmouth Studies)


  • Fee-for-service: The prevailing method of paying doctors based on reimbursement for itemized services, whereby doctors are rewarded for doing more. Bills are either paid by the patient, who then submits them to the insurance company, or are submitted by the service provider to the patient’s insurance carrier (cf. pay-for performance)

  • Health Maintenance Organization (HMO): A type of managed care health plan which provides health care to insured people through a network of providers within a defined geographic area. The providers may be employees (Kaiser Permanente, Mayo Clinic) or contractors (Blue Cross/Blue Shield) of the HMO. In theory, the HMO “gatekeeper” or primary care provider coordinates a patient’s care and determines when specialty care is warranted.

  • Medical Home: A primary care practice where a patient routinely seeks medical care and where a patient's health history is known. A medical home is a place where health care should be accessible, consistent, comprehensive, family-centered, coordinated, compassionate and culturally competent. (cf. primary care provider)

  • Pay-for-performance (P4P): A healthcare payment method linking reimbursement not to services performed but to health outcomes. Pay-for-performance uses a spectrum of results-based incentives to promote higher quality, more efficient care, instead of high volume, fee-for-service medicine. (cf. fee-for-service)

  • Preventive care: Health care which emphasizes avoidance of disease (primary prevention) and it's early detection and treatment. The focus on prevention is intended to keep people healthier longer. (cf. rescue care)

  • Primary care provider: A provider, usually a physician specializing in internal medicine, family practice or pediatrics (but also a nurse practitioner, physician’s assistant or health care clinic), who is responsible for providing primary care and coordinating other necessary health care services for patients. (cf. medical home)

  • Rescue care: Healthcare provided only once an illness has progressed to a critical stage, often initially in an emergency room and usually requiring aggressive cutting-edge medical intervention. (cf. preventive care)

  • Supply-driven demand: An anomalous economic phenomenon where supply determines demand rather than the reverse. In most areas of the economy, buyers can decide what they want to purchase. But in the healthcare market, the doctor or hospital tells the patient what he needs. Typically, the patient lacks the information and expertise to question or reject prescribed treatments. When supply drives demand, one sector of the economy can become “over-built,” while others sectors are deprived of needed investment.

  • Underinsured: People who have “Swiss Cheese” health insurance that is filled with holes, or who face high deductibles and co-pays which may affect their ability to actually use the insurance.

 

GLOSSARY: HEALTHCARE POLICY

 

  • Crowd-out: The substitution of public coverage for private coverage, on the assumption that expanding coverage to the uninsured will prompt some insured individuals to drop their existing coverage and take advantage of a public plan that may provide better care for less. While this would draw patients from private insurers, better, more affordable coverage would benefit the patient.

  • Death panel: A phrase used by critics of healthcare reform suggesting that voluntary end-of-life counseling is designed to “pull the plug on grandma." Proponents argue that such counseling is designed to give patients’ choice over the treatments they receive.

  • Deficit neutral: The requirement that any healthcare overhaul package not add to the federal deficit; in other words, increased expenditures must be matched by increased revenues or cuts in other expenditures.

  • Disparities in health: Differences in the incidence, prevalence, mortality, and burden of disease and other adverse health conditions which exist among specific population groups.

  • Disparities in healthcare – Differences between two or more population groups in health care access, coverage, and quality of care not resulting from different health needs. This can include differences in preventive, diagnostic, and treatment services between population groups.

  • Electronic health records: Computerized records of a patient’s lifelong health information which can be created and stored within one healthcare organization or shared across healthcare organizations and delivery sites.

  • Entitlement programs: Federal programs, such as Medicare and Medicaid, which entitle eligible recipients to specific benefits. Changes to eligibility criteria and benefit levels require federal legislation; in its absence, all entitlement programs must be fully funded.

  • Employee benefits exemption: Tax exemption for employees on the value of health benefits provided through an employer-sponsored plan. Some reform proposals would remove this exemption or cap it as a way to achieve deficit neutrality.

  • Health insurance exchange or connector: An insurance marketplace established and regulated by national, state or local government, where individuals and small firms can shop among health plans for coverage. These are a feature of some healthcare reform proposals and presently exist in Massachusetts and San Francisco.

  • Federal poverty level (FPL): The federal government’s working definition of poverty used as an income standard or means-test for eligibility to public programs. In calendar year 2009 the FPL for a family of four was $22,050.

  • Guaranteed access: A reform provision which would bar health insurers from rejecting applicants because of pre-existing health conditions.

  • Harry and Louise: Fictional couple used in 2009 healthcare reform in ads; in the 1990s, the two starred in TV commercials paid for by the insurance industry opposing such reform.

  • Healthcare co-ops: Small private, non-profit health organizations run in states or regions, which compete with for-profit insurance companies. Co-ops are presented as an alternative to a “public option,” though it is argued they would lack the clout to compete with private insurers.

  • Individual mandate: Requires every person to purchase health insurance or pay a penalty.  Reform plans would give subsidies to low-income and many middle-income families to insure that such coverage is affordable.

  • Malpractice reform: Many doctors would like to see malpractice awards capped, though there are other legislative means to protect doctors against unwarranted suits.

  • Medicare: Federal insurance program for people 65 and older and the disabled. It now covers about 45 million Americans. Recipients are already covered by a "public option". Some reform proposals would cut Medicare spending by excluding reimbursement for ineffective or unnecessary treatments to help achieve deficit neutrality.

  • Medicare Payment Advisory Commission (MedPAC): An independent body established by Congress to advise it on issues affecting the Medicare program. Some advocates of healthcare reform believe that similar panels should set standards for “evidence-based” treatments.

  • Medicaid: Government insurance plan for the poor and disabled now covering roughly 60 million people. Its size would be expanded under some health reform plans, though it too, could be subject to spending cuts.

  • Pay-or-play: A requirement that employers provide health insurance for their workers or pay a fee or penalty to the government. Also known as an employer mandate, it would exempt some small businesses under various reform scenarios.

  • Pre-existing conditions: Medical conditions which exist prior to a person seeking a new health insurance policy. Some insurance companies reject applicants for insurance or limit their coverage if they have pre-existing conditions. Reform plans would prohibit insurance companies from denying coverage due to health status.

  • Premium: The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government and individuals.

  • Premium Subsidies: A fixed amount of money or a designated percentage of the cost of the premium, usually means-tested, to subsidize the purchase of health coverage.

  • Public option or plan: A government run health plan, similar to Medicare, which would compete with private insurance plans in a marketplace or exchange, a major point of contention between reform supporters and opponents.
  • Rationed care: The allocation by government or another entity of scarce medical services among patients.  Opponents of reform proposals claim expensive drugs and medical treatments would be rationed under reform. Supporters say the current system already rations care based on a patient’s ability to pay for services.
  • Single payer: A universal healthcare payment system in which doctors and hospitals bill a single entity, such as the federal government, for their services. Such systems exist in Canada and the UK.

  • Social safety net: In medicine, it refers to care providers who deliver care to patients regardless of their ability to pay. These providers may be public hospital systems, community health centers, local health departments and other providers who serve a disproportionate share of uninsured and low-income patients.

  • Socialized medicine: A healthcare system where the government employs healthcare providers and owns and operates healthcare facilities. Opponents claim healthcare reform proposals would eventually lead to this type of government-run health system, though none of the current reform proposals suggests nationalizing any part of the healthcare sector.

  • Surcharge or surtax: A proposed added tax on the income of the wealthiest 1½% of all Americans to help offset the cost of universal coverage.

  • Underinsured: People who have health insurance but whose coverage leaves high out-of-pocket costs when they receive medical services.

  • Universal coverage: One goal of healthcare reform is to provide affordable, high quality healthcare for all Americans.