GLOSSARY OF COMMONLY USED HEALTH CARE TERMS AND ACRONYMS Vermont Health Care Resources 1 Health Care Terms A and dividends, as well as conducted other statistical studies. academic medical center A group of acute care Medical treatment rendered to related institutions including a teaching individuals whose illnesses or health hospital or hospitals, a medical school and problems are of short-term or episodic its affiliated faculty practice plan, and other nature. Acute care facilities are those health professional schools. hospitals that mainly serve persons with short-term health problems. access An individual’s ability to obtain appropriate health care services. Barriers to acute disease A disease characterized by a access can be financial (insufficient single episode of a relatively short duration monetary resources), geographic (distance to from which the patient returns to his/her providers), organizational (lack of available normal or pervious state of level of activity. providers) and sociological (e.g., While acute diseases are frequently discrimination, language barriers). Efforts to distinguished from chronic diseases, there is improve access often focus on no standard definition or distinction. It is providing/improving health coverage. worth noting that an acute episode of a chronic disease (for example, an episode of accident insurance A policy that provides diabetic coma in a patient with diabetes) is benefits for injury or sickness directly often treated as an acute disease. resulting from an accident. adjusted average per capita cost accreditation A process whereby a program (AAPCC) The basis for HMO or CMP of study or an institution is recognized by an (Competitive Medical Plan) reimbursement external body as meeting certain under Medicare-risk contracts. The average predetermined standards. For facilities, monthly amount received per enrollee is accreditation standards are usually defined currently calculated at 95 percent of the in terms of physical plant, governing body, average costs to deliver medical care in the administration, and medical and other staff. fee-for-service sector. Accreditation is often carried out by organizations created for the purpose of adjusted community rate (ACR) An assuring the public of the quality of the HMO’s estimate of the premium it would accredited institution or program. The State charge to Medicare beneficiaries if these or Federal governments can recognize beneficiaries were enrolled as commercial accreditation in lieu of, or as the basis for enrollees and not covered by Medicare. The licensure or other mandatory approvals. ACR is intended to gauge the Public or private payment programs often appropriateness of CMS’s (Center for require accreditation as a condition of Medicare and Medicaid Services) payment for covered services. Accreditation reimbursements to plans. If CMS’s payment may either be permanent or may be given is higher than a plan’s ACR, the plan is for a specific period of time. required by law to provide the difference to Medicare enrollees through lower premiums activities of daily living (ADL) An index or or higher benefits or to return it to the scale which measures a patient’s degree of Medicare program (see also independence in bathing, dressing, using the Medicare+Choice). toilet, eating, and moving from one place to another. administrative costs Costs the insurer incurs for utilization review, insurance actuary A person trained in the insurance marketing, medical underwriting, agents’ field who determines policy rates, reserves Vermont Health Care Resources 2 Health Care Terms commissions, premium collection, claims National Center for Health Services processing, insurer profit, quality assurance Research and Health Care Technology activities, medical libraries, and risk Assessment. AHCPR is now AHRQ management. Agency for Healthcare Research and Quality www.ahcpr.gov Administrative Services Organization (ASO) An arrangement under which an The Agency for Healthcare Research and insurance carrier or an independent Quality's (AHRQ) mission is to improve the organization will, for a fee, handle the quality, safety, efficiency, and effectiveness administration of claims, benefits and other of health care for all Americans. Information administrative functions for a self-insured from AHRQ's research helps people make group. more informed decisions and improve the quality of health care services. AHRQ was adverse selection A tendency for utilization formerly known as the Agency for Health of health services in a population group to Care Policy and Research. be higher than average. From an insurance perspective, adverse selection occurs when aggregate The maximum amount of money persons with poorer-than-average health an insurance company will pay on an status apply for, or continue, insurance insured’s policy per year, regardless of the coverage to a greater extent than do persons number of claims. with average or better health expectations. Aid to Families with Dependent Children affiliated provider A health care (AFDC) A state-based federal cash professional or facility that is part of the assistance program for low-income families. Managed Care Organization’s (MCO) In all states, AFDC recipiency may be used network and has a contractual arrangement to establish Medicaid eligibility. to provide services to the MCO’s covered members. affiliation agreement 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. Agency for Health Care Policy and Research (AHCPR) The Agency’s primary goal is to enhance the quality, appropriateness and effectiveness of health care services by conducting and sponsoring credible and timely research. It is the federal government’s focal point for health services research, AHCPR’s predecessor, the Vermont Health Care Resources 3 Health Care Terms all patient diagnosis related groups and Medicaid reimburse hospitals on the (APDRG) An enhancement of the original basis of only certain costs. Allowable costs DRGs (diagnosis related groups), designed may exclude, for example, luxury to apply to a population broader than that of accommodations, costs that are not Medicare beneficiaries, who are reasonable expenditures that are unnecessary predominately older individuals. The for the efficient delivery of health services APDRG set includes groupings for pediatric to persons covered under the program in and maternity cases as well as of services for question, or depreciation on a capital HIV- related conditions and other special expenditure that was disapproved by a cases. health-planning agency. allowable costs Charges for services alternative delivery systems A phrase used rendered or supplies furnished by a mental to describe all forms of health care delivery health professional that qualify as covered except traditional fee-for-service, private expenses. practice and inpatient hospitalization. The term may also include HMOs, PPOs, IPAs, all payer contract An arrangement and other systems of providing health care. allowing for payment of health services delivered by a contracted clinician American Association of Health Plans regardless of product type (e.g., HMO, PPO, (AAHP) The trade organization that indemnity) or revenue source (e.g., premium represents managed care organizations or self-funded) (HMOs and PPOs). all-payer system A system in which prices ambulatory care All types of health for health services and payment methods are services that are provided on an outpatient the same, regardless of who is paying. For basis, in contrast to services provided in the instance, in an all-payer system, federal or home or to persons who are inpatients. state government, a private insurer, a self- While many inpatients may be ambulatory, insured employer plan, an individual or any the term ambulatory care usually implies other payer could pay the same rates. The that the patient must travel to a location to uniform fee bars health care providers from receive services that do not require an shifting costs from one payer to another. See overnight stay. See also ambulatory setting cost shifting. and outpatient. allied health personnel Specially trained ambulatory setting A type of institutional and licensed (when necessary) health organized health setting in which health workers other than physicians, dentists, services are provided on an outpatient basis. optometrists, chiropractors, podiatrists, and Ambulatory care settings may be either nurses. The term has no constant or agreed- mobile (when the facility is capable of being upon detailed meaning; sometimes used moved to different locations) or fixed (when synonymously with paramedical personnel, the person seeking care must travel to a sometimes meaning all health workers who fixed service site). perform tasks that must otherwise be performed by a physician, and at other times amendment A formal document changing referring to health workers who do not the provisions of an insurance policy signed usually engage in independent practice. jointly by the insurance company and by the policyholder or his authorized representative allowable costs Items or elements of an See also endorsement. institution’s costs that are