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Nursing 102


Access The ability of an individual to receive healthcare services when needed
What is the primary means for ensuring health care access? Health insurance
Capitation Payment mechanism in which all healthcare services are included under one set fee per covered individual. It is generally paid per month (PMPM).
Demand The quantity of health care demanded by consumers based solely on the price of those services
An enrollee An individual enrolled in a health plan and therefore entitled to receive health services the plan provides.
A free market characterized by the unencumbered operation of the forces of supply and demand when numerous buyers and sellers freely interact in a competitive market.
Gatekeepers are managed care general practitioners or primary care providers who typically manage routine services and determines appropriate referrals for higher-level or specialty services
Global budgets used to control costs in centrally managed systems. System-wide health care expenditures are budgeted.
Health Care Delivery and Health Services Delivery both terms refer to the major components of the system and the processes that enable people to receive health care.
Health plan contractual arrangement between the MCO and the enrollee-including the collective array of covered health services that the enrollee is entitled to. -uses selected providers
Integrated Delivery network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and that is willing to be held clinically
Item-based pricing the costs of ancillary services that often accompany major procedures such as surgery.
Managed care seeks to "manage" the utilization of medical services, the price at which these services are purchased, and consequently how much the providers get paid. -Most dominant health care delivery system in US
Market Justice places the fair distribution of health care on the market forces in a free economy. -Medical care and its benefits are distributed on the basis of people’s willingness and ability to pay.
Medicaid the government insurance program for the indigent. Medicare is the government insurance program for the elderly and certain disabled individuals.
Military Medical Care System a well-organized, highly integrated system that is comprehensive and covers preventive as well as treatment services to active duty military personnel of the US Army, Navy, Air Force, Coast Guard, and certain uniformed nonmilitary services.
Moral hazard the term used to explain the increased utilization of health care ser vices when people have health insurance coverage.
National health insurance (NHI) is a tax-supported health plan that ensures universal access. -Services are financed by the government but are rendered by private providers.
National health system (NHS) a tax-supported health plan that ensures universal access, but in this case the government also controls the service infrastructure.
Need for a health service (in contrast to demand for health services) -based on individual judgment. -patient makes the primary determination of the need for health care
Primary care is basic and routine care delivered by a general practitioner. In a managed care system, the primary care physician also makes the determination for the need for higher-level services.
A provider can be an individual health care professional, a group, or an institution that delivers health care services and receives reimbursement directly for those services. -someone who can be billed for reimbursement
The quad-function model the key functions of financing, insurance, delivery, and payment.
Created by: JadeaGuldan