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Vocabulary

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Question
Answer
Access   The ability of an individual to receive healthcare services when needed  
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What is the primary means for ensuring health care access?   Health insurance  
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Capitation   Payment mechanism in which all healthcare services are included under one set fee per covered individual. It is generally paid per month (PMPM).  
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Demand   The quantity of health care demanded by consumers based solely on the price of those services  
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An enrollee   An individual enrolled in a health plan and therefore entitled to receive health services the plan provides.  
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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.  
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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  
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Global budgets   used to control costs in centrally managed systems. System-wide health care expenditures are budgeted.  
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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.  
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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  
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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  
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Item-based pricing   the costs of ancillary services that often accompany major procedures such as surgery.  
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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  
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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.  
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Medicaid   the government insurance program for the indigent. Medicare is the government insurance program for the elderly and certain disabled individuals.  
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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.  
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Moral hazard   the term used to explain the increased utilization of health care ser vices when people have health insurance coverage.  
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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.  
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National health system (NHS)   a tax-supported health plan that ensures universal access, but in this case the government also controls the service infrastructure.  
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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  
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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.  
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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  
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The quad-function model   the key functions of financing, insurance, delivery, and payment.  
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