Healthcare Systems and Providers
Expert-defined terms from the Certified Specialist Programme in Healthcare Actuarial course at London School of International Business. Free to read, free to share, paired with a globally recognised certification pathway.
Healthcare Systems and Providers Glossary #
Healthcare Systems and Providers Glossary
Accountable Care Organization (ACO) #
Accountable Care Organization (ACO)
An ACO is a group of healthcare providers that work together to coordinate care… #
ACOs are often paid based on the quality of care they provide rather than the quantity of services.
Acute Care #
Acute Care
Acute care refers to medical treatment provided for a brief period of time for p… #
This type of care is typically provided in hospitals or emergency rooms.
Adverse Selection #
Adverse Selection
Adverse selection occurs when individuals with higher risk profiles are more lik… #
This can lead to higher costs for the insurer and may result in higher premiums for all members of the plan.
Capitation #
Capitation
Capitation is a payment model in which healthcare providers are paid a fixed amo… #
This payment model is intended to incentivize providers to deliver cost-effective care.
Case Management #
Case Management
Case management is a collaborative process that involves assessing, planning, co… #
Case managers work to ensure that patients receive appropriate care in a timely manner.
Chronic Care Management #
Chronic Care Management
Chronic care management involves the ongoing monitoring and treatment of patient… #
This type of care is aimed at preventing complications and improving quality of life for patients.
Clinical Integration #
Clinical Integration
Clinical integration refers to the coordination of care across different healthc… #
This can involve sharing information, coordinating treatment plans, and aligning incentives.
Community Health Center #
Community Health Center
Community health centers are non #
profit healthcare facilities that provide primary care services to underserved populations, regardless of their ability to pay. These centers play a critical role in improving access to care and addressing health disparities.
Coordinated Care #
Coordinated Care
Coordinated care involves the organization and delivery of healthcare services i… #
This approach is designed to improve patient outcomes and reduce costs.
Credentialing #
Credentialing
Credentialing is the process of verifying the qualifications and experience of h… #
This process may involve verifying education, training, licensure, and professional references.
DRGs are a system used to classify inpatient hospital stays into groups based on… #
This classification is used to determine the payment rate for each case.
Electronic Health Record (EHR) #
Electronic Health Record (EHR)
An EHR is a digital version of a patient's paper chart that contains information… #
EHRs are designed to improve communication and coordination among healthcare providers.
Evidence #
Based Medicine
Evidence #
based medicine involves using the best available research evidence to inform clinical decision-making and improve patient outcomes. This approach relies on scientific studies, clinical guidelines, and expert consensus to guide treatment choices.
Fee #
for-Service
Fee #
for-service is a payment model in which healthcare providers are reimbursed based on the number of services they deliver. This model can incentivize providers to deliver more services, regardless of the patient's outcomes.
Health Maintenance Organization (HMO) #
Health Maintenance Organization (HMO)
An HMO is a type of health insurance plan that requires members to choose a prim… #
HMOs typically have a network of providers who agree to provide services at a discounted rate.
Health Risk Assessment #
Health Risk Assessment
A health risk assessment is a tool used to evaluate an individual's health statu… #
This assessment can help identify areas for intervention and guide preventive care efforts.
Home Health Care #
Home Health Care
Home health care involves the provision of medical services, such as nursing car… #
This type of care is often used for individuals who are recovering from illness or surgery.
Hospitalist #
Hospitalist
A hospitalist is a physician who specializes in caring for patients while they a… #
Hospitalists work closely with other members of the healthcare team to coordinate treatment and ensure continuity of care.
Long #
Term Care
Long #
term care refers to a range of services designed to support individuals who have chronic illnesses, disabilities, or other conditions that require ongoing assistance. This care can be provided in a variety of settings, including nursing homes and assisted living facilities.
Managed Care #
Managed Care
Managed care is a healthcare delivery system that aims to control costs and impr… #
This system often involves insurance plans that require members to use a network of providers and obtain referrals for specialty care.
Medical Home #
Medical Home
A medical home is a primary care practice that provides comprehensive, coordinat… #
This model emphasizes preventive services, care coordination, and shared decision-making between patients and providers.
Medically Necessary #
Medically Necessary
Medically necessary refers to healthcare services that are required to diagnose… #
These services must be appropriate, effective, and consistent with the standards of medical practice.
Medicare Advantage #
Medicare Advantage
Medicare Advantage is a type of Medicare plan offered by private insurance compa… #
These plans often include additional benefits, such as prescription drug coverage.
Patient #
Centered Care
Patient #
centered care is an approach to healthcare that prioritizes the needs and preferences of the patient. This model emphasizes communication, shared decision-making, and collaboration between patients and providers.
Pay for Performance #
Pay for Performance
Pay for performance is a reimbursement model that ties provider payments to qual… #
This model is intended to incentivize providers to deliver high-quality care and achieve better patient outcomes.
Population Health Management #
Population Health Management
Population health management involves the systematic analysis and management of… #
This approach focuses on improving the health of the entire population and reducing disparities in care.
Preferred Provider Organization (PPO) #
Preferred Provider Organization (PPO)
A PPO is a type of health insurance plan that allows members to see any healthca… #
PPOs do not require members to obtain referrals to see specialists.
Quality Improvement #
Quality Improvement
Quality improvement involves the systematic process of identifying, analyzing, a… #
This process often involves measuring performance metrics, identifying areas for improvement, and implementing evidence-based practices.
Readmission Rate #
Readmission Rate
The readmission rate is the percentage of patients who are readmitted to the hos… #
High readmission rates can indicate problems with care transitions, follow-up care, or care quality.
Risk Adjustment #
Risk Adjustment
Risk adjustment is a method used to account for differences in the health status… #
This process helps ensure that providers are fairly compensated for caring for patients with complex medical needs.
Telemedicine #
Telemedicine
Telemedicine is the remote delivery of healthcare services using technology, suc… #
This approach allows patients to access care from a distance and can improve access to specialists and reduce costs.
Utilization Review #
Utilization Review
Utilization review is the process of evaluating the appropriateness and necessit… #
This process helps ensure that care is delivered efficiently and that resources are used effectively.
Value #
Based Care
Value #
based care is a healthcare delivery model that focuses on improving patient outcomes and reducing costs by rewarding providers for delivering high-quality, cost-effective care. This model emphasizes preventive services, care coordination, and patient engagement.
Wellness Program #
Wellness Program
A wellness program is a set of activities and initiatives designed to promote he… #
These programs often include health screenings, education, incentives, and support for lifestyle changes.
Wraparound Services #
Wraparound Services
Wraparound services are additional support services, such as transportation, hou… #
These services are designed to address the underlying factors that can impact health and wellbeing.