GLOSSARY OF MANAGED CARE TERMS

MANAGED CARE ISSUES FOR THE GASTROENTEROLOGIST 0889-8553/97 $0.00 + .20

GLOSSARY OF MANAGED CARE TERMS

James T. Frakes, MD, MS

Access An individual’s ability to obtain quality medical services on a timely, financially, geographically, and culturally acceptable basis. Accrual A method for anticipating medical expenses for an enrolled population over a period of time to allow setting aside of funds in a reserve to be used for medical expenses incurred during that period. Actuarial Assumptions based on probabilities; used in predicting utilization, costs, and revenues for a defined population. Actuary A person trained and accredited in insurance mathematics who calcu- lates dividends, rates, reserves, and other valuations and makes statistical stud- ies and reports. Adjusted Average Per Capita Cost (AAPCC) The cost of care for Medicare beneficiaries in a given geographic area as estimated by the Health Care Financ- ing Administration. Adjusted Community Rate (ACR) The premium charged by a managed care organization for providing Medicare-covered benefits to a group adjusted for expected increased utilization by Medicare beneficiaries. Administrative Loading The amount added to the predicted actuarial cost of health care services for expenses of administration, marketing, and profit. This is usually no greater than 15% of the total premium. Administrative Services Only (ASO) Administrative services provided by a third-party insurance company or its subsidiary to a self-funded plan. These services typically include claims processing, actuarial analysis, utilization review, data reporting, stop loss coverage, and benefit plan design. The third party does not assume any risks. Admissions/1000 The number of hospital admissions per 1000 plan enrollees.

From the Department of Medicine, University of Illinois College of Medicine at Rockford; and Rockford Gastroenterology Associates, Ltd., Rockford, Illinois

GASTROENTEROLOGY CLINICS OF NORTH AMERICA

VOLUME 26 NUMBER 4 DECEMBER 1997 923

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This is the usual benchmark for judging provider performance in relation to hospital risk pools. Adverse Selection The enrollment of a disproportionate percentage of persons who are more likely to file claims and use services because of higher health risk conditions or a propensity to use services. AgelSex Rating A method of structuring payment based on the average demo- graphic risk of anticipated medical claims related to age and sex of the membership. All Payer System A plan of financing health care that assigns uniform fees for all medical services regardless of who pays for the service. Alternative Delivery System (ADS) A system using methods other than traditional indemnity methods for providing health care benefits. Ambulatory Patient Groupings (APGs) A payment mechanism for outpatient services based on ambulatory patient case types; similar to diagnosis related groups. Anniversary The beginning of a subscriber group’s benefit year. Any Willing Provider (AWP) Legislation requiring a managed care organization (MCO) to accept any provider who meets the organization’s usual selection criteria, is willing to accept reimbursement at the MCOs rates, and agrees to the MCOs utilization guidelines. Assignment The process of payment of medical benefits directly to the provider rather than to the member of the health plan. This may occur either through patient request or by contract between the health plan and the provider. Attrition Rate The percentage of a health plan’s total membership leaving a program in a given time period. Average Length of Stay (ALOS) The average number of inpatient hospital days per admission calculated by dividing total patient days by the number of admissions during that time period. It may also be referred to as length of stay or estimated length of stay. Average Payment Rate (APR) The amount of money the government could pay a managed care organization for services to Medicare beneficiaries under a risk contract. Balance Billing A process whereby a patient is billed for the difference between charges and the amount of payment covered by the insurance plan. Basic Health Services Benefits that all federally qualified health maintenance organizations must offer under federal regulations. Benchmarking/Profiling The comparison of one physician’s performance with that of other physicians. Also describes best practices in an industry that lead to superior performance. Benefit Year A 12-month period for administration of a group‘s fringe benefits program. May be a calendar year, fiscal year, or any other designated 12- month period. Benefits Package A collection of specific services or benefits that a managed care organization is required to provide under terms of its contracts with subscriber groups. Bonus Pool Money set aside for later distribution to providers for meeting certain performance standards. Break-Even Point Health maintenance organization membership level at which revenues and costs are equal. Broker One who undertakes insurance business with more than one company and who has no exclusive contract with any one single company.

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Bundling The establishment of a package price or global fee for all services required for a specific procedure (e.g., both professional and facility services). Business Coalition A collaborative effort by several employers in a community to purchase employee health care at a lower cost. Capital Money available for investment or purchase of capital goods. Capital Expenditure Review A review of proposed capital expenditures of hospitals or other facilities by a regulatory agency; designed to discourage unneeded expenditures. Capitation A method of payment for health care services in which the provider accepts a fixed amount of payment for a specific menu of health services per subscriber over a set period of time; usually described in units of per member per month. Carrier The insurer in the group contract who agrees to underwrite (carry the risk) and provide certain types of coverage and service. In Medicare terms, this is the private organization that administers the Part B program at the local level. Carve-Out Services contracted to an exclusive independent provider by a managed care plan. These are accounted for separately by the managed care organization. Case Management Coordination of patient care to ensure appropriate cost- effective service. Such management is usually undertaken by a physician, nurse, or other designated professional to ensure continuity of services and access and to prevent overutilization or underutilization. Case Mix The clinical composition of a hospital's inpatient population among various diagnoses; used as a factor in determining cost of service and rate set-

Cash Indemnity Benefits Amounts paid to insureds for covered services and requiring submission of a filed claim. Such benefits may be assigned directly to providers of services. Catastrophic Health Insurance Insurance for severe and prolonged illness beyond basic and major medical insurance. Catchment Area The geographic area from which a health plan draws its patients. Census A listing of enrollees by age, sex, and number of dependents. Certificate of Need (CON) A document issued by a government body verifying that a new or modified facility or service is essential and will meet the needs of those for whom it is intended. CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) The federal health plan for families of military personnel, military retirees, and certain spouses and dependents of such personnel. Channeling The process by which a managed care organization uses patient financial responsibility (deductibles and copayments) to direct patients to physicians under contract in its system. Cherry Picking An insurance plan practice of enrolling only healthy individuals while not accepting persons who are poor risks. Churning A practice of seeing a patient more than is medically necessary to increase revenue through increasing services. Claim A request by an insured person for the benefits provided under a group contract. Claim Lag The time interval between the date of service and its submission to the insurer for payment. Also sometimes used to indicate the time between the date of service and the date of payment.

ting.

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Clinic A group practice or medical office where several physicians work cooperatively. Clinic Without Walls (CWOW) A group practice that operates from multiple sites. Practices are usually linked economically and share a common administration. The physicians in such practices retain independence by maintaining private offices and practice styles and by not merging assets. Clinical Data Repository (CDR) A database containing all clinical, demo- graphic, and financial data for a patient population. Closed Access A situation wherein persons covered under a health plan are required to choose a primary care physician from a limited list of providers and are not permitted self-referral for specialty care. Closed Panel System A health care plan that contracts with physicians on an exclusive basis and that allows members to use only physicians in that group for their medical care. In addition, those physicians may not be able to see patients from other managed care plans. A staff model health maintenance organization is an example of a closed panel system, whereas a preferred provider organization is an open panel system. Coinsurance The portion of the cost for care received for which an individual is financially responsible. That portion of risk borne by the insured; differs from deductible in that coinsurance provides first dollar coverage. Community Rating A method for determining health insurance premiums without respect to individual characteristics or utilization. The method looks at actual or anticipated costs in a specific geographic area based on the expected utilization by the population as a whole rather than individual characteristics of the insureds. This prohibits charging a higher premium to a group at higher risk for utilization. Competitive Medical Plan (CMP) The type of managed care organization created by law to facilitate the enrollment of Medicare beneficiaries into managed care plans. These plans are similar to health maintenance organizations but not bound by all of the regulatory requirements. Composite Rate A weighted average premium applicable to all members of a subscriber group regardless of number of claimed dependents. Computer-Based Patient Record (CPR) An electronic representation of a patient’s clinical data, including entries for laboratory and imaging investiga- tions, progress notes, and correspondence. An electronic patient chart. Concurrent Review Review of medical services conducted concurrently with the delivery of services, usually by a health care professional other than the one providing the care. Consolidated Omnibus Reconciliation Act (COBRA) An act of Congress allowing terminated employees to purchase continuing insurance coverage under the employer’s group medical plan for a period of time after termination. Continuous Quality Improvement (CQI) A quality-control system used to monitor patient care. Also sometimes referred to as total quality management. Contract Size The number of patients or enrollees per contract. Contractual Allowance The difference between what a health care provider bills and what is received from third-party payers. Contractual allowances are usually shortfalls and often the result of participation in a government program that pays less than usual charges or a negotiated discount or other contract arrangement with a private payer. Conversion Privilege The right to convert from a group health policy to an individual policy in the event of an individual’s leaving the group.


Coordination of Benefits (COB) An insurance provision that prevents duplicate payment for services by more than one source. Copayment An amount of money paid by the patient at the time that selected services are rendered. This serves to shift some financial burden to the patient and discourages overutilization Cost-Based Reimbursement A method of paying hospitals for actual costs incurred by patients. CostrSenefit Analysis An analytic technique that compares costs of a project to the resultant benefits. Both costs and benefits are usually expressed in monetary terms. Contrast with a cost-effective analysis, in which the cost is measured in monetary terms but the outcome in other terms, such as lives saved or quality- adjusted years gained. Cost Center A unit in a business or organization that spends money. Cost-Effective The allocation of resources to achieve maximal outcome at minimal cost. Cost Sharing A policy of requiring partial payment by patients for services rendered; includes coinsurance, copayment, and deductibles. Cost Shifting The practice of assessing higher charges to one consumer to compensate for costs not paid by another. Covered Lives The total patient base in a capitated system. Credentialing The process of obtaining, reviewing, and verifying a practitioner’s credentials for the purpose of granting clinical privileges. Includes training, experience, certification, and abilities. Current Procedural Terminology (CPT) A standardized set of codes prepared by the American Medical Association to describe medical services delivered. Customary, Prevailing, and Reasonable (CPR) A fee based on past rates and what other physicians in the area charge. Data Warehouses (DW) Specialized tabular databases, created by filtering clinical or other data repositories using a process known as data scrubbing. Analytical processing or data mining of data warehouses can highlight trends in the data sources and repositories from which they are created. Days per Thousand A measure of utilization of hospital days annually for each 1000 covered lives. Decision Support System (DSS) A suite of applications and supporting infra- structure that assists caregivers in clinical decision making, while acquiring sufficient data to support clinical practice assessment. Deductible The part of an individual’s health care expenses that the patient must pay out of pocket before any insurance coverage applies. Demographics The statistical characteristics of a defined population, such as age, sex, income level, race, education, housing, and employment. Deselection Termination of a physician’s contract or status with a managed care organization. Diagnosis Related Groups (DRGs) A classification system for all inpatient hospital admissions dividing patients into discrete groups for the payment of a fixed rate reimbursement by Medicare. Differentiated Oligopoly A market situation dominated by a small number of interdependent firms whose products are not identical but are relatively close substitutes. Typically these firms attempt to gain market share by increasing the real or perceived differences between their products and competing products of other firms. Direct Contract Model A managed care organization that contracts directly

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with physicians rather than through an intermediary such as an independent practice association or medical group. Direct Contracting Direct contracts between individual employers or business coalitions and providers of health care services with no intermediary. Discounted Fee for Service Payment for physician services on a fee-for-service basis but at a negotiated discount from usual fees; commonly used by preferred provider plans. Disenrollment Termination of a member’s coverage. Drug Formulary A list of medications covered by a plan. Dual Choice A health benefit offered by an employment group permitting voluntary choice of health plans, usually including a health maintenance organization. Due Diligence A level of prudence expected from a reasonable person. Due Process A managed care provision under law that imposes certain fairness requirements related to provider selection, participation, and termination from health plans. Durable Medical Equipment (DME) Nondisposable medical equipment related to the care of a medical condition. Economic Credentialing Data regarding an individual physician’s cost efficiency; can be used by health plans to decide which physicians to add to or delete from their staffs. Economies of Scale Benefits of efficiency and cost savings that result from mass production or the expansion of production to reduce per-unit costs. Elective Medical procedures not immediately necessary to maintain life or health and that usually can be scheduled weeks or months in advance. Patient status with regard to receiving medical services as covered benefits. Emerging Health Care Organizations (EHO) Hospitals, providers, or payers that are merging, integrating, or affiliating in response to pressures from the health care environment. Employee Retirement Income Security Act of 1994 (ERISA) A federal law permitting self-funded employer or union plans to avoid paying premium taxes, complying with state-mandated benefits, or otherwise complying with state laws and regulations regarding insurance even when insurance companies and managed care plans that are at risk for medical costs must do so. ERISA sets federal requirements for pension and employee benefit plans including employer health plans. It addresses plan design issues and discrimination within a benefit plan. Employer Mandate A law requiring an employer to provide health coverage or pay a share of an employee’s health insurance. Encounter One face-to-face visit to a provider by a covered person during which services are rendered. Encounters Per Member Per Year The number of annual physician encounters for each health maintenance organization member. Endorsement An official change in the provisions of coverage issued by the insurer and attached to the policy or certificate. Enrollee Anyone enrolled in a health plan and entitled to receive benefits; also called a member. Evergreen Clause A clause in managed care contracts that results in automatic renewal after the initial term has been completed. Exclusive Provider Organization (EPO) A health care plan that combines the features of a health maintenance organization (enrolled population, limited provider panel, gatekeepers, utilization review) and preferred provider organi-


zation (flexible benefit design, negotiated fees, fee for service). Employers agree not to contract with providers outside the network, and subscribers cannot leave the network unless they pay out of pocket. Experience Rating A method of determining health maintenance organization (HMO) or insurance premiums based on the average cost of actual or anticipated utilization by individual subscriber groups. Premiums take into account age, sex, health status, and utilization experience. Federal HMO qualification requirements do not allow this rating method. This is the most prevalent method of setting premiums outside the HMO setting. Explanation of Benefits (EOB) An explanation provided to a member ex- plaining how and why a claim was paid or denied and informing that person of rights of appeal. Faculty Practice Plan A group practice organized around a medical school wherein the faculty provides patient care as part of the teaching and research responsibilities of the medical school. The plan is responsible for billing and collections as well as contract negotiations and redistribution of income. Federal Employee Health Benefits (FEHB) A program of health benefits for federal employees administered through the U.S. Office of Personnel Manage- ment. Federally Qualified Health Maintenance Organizations: Health maintenance organizations that meet certain stipulated provisions under the Health Mainte- nance Organization Act of 1973, which mandated a broad range of basic health services, assurances of financial solvency, and monitoring of the quality of care. Health maintenance organizations that comply with these regulatory requirements are eligible to receive federal grants and loans. The qualification process is administered by the Health Care Financing Administration. Fee for Service (FFS) A system of payment for health care services wherein the patient is charged a fee for each service or procedure provided and billed at the time of service. The aggregate bill varies by the number of services and procedures provided. Fee Schedule A comprehensive list of maximal fees used to reimburse a provider on a fee-for-service basis. First Dollar Coverage An insurance policy that has no deductibles and covers the first dollar of a member’s expenses. Formulary A list of drugs from which a physician is requested or required to prescribe, unless there is a valid medical reason to use an unlisted drug. For-Profit An organization that exists for the purpose of receiving a return on its investment. Foundation A nonprofit corporation established to acquire the assets of a medical group and then contract for physician services. The foundation provides management and employs the nonphysician staff. The medical group remains self-governing and retains physician autonomy. Freedom of Choice (FOC) Laws requiring health plans to allow members access to nonparticipating providers. Gatekeeper A physician, usually a primary care physician, who serves as the patient’s initial contact for medical care, who supervises all aspects of that care, and who must authorize care from all other providers except in emergencies. Sometimes called a care manager. Generic Substitution Substituting a generic version of a branded, off-patent pharmaceutical for the brand name product when the latter is prescribed. Global Capitation The total amount of money provided to cover the full range

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of cost under a managed care plan, including primary and specialty physician services as well as hospital and ancillary services. Global Fees A fixed payment for all services required for a defined procedure or episode of care that does not vary with the acuity, severity of illness, or amount of services provided. Group Contract An agreement between a managed care company and a subscribing group specifying payment rates, performance covenants, relation- ships among parties, schedule of benefits, and other conditions whose term is generally limited to a 12-month period and may be renewed. Group Model Health Maintenance Organization (HMO) A managed care plan that contracts with a medical group for the provision of health care services on a prepaid, capitated basis. There are two types of group model HMOs. The first is called a closed panel group model, in which services are delivered in an HMO-owned health center or satellite clinic by physicians belonging to a spe- cially formed but legally separate medical group serving only the HMO. The second type of group model is that of the HMO contracting with an existing independent group of physicians to deliver care at the group’s clinic facilities. The group may contract with more than one HMO, in contrast to the closed panel setting, in which the medical group serves only the HMO. Group Practice Three or more physicians who deliver patient care, share equipment and personnel, and divide income by a prearranged formula. Group Practice Without Walls (GPWW) A network of physicians who have formed a single legal entity but maintain individual practices, with central management providing administrative support. Health Alliance A purchasing entity designed to negotiate with managed care plans and insurance companies to obtain the best benefits at the most reasonable price for its members, usually small to medium-sized businesses. Health Care Financing Administration (HCFA) A regulatory agency under the U.S. Department of Health and Human Services that is responsible for the Medicare and Medicaid programs. Health Care Plan A financial arrangement or organization that provides for the delivery or payment of health care services. Examples include traditional indemnity insurance plans, health maintenance organizations, employer self- insurance plans, preferred provider organizations, government sponsored plans, and others. Health Insurance Purchasing Corporation (HIPC) An entity that acts as a purchasing agent for health insurance for large groups of people. An important feature of managed competition. Health Maintenance Organization (HMO) A prepaid health plan in which providers are paid a fixed fee to treat patients covered by the plan. HMOs may employ physicians as salaried staff members or contract with a specific physician group (a closed panel) or with any physician in a community who can meet the conditions for participation (an open panel). The HMO may be organized as a group model, an independent practice association model, a network model, or a staff model. Health Maintenance Organization Regulatory Agency A state agency, usually under the Department of Insurance, empowered to regulate health maintenance organizations. Health Plan Employer Data and Information Set (HEDIS) A standardized method for collecting information and rating quality of care from managed care plans. It includes 60 measures and covers quality, utilization, enrollee access and satisfaction, and finances.


Health Professions Shortage Areas (HPSAs) Areas designated by the federal government as having shortages of health care providers. Hold Harmless Clause (Indemnification) A clause frequently found in managed care contracts stating that the health maintenance organization and the physician hold each other to be not liable for malpractice or corporate malfea- sance if either of the other parties is found to be liable. It may also refer to a clause that prohibits providers from billing patients if the insurance company becomes insolvent. Horizontal Integration The combining of providers who provide similar or competitive services that typically would be provided during the same stage of care. Incentives In the medical care setting, this term refers to economic incentives for providers to motivate efficiency in patient care management. Incurred But Not Reported (IBNR) An amount of money held in reserve for payment of medical expenses incurred or for which the plan or provider is responsible but has not yet been billed. Indemnify To make good a loss. Indemnity Insurance Insurance that typically covers the beneficiary by reimbursement after the fact for medical expenses. Payments are made to the beneficiary or directly to providers for a financial loss incurred by the beneficiary. The indemnity is a benefit paid by an insurance policy for an incurred loss. Independent Physician Organization (IPO) A physician-initiated and physician-controlled entity through which physicians can offer services and products to managed care systems. Independent Practice Association (IPA) A managed care delivery model in which the entity holds managed care contracts to provide services. The IPA, in turn, contracts with the individual physicians to provide care on a fee-for- service or capitation basis. This type of system combines prepayment with the traditional means of delivering health care. Integrated Delivery System (IDS) A single provider organization or group of provider organizations that offer comprehensive medical services to its members. This system consolidates groups of providers and focuses on continuous coordinated organization, delivery, and management of care. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM) The numerical classification of disease by diagnosis. Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) A private not-for-profit organization that performs accreditation reviews on hospitals, other institutional facilities, and outpatient facilities. Length of Stay (LOS) The total number of days for which a patient is hospital- ized. Lock-In An expression referring to a condition whereby the medical care of a member is not covered by the health maintenance organization (HMO) unless it is rendered by an HMO physician or physician/institution otherwise authorized by the HMO. Loss Ratio The ratio between costs incurred for health care services and revenues received from premiums. Managed Care A system of health care delivery, provided by contracted providers, in which those responsible for financing the cost of care exert influ- ence on the clinical decision making of those who provide the care. This is done in an attempt to provide health care that is cost-effective, accessible, and of high quality. Common features include a limited number of contracted providers, channeling of patients to contracted providers through limitations of benefits to

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insureds who use noncontracted providers, and some system of utilization management and quality assurance. Managed care is actually a spectrum of health care delivery systems ranging from managed indemnity insurance through preferred provider organizations, point of service plans, and various types of health maintenance organizations. All managed care systems attempt, to a greater or lesser extent, to shift financial risk to the providers of care. Managed Care Information Systems (MCIS) A generic term referring to applications and application suites that address various requirements of managed care organizations, such as management of referrals, eligibility, benefits, claims, and contracts. Managed Care Organization (MCO) A general term applied to a managed care plan. This term includes all forms of organizations that provide managed care, e.g., health maintenance organizations, preferred provider organizations, competitive medical plans, and exclusive provider organizations. These plans usually integrate the financing and delivery of health care services to an enrolled population. Managed Competition A plan for health care reform that would combine limited government regulation with free market forces to reduce costs and increase access to care. Consumers and businesses would form large groups to buy health care from organized networks of physicians and hospitals that would compete to attract patients by offering the best quality at the lowest price. Management Information System (MIS) A computerized tool used for analysis and reporting of important data so that timely, informed decisions can be made. Management Services Organization (MSO) A business entity that provides practice management services to a hospital, physician, or physician-hospital organization through a direct contract, an affiliation agreement, or indirectly through a subsidiary arrangement. The MSO markets the group to managed care plans, but physicians themselves hold the contracts and provide the care. Mandated Benefits Benefits that a health plan is required to provide by law. Marginal Cost The cost of produaing an additional unit of product or increasing the quantity of services being provided. Marginal cost is a key consideration in pricing and is a useful method of calculating cost implications of business expansion or contraction. Market-Driven Health Reform Structural changes in the health care system, both in terms of financing and delivery of services, that originate in the private sector. Market Share That part of the potential market that a managed care company has captured; usually expressed as a percentage of the market potential. Maximum Allowable Charge The amount set by an insurance company as the highest amount that can be charged for a particular medical service. Medical Cost Ratio (MCR) A comparison of the cost of providing a service to the amount paid for the service. Medical Director The physician responsible for bridging health care delivery to management and administration and whose major responsibilities include maintaining a provider network, utilization review, and quality assurance. Medical Individual Retirement Account (IRA) A variation of the individual retirement account that would establish a tax-deferred savings account for an individual to cover the cost of health care services. Medical Loss Ratio The cost of care provided as a percentage of premium revenues or the total cost of medical services as a percentage of premium revenues. Medical Savings Account (MSA) Individual personal savings account depos-


ited to cover medical expenses. Usually would be combined with high-deductible catastrophic coverage. Individuals would be responsible for the full amount of personal health care costs up to the deductible, and the MSA would be used to pay for this care. Any funds in an MSA at the end of the year could be withdrawn or carried forward, thus providing an incentive to choose health care services carefully. Medically Necessary Those covered services required to preserve and maintain the health status of a member or eligible person based on the community standards of medical practice. Medicare Risk Contract A contract between a managed care plan and the Health Care Financing Administration to provide services to Medicare beneficiaries for a fixed monthly payment and that requires all services to be provided on an at-risk basis. Medicare Supplement Voluntary private insurance purchased by Medicare enrollees to cover the cost of services not covered by Medicare. Member Anyone enrolled in a health plan who is entitled to receive covered benefits. Member Month A unit of volume measurement equal to one member enrolled in a health maintenance organization for 1 month whether or not the member actually receives any services during the period. Mid-Level Practitioner (MLP) Nonphysicians who deliver medical care generally under the supervision of a physician but at less cost. Examples include physician assistants, clinical nurse-practitioners, and nurse-midwives. Mixed Model A managed care plan that mixes two or more types of delivery systems, such as a health maintenance organization that has both closed panel and open panel delivery systems. Monopsiny A mirror image of monopoly in which the market is dominated by a single buyer or a group of buyers acting in concert. Morbidity Rate Actuarial term showing likelihood of medical expenses occurring. Mortality Rate Actuarial term for the expected number of deaths per population. Most Favored Nation Clause A contractual provision in which the physician must automatically offer a managed care organization the lowest fee the provider offers anyone else. Multispecialty Group A group of physicians who represent various medical specialties and who work together in a group practice. National Committee on Quality Assurance (NCQA) A not-for-profit organization performing accreditation review of managed care plans. National Practitioner Data Bank (NPDB) A national central clearing house for malpractice actions taken against providers. Created in 1986, this data bank also maintains records of any actions concerning competence or conduct, such as suspensions, censures, and license revocations. Requests for reports from the NPDB are required when a physician applies for staff privileges. Network Model An organizational form in which a health plan contracts with more than one physician group to deliver health care to members. The network is generally limited to large single or multispecialty groups and is distinguished from group model plans that contract with a single medical group, independent practice associations that contract through an intermediary, and direct contract model plans that contract with individual physicians in the community. Nonprice Competition Competition between two products or services based on factors other than price, such as quality, name brand, or convenience.

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Not-for-Profit Organization An organization that exists at a level at which marginal costs exactly equal marginal revenue. Such an organization may be tax exempt for some purposes. Office of Personnel Management (OPM) Headquartered in Washington, D.C., this agency administers and directs the Federal Employee Health Benefits Plan and is the contracting source for health maintenance organizations wishing to become Federal Employee Health Benefits Plan carriers. Office of Health Maintenance Organizations (OHMO) Headquartered in Rock- ville, Maryland, a component of the U.S. Department of Health and Human Services charged with directing the federal health maintenance organization program. Omnibus Reconciliation Act (OBRA) The inclusive term used by Congress for the many annual tax and budget reconciliation acts. Most contain language important to managed care, generally in the Medicare market segment. Open Access A self-referral arrangement allowing members to see participating providers for specialty care without a referral from another physician. Open-Ended Health Maintenance Organization (HMO) Enrollees are allowed to receive services outside the HMO provider network without referral authorization but are usually required to pay an additional copay or deductible (or both). Open Enrollment The time period during which persons can select one of several health plans offered by their employer. Also, the period referred to in the Federal Qualification Regulations during which a federally qualified health maintenance organization must make its coverage available without restrictions to individual subscribers who wish to enroll. Open Panel A managed care plan that contracts with private physicians to deliver care in their individual offices. Examples include a direct contract health maintenance organization and an independent practice association. Opportunity Cost The cost of having foregone what might have been; the price of lost opportunities used in the context of allocation of resources. Organized Delivery System (ODS) A network of providers and payers who provide care and compete with other systems for enrollees in a geographic region. Out-of-Area Benefits The coverage allowed health maintenance organization members for emergency situations occurring outside of the prescribed geographic area of the health maintenance organization. Out-of-Area Care Care received by an health maintenance organization's (HMOs) enrollees when they are outside the HMOs geographic territory. Ser- vices received are usually not prearranged by the HMO and are usually not covered unless a delay would adversely affect the individual's health status. Out-of-Pocket Limit The total payments for covered medical services for which a covered person is responsible. When the limit is reached, all of covered health services received during the remainder of that calendar year will be covered. Outcome The qualitative or quantitative result of medical treatment. Outcome Audit A type of patient/medical care evaluation study that focuses on the desired patient outcome rather than the discrete components of appropriate clinical intervention. Outcome Management A system that encourages physicians to follow a set of guidelines that research has shown to be the best way to treat a medical ailment. Outcomes Measurement Formal process for measuring the effectiveness of medical treatment and patient satisfaction with treatment results. Outcomes Research The attempt to determine which medical treatments get


the best results. The goal is to standardize care and insure predictable desired outcomes in patients’ health. Outliers Patients who vary significantly from other patients in the same disease category (such as a longer or shorter length of stay, death, leaving against medical advice). Outpatient A patient who receives medical care services that do not require being admitted for an overnight stay. Outside Referral Referral to a provider not on the managed care plan staff or not within the group contracting to deliver medical services. Participating Provider A physician or other health care provider who is contracted with a plan to provide services to its members. For Medicare, this refers to a physician who has signed a calendar year agreement to accept Medicare assignment for all Medicare enrollees. Patient Panel The population of subscribers assigned to a provider. Peer Review Evaluation of a physician’s performance by other physicians, usually within the same geographic area and medical specialty. Peer Review Organization (PRO) An organization charged with reviewing quality and cost for Medicare. Generally operates at the state level. Penetration The percentage of business that a health maintenance organization is able to capture in a particular subscriber group or in the market area as a whole. For example, signing of 10 enrollees or members out of 100 eligibles yields a 10% penetration. Per ContracVPer Month (PCIPM) The amount of dollars for each contract for each month. Per Diem Reimbursement Total payment rate per day regardless of actual charges. Per Member Per Month (PMPM) The revenue or cost from each plan’s member for 1 month. For example, under capitation, a physician receives a PMPM amount from the managed care plan for each enrollee in the plan whose care is managed by that physician. If a 10,000-member health maintenance organization in 1 month’s time spends $20,000 on cardiovascular surgery, the cost on a PMPM basis would be $20,000 divided by 10,000, equaling $2 PMPM. Per Thousand Members Per Year (PTMPY) A common indicator of hospital utilization. Performance Standards Standards an individual provider is expected to meet, especially with respect to quality of care. The standards may also define volume of care delivered during a given time period. Pharmaceutical Benefit Management Company (PBMC) A high-volume pharmaceutical marketing company that specializes in buying pharmaceuticals at discounted prices from manufacturers and selling them at discounted prices to hospitals and large employer health plans. May also provide prescription drug insurance coverage to employers or managed care plans. Physician Care Groups (PCGs) A patient classification system to be used as a payment system for physician services. Ambulatory patient groups serve as a classification system for the facility component for outpatient reimbursement, and PCGs constitute the professional component. PCGs are expected to combine historical charges and relative value units. Physician-Hospital Organization (PHO) A legal entity uniting a hospital (or hospital system) and a group of physicians (and possibly other providers) for the purpose of contracting with managed care plans. Physicians maintain ownership of their practice while agreeing to accept managed care patients under the terms of the PHO contract. The PHO serves as a negotiating, con-

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tracting, and marketing unit. PHOs are frequently formed between a hospital and an independent practice association and serve a more specific area than the broad range of a preferred provider organization. PHOs operate increasingly on a capitated basis and are designed to manage risk. Physician Organization (PO) Network of physicians that contracts with managed care organizations. Physician Payment Review Commission (PPRC) An advisory commission created by Congress in 1986 to recommend changes in current reimbursement procedures and policies for physicians receiving payments from Medicare. Physician Practice Management Company (PPMC) An investor-owned business that purchases, partners with, or manages physician practices. The PPMC provides investment capital for practice development or expansion. Point of Service (POS) A plan option of a health maintenance organization or preferred provider organization in which members choose their provider at the time of service. Beneficiaries have the option to go outside the network for an additional cost. These plans provide a difference in benefits depending on whether the member chooses to use the plan’s providers and authorization system or to go outside of the plan for services. Pooling Combining risk. Population per Health Maintenance Organization A ratio of a metropolitan area market population divided by the number of health maintenance organizations in that market area. Practice Guidelines Written descriptions of appropriate treatment for a specific diagnosis or medical condition. The Institute of Medicine defines practice guidelines as ”systematically developed statements to assist practitioner and patient decisions about appropriate health care services for specific clinical circumstances.” Precertification Evaluation by the payer or financial intermediary to determine if specific medical services are appropriate treatment for a patient. Also called prior authorization. Also called preadmission review if the precertification involves hospitalization. Preexisting Condition A current or previous health condition that may limit an individual’s ability to obtain health insurance. Preferred Provider Organization (PPO) A group of physicians or hospitals who contract with an employer to provide services to their employees at a discounted fee. In a PPO, the patient may go to the physician of his or her choice even if that physician does not participate in the PPO, but the patient receives care at a lower benefit level. Premium Used interchangeably with the term rate; an expression of the price charged for each class of coverage within a given rate structure. In a broader sense, premium is often used to express the dollar volume contributed by a subscriber group. Prepaid Plan A health plan in which providers are paid before delivering services, as in a health maintenance organization or independent practice association; contrast fee-for-service. Preventive Health Care Health care that promotes the prevention of disease and morbidity and that concentrates on keeping patients well. Primary Care First-level outpatient medical services, as opposed to surgery or complex medical services and procedures. Primary care may also be defined as the medical services typically provided in internal medicine, family or general practice, pediatrics, and sometimes obstetrics/gynecolog. Primary Care (or PCP) Capitation The portion of capitation directed to the


primary care physician (PCP) for providing patient care services. The PCP does not receive a fee for each service rendered, and payment usually is made on a monthly basis. The PCP is expected to manage care within the pool of funds collected for all patient members of the plan. A portion of the capitation fee is sometimes retained and awarded to physicians based on their utilization profile. Primary Care Network Networks of primary care physicians ranging from a loose association of physicians in a geographic area with a limited sharing of overhead, patient referral, and call to a more structured association with commonly owned satellite clinics. Primary Care Physician (PCP) A physician who is in some sense a generalist, such as a family practitioner, pediatrician, or general internist. These physicians deal with the entire person, whereas subspecialist physicians usually deal with single body systems. PCPs typically act as gatekeepers or case managers in a managed care organization. Prior Authorization Procedure use in managed care to control utilization of services by prospective review and approval. Private Inurement The transfer of something of value from a not-for-profit entity to a for-profit individual or entity. Profiling The use of statistics to identify physicians who either overutilize or underutilize services. This information is used as feedback to change utilization patterns. Progressive Rates A method employed by some health maintenance organizations in which they implement new rates monthly, quarterly, or semiannually. Any new or renewal subscriber groups with anniversaries falling within such periods would automatically be subject to prevailing rates in effect during these periods, and those rates are generally guaranteed for the full 12-month benefit year. This method is said to offer greater rate parity than a fixed rate throughout the health maintenance organization’s fiscal year. Consequently, it has the effect of containing rate changes on a group-to-group basis each benefit year. Prospective Payment Assessment Commission (ProPAC) Congressional commission advising Congress on hospital payment policy. Prospective Payment System A standardized payment system implemented by Medicare in 1983 giving hospitals a fixed reimbursement based on the diagnosis of the patient. Provider Any person or organization providing medical care to consumers, including physicians, hospitals, pharmacies, and home health care agencies. Provider Sponsored Network (PSN) Locally organized health care delivery systems focused on coordinating care and initiated by physician group practices, by hospitals or health systems, or both. Many already exist and provide coordinated care to health plans and self-insured employers. Public Law 93-222 The Health Maintenance Organization Act of 1973, which created Title XI11 of the Public Health Service Act establishing the federal health maintenance organization program. Public Law 94-460 The public law that created the 1976 amendments to the Health Maintenance Organization Act of 1973. This legislation gave greater flexibility to health maintenance organizations in their organization and structure. The amendments also increased federal monies to support health maintenance organization development and operation. Quality Assurance (QA) A term for the activities and programs intended to ensure quality of care in the managed care setting. Such programs include peer or utilization review components (to identify and remedy deficiencies in quality) and mechanisms for assessing effectiveness.

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Quality Improvement (QI) A continuous process that identifies problems in health care delivery, proposes and implements solutions to those problems, and constantly monitors and reevaluates the solutions for improvement. Quality Management (QM) The current term for the process designed to monitor and evaluate objectively the quality and appropriateness of health care. Includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative, and support services. Quality of Care The degree or grade of excellence with respect to medical services received by patients, administered by providers or programs, in terms of technical competence, need, appropriateness, acceptability, humanity, and structure. Quality Report Cards Monthly, quarterly, or annual evaluation reports given by managed care plans to physicians. Physicians are rated on the basis of overall quality of care and utilization. Rating Bands Limits set on the difference between the lowest and highest premium rates to be charged to different employer groups that have different case characteristics, such as age, industry, and location. Reenrollment In subsequent open enrollment periods, the number of subscribers currently enrolled plus those who elect to join the health maintenance organization (HMO) less those subscribers who leave the HMO, i.e., the net number of subscribers who enroll in the HMO. Regional Health Care System (RHCS) An integrated system (including hospital, physicians, and other providers) offering a full range of services within part of a city or region. Reinsurance A type of insurance purchased by health maintenance organizations (HMOs) to protect against specific risks. Typical reinsurance risk coverages include (1) individual stop loss, (2) aggregate stop loss, (3) out of area, and (4) insolvency protection. As HMOs grow in membership, their reinsurance costs may be reduced by assuming such risks themselves and relying on larger reserves. Reinsurance is a cost of doing business for HMOs. Relative Value Scale (RVS) A guide that attempts to show in a general way the relationship between the time, competency, experience, severity, and other factors to perform one professional service as compared to those required for other professional services under usual conditions. RVS is the basis for a fee schedule when dollar conversion factors are applied. Relative Value Unit (RVU) A ranking for a service or procedure code based on the relative costs of the resources required to provide the service or procedure. The universe of R W s makes up the RVS. For example, a service with 1.0 RVU consumes twice as many resources as a service with 0.5 RVU. Reserves Restricted cash investments or highly liquid investments intended to protect the health maintenance organization against insolvency or bankruptcy. Regulatory agencies may mandate reserve requirements. Also, some health maintenance organizations establish voluntary reserves by systematically setting aside a small portion of each month's realized revenues. Resource-Based Practice Expense Relative Values This project is being undertaken by the Health Care Financing Administration to construct a database of direct and indirect practice expenses by site for all services reimbursed by Medicare. These data will also be used to determine costs for these procedures. Resource-Based Relative Value Scale (RBRVS) The most well-known resourcebased relative value scale, which was developed for Medicare. The RBRVS assigns relative values to each current procedural terminology code on the basis of the relative costs of the resources (physician work, practice expenses, and


liability expenses) required to provide the procedure or service rather than simply on the basis of billing customs or historical trends. Currently, under Medicare, only physician work is resourcebased. Return on Investment (ROI) The money made by an individual or business from a financial investment. ROI is often used to evaluate management and liability of product or service lines. Risk The possibility of financial liability or loss. For example, physicians may be held at risk if hospitalization rates exceed agreed on thresholds. The sharing of risk is often employed as a utilization control mechanism within the health maintenance organization setting. Risk is also defined in insurance terms as the probability of loss associated with a given population. Risk Contract A contract between a health maintenance organization or a certified medical plan and Medicare to provide services to Medicare beneficiaries on an at-risk basis. The health plan receives a fixed monthly payment for enrolled members in exchange for the provision of all services. Also known as a Medicare risk contract. Risk Management The processes designed to reduce the probability of adverse outcomes. Risk Pool A pool of money set aside to pay for defined expenses, particularly overutilization, or to encourage limits on utilization. More commonly seen in primary care than with specialists. Commonly, if there is a balance in the risk pool at the end of the year, it is returned in part or in total to those managing the risk. Risk Retention A description of the limitations of financial liability remaining with a major entity to the health maintenance organization (HMO) program. For example, the HMO may accept all risk to guarantee provision of services to its enrolled population. This risk may be limited by arrangements with reinsurers. Also, the fee-for-service/prepaid medical group may take full risk or limit its risk by contractural arrangements with the HMO corporation. Risk Sharing Sharing the opportunity for reward or loss, usually among the physicians, the managed care plan, and the hospital. Saturation A condition that occurs when a health maintenance organization achieves its maximal penetration either in a subscriber group or in the market- place itself. When this condition becomes evident, a health maintenance organization’s first goal is to retain its saturation level while assessing how to achieve an increase in market share or how to expand its service or market area. Self-Funded Plan A health plan in which the risk for medical cost is assumed by the employer or union rather than by an insurance company or managed care plan. Under the Employee Retirement Income Security Act, self-funded plans are exempt from state laws and regulations such as premium taxes and mandatory benefits. Self-funded plans often contract with insurance companies or third-party administrators to administer the benefits. Self-Insurance An entity itself assumes the risk of coverage and makes appropriate financial arrangements rather than purchasing insurance from a third party and paying a premium for this coverage. Self-Referrals Arrangements for care beyond primary care that are made by the patient rather than by a gatekeeper or other providers. Typically, patients are not allowed to self-refer to noncontracted providers if the care is to be paid by the health maintenance organization except in emergencies. Service Area The territorial boundaries that a health maintenance organization designates for providing service to members. Some health maintenance organi-

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zations establish a mileage radius from their medical delivery sites; some rely on ZIP codes; others use county boundaries in defining service areas. Service Plan Health insurance plans, such as Blue Cross and Blue Shield, which have direct contracts with providers but are not necessarily managed care plans. The contract applies to direct billing of the plan (rather than the member) by providers, a provision for direct payment of the provider (rather than reimbursement of the member), a requirement that the provider accept the plan’s determi- nation of usual customary and reasonable and not balance bill the member in excess of that amount, and a range of other terms. Shadow Pricing In health care, a technique for setting prices for health maintenance organizations just below those of indemnity plans to make the health maintenance organization price competitive while maximizing revenues. Shared Risk A managed care arrangement that apportions financial risk among two or more parties and gives financial incentives to keep expenses under defined limits. Generally, more than one party is responsible for keeping expenses under a predetermined target and assumes responsibility for expenses that exceed the target. For example, a health maintenance organization and physician group may each agree to share hospital costs evenly over a projected utilization rate. Single Contract Coverage for one person as designated on the enrollment or enrollment change card by the enrollee. Single Payer System Financing mechanism in which government acts as the only insurer and sets reimbursement rates for providers. Skilled Nursing Facility (SNF) A freestanding facility or part of a hospital that has been certified by Medicare to admit patients requiring subacute care and rehabilitation. Skimming The practice of encouraging the enrollment of healthy low-risk individuals in health plans and discouraging the enrollment of sick individuals, usually through the practice of risk selection. Small Subscriber Group Aggregate A combination of small businesses, professional associations, or other entities formed for the purpose of being considered a single large subscriber group. Social Health Maintenance Organization (SHMO) A Health Care Financing Administration project that began in 1982 designed to integrate acute and long- term care for enrolled Medicare beneficiaries over age 65. Solvency A financial condition in which a health maintenance organization, a medical group, or another organization is able to pay or retire its debts when due. Specialist Capitation The amount within which a specialist is expected to manage specialty care on a per capita basis. Specialty Health Maintenance Organization A health maintenance organization organized around a specific medical specialty, such as cancer or cardiac care, to provide prepaid and comprehensive coverage to patients. Staff Model The organizational structure of a health maintenance organization (HMO) in which physicians are salaried employees of the HMO. Medical services in staff models are delivered at HMO-owned health centers and generally only to HMO members. The physicians are usually limited in their fee-for- service activities. Standard Class Rate Used to calculate monthly premium rates using a base revenue requirement per member or per employee multiplied by group demo- graphic information. Stop Loss The purchase of insurance coverage from a third party to cover


excessive unexpected financial loss to the plan or provider. It may be individual or aggregate and usually both. In the event of a catastrophic claim, stop loss limits the exposure for both the insurer and the purchaser. Subrogation The contractual right of a health plan to recover payments made to a member for health care costs after that member has received payment for the damages in an action from sources such as workers compensation, third- party negligence liability, or automobile medical coverage. Subscriber An employer, union, or association that contracts with a health maintenance organization for its prepaid health care plan, which is offered to eligible enrollees. Subspecialist Someone who is recognized to have expertise in a specialty of medicine or surgery. Within health maintenance organizations, it usually refers to physicians who are able to receive referrals from primary care physicians. Supplemental Health Services The benefits a health maintenance organization offers that exceed their basic health service requirements. Tax Equity and Fiscal Responsibility Act (TEFRA) An act that prohibits employers and health plans from requiring workers age 65 to 69 to use Medicare instead of the employer's health plan. Tertiary Care Care that usually requires the facilities of a university-affiliated or teaching hospital with extensive diagnostic and treatment capabilities. Third-Party Administrator (TPA) An administrative organization other than the employee benefit plan or health care provider that collects premiums, pays claims, and provides other administrative services. Third-Party Payer An entity that acts as the financing organization between the provider and consumer of care. Examples include insurance carriers, health maintenance organizations, Medicare, and Medicaid. Third-Party Reimbursement A general term applied to health care benefit payments. Under normal market transactions, there are only two parties, the buyer and the seller. Under a benefit plan, a third party is ultimately responsible for paying the costs of services provided to covered persons. Three-Tier Rate A rate structure that sets monthly premiums based on (1) single-person coverage, (2) two-person coverage, and (3) family coverage. Title XIX Commonly refers to the Medicaid program. Title XVIII Commonly refers to the Medicare program. Total Quality Management (TQM) Also called continuous quality improvement. This uses systems and processes to identify and eliminate sources of error, waste, or redundancy by soliciting feedback and participation from all staff (especially nonmanagement) and consumers (i.e., patients). Treatment Protocols The standard procedures for treating a patient with a predefined set of conditions. In managed care plans, these protocols typically are part of the quality management programs and may be used in benchmarking. Triple Option The offering of a health maintenance organization, preferred provider organization, and traditional insurance plan by one carrier as a package for employers to offer employees. Two-Tier Rate A rate structure that sets monthly premiums based on (1) single- person coverage and (2) family coverage. UB-92 The common claim form used by hospitals to bill for services. Some managed care plans demand greater detail than is available on the UB-92, requiring hospitals to send additional itemized bills. Unbundling Billing separately for the components of a service previously included in a single fee.

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Underwriting The process of selecting, classifying, evaluating, and assuming risks according to their insurability. Upcoding The practice of a provider billing for a procedure that pays better than the service actually performed, such as billing for an office visit with a greater intensity level than the actual service justifies. Usual Customary and Reasonable (UCR) A method of profiling historical fees in an area and reimbursing providers on the basis of that profile. Utilization The frequency with which a benefit is used. For example, 3200 physician office visits per 100,000 health maintenance organization members per year. Utilization experience multiplied by the average cost per unit of service delivered equals capitated costs. Utilization Management (Utilization Review, Utilization Control) A process that monitors the use of available resources (including professional staff, facilities, and services) to determine medical necessity, cost-effectiveness, and confor- mity to criteria for optimal use. It is a three-part process that is (1) prospective, including prior authorizations and the use of guidelines for medical appropriateness and necessity; (2) concurrent, including patient case management during treatment or surgery or during hospitalization; and (3) retrospective, evaluating costs, utilization patterns, and provider practice patterns after the fact to determine whether some providers fall outside the accepted standards of care. Value A function of both the cost and the quality of a product or service. Value purchasing in managed care refers to seeking providers or treatment modalities that are not only cost-effective, but also associated with good clinical outcomes. Variable Cost A cost that changes with a change in the level of output. For instance, supplies used in examination rooms. Vertical Integration The combination of all economic steps required in production of a product or service within one’s system. The goal is to reduce costs, maximize efficiency, and gain broader marketing power. In medical terms, it is the combination of providers and services of various types in one organization, such as a hospital and physician organization, to extend the reach of the organization. Voluntary Enrollment The nature of how patients come to be health maintenance organization members-they consciously and explicitly choose to enroll. Further, health maintenance organization membership is almost always offered as one of at least two health coverage options, whereas insurance is sometimes the only offered option. Withhold A percentage of payment to the provider held back by the health maintenance organization until the cost of referral or hospital services has been determined. Physicians exceeding the amount determined as appropriate by the health maintenance organization lose the amount held back. The amount of withhold returned depends on individual utilization by the gatekeeper; referral patterns through the year by the gatekeeper, groups of physicians, or the overall plan pool; and financial indicators for the overall capitated plan. The withhold is at risk. If utilization targets are exceeded, the withhold is not returned. This serves as a financial incentive for lower utilization. Working Capital In business, a company’s current assets minus liabilities; the amount of money available to be spent. Wraparound Plan Commonly used to refer to insurance or health plan coverage for copayments and deductibles that are not covered under a member’s base plan. This is often used for Medicare.


References

1. Bendel A Glossary of Terms Used in Managed Care 1996. Englewood, CO, Managed Care Assembly, Medical Group Management Association, 1996

2. Freudenheim E: Healthspeak A Complete Dictionary of America’s Health Care System. New York, Facts on File, 1996

3. Gammel JD, Barnes CE, Lutes ME: Glossary. In The Internist’s Guide to Practice Integration. Washington, DC, American Society of Internal Medicine, 1995

4. Vogel DE Glossary of managed care terms. In Gastroenterology and Managed Care: Preparing to Meet the Challenge. Manchester, MA, American Society for Gastrointesti- nal Endoscopy, 1994

5. Wieland J B Glossary. In The Internist’s Guide to Negotiating Managed Care Contracts and Capitation RatesGastroenterology Edition. Bethesda, MD, American Gastroenter- ological Association and American Society for Gastrointestinal Endoscopy, 1995

Address reprint requests to: James T. Frakes, MD, MS

Rockford Gastroenterology Associates, Ltd. 401 Roxbury Road Rockford, IL 61107

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GLOSSARY OF MANAGED CARE TERMS

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