All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to inpatients. Although many inpatients may be ambulatory, the term usually implies that the patient must travel to a location to receive services that do not require an overnight stay. Ambulatory care settings may be either mobile (when the facility is capable of being moved to different locations) or fixed (when the person seeking care must travel to a fixed service site). *
Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy, that are provided in conjunction with medical or hospital care.*
Income lost to a provider (or institution) because of the failure of patients to pay amounts owed. Bad debts may sometimes be recovered by increasing charges to paying patients. Some cost-based reimbursement programs reimburse certain bad debts. The impact of the loss of revenue from bad debts may be partially offset for proprietary institutions by the fact that tax is not payable on income not received.*
A geographic area defined and served by a health program or institution such as a hospital or community mental health center that is delineated
Adapted from the Academy for Health Services Research and Health Policy glossary at http://www.academyhealth.org/publications.glossary.pdf. Accessed February 4, 2002.
on the basis of such factors as population distribution, natural geographic boundaries, and accessibility of transportation. By definition, all residents of the area needing the services of the program are usually eligible for them, although eligibility may depend on additional criteria.*
The markup on the underlying cost of a service.
Generally, physician and hospital services provided to persons who are unable to pay for the cost of services, especially those who are low income, uninsured, and underinsured. A high proportion of the costs of charity care is derived from services for children and pregnant women (e.g., neonatal intensive care). *
Community Health Center (CHC)
An ambulatory health care program (defined under section 330 of the Public Health Service Act) usually serving a catchment area that has scarce or nonexistent health services or a population with special health needs; sometimes known as a neighborhood health center. Community health centers attempt to coordinate federal, state, and local resources in a single organization capable of delivering health and related social services to a defined population. Although such a center may not provide all types of health care directly, it usually takes responsibility to arrange all health care services needed by its patient population. *
The difference between hospital charges and the amount actually paid by a third-party payer.
Conversion, Hospital Conversion
A transaction in which all or part of the assets of a health care organization undergo a shift in ownership status (nonprofit, public, or for-profit) through sale, lease, joint venture, or operating or management agreements. *
Payment made by a health plan or payer to health care providers based on the actual costs incurred in the delivery of care and services to plan beneficiaries. This method of paying providers is still used by some plans; however, cost-based reimbursement is being replaced by prospective payment and other payment mechanisms. *
Recouping the cost of providing uncompensated care by increasing revenues from some payer(s) to offset losses and lower net payments from others.
Critical Access Hospital (CAH)
A rural hospital designation established by the Medicare Rural Hospital Flexibility Program enacted as part of the Balanced
Budget Act of 1997. Rural hospitals meeting criteria established by their state may apply for CAH status. Designated hospitals are reimbursed based on cost (rather than prospective payment), must comply with federal and state regulations for CAHs, and are exempt from certain hospital staffing requirements. *
Payments made for services rendered to one individual or group are used to cover shortfalls in individual payments for services rendered to another individual or group.
Disproportionate Share Adjustment, Hospital (DSH)
A payment adjustment under Medicare’s prospective payment system or under Medicaid for hospitals that serve a relatively large volume of low-income patients. *
Federally Qualified Health Center (FQHC)
A health center in a medically underserved area that is eligible to receive cost-based Medicare and Medicaid reimbursement and to provide direct reimbursement to nurse practitioners, physician assistants, and certified nurse midwives. Federal legislation creating the FQHC category was enacted in 1989. *
Graduate Medical Education (GME)
Medical education after the receipt of the M.D. or equivalent degree, including the education received as an intern, resident (which involves training in a specialty), or fellow, as well as continuing medical education. The Centers for Medicare and Medicaid Services partially finances GME through Medicare direct and indirect payments. *
Health Professions Shortage Area (HPSA)
An area or group designated by the U.S. Department of Health and Human Services as having an inadequate supply of health care providers. HPSAs can include (1) an urban or rural geographic area, (2) a population group for which access barriers can be demonstrated to prevent group members from using local providers, or (3) medium- and maximum-security correctional institutions and public or nonprofit private residential facilities. *
A subsidized health insurance pool organized by some states as an alternative for individuals who have been denied health insurance because of a medical condition or whose premiums are rated significantly higher than the average due to health status or claims experience. It is commonly operated through an association composed of all health insurers in a state. The Health Insurance Portability and Accountability Act of 1996 allows states to use high-risk pools as an “acceptable alternative mechanism” that satisfies the statutory requirements for ensuring access to health insurance coverage for certain individuals.
Coined from the names of the principal sponsors of P.L. 79-725 (the Hospital Survey and Construction Act of 1946). This program provided
federal support for the construction and modernization of hospitals and other health facilities. Hospitals that have received Hill-Burton funds incur an obligation to provide a certain amount of charity care. *
Health services provided to the poor or those unable to pay. Since many indigent patients are not eligible for federal or state programs, the costs which are covered by Medicaid are generally recorded separately from indigent care costs. *
Revenues from sales minus current costs of goods sold. *
Persons who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance. *
Medically Underserved Population
A population group experiencing a shortage of personal health services that may or may not reside in a Health Professions Shortage Area or be defined by its place of residence. Thus, migrants, American Indians, or the inmates of a prison or mental hospital may constitute such a population. The term is defined and used to give priority for federal assistance (e.g., the National Health Service Corps). *
National Health Service Corps
A program administered by the U.S. Department of Health and Human Services that places physicians and other providers in health professions shortage areas by providing scholarship and loan repayment incentives. Since 1970, Corps members have worked in community health centers, migrant centers, Indian health facilities, and other sites targeting underserved populations. *
Overcrowding, Emergency Department
A situation in which the demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to feel too rushed to provide quality care (Derlet and Richards, 2000).
The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Donaldson et al., 1996).
Prospective Payment, Prospective Payment System (PPS)
Any method of paying hospitals and other health programs in which amounts or rates of payment are established in advance for a defined period (usually a year). Institutions are paid these amounts regardless of the costs they actually incur. These systems of payment are designed to introduce a degree of constraint on charge or cost increases by setting limits on amounts paid during a future period. In some cases, such systems
provide incentives for improved efficiency by sharing savings with institutions that perform at lower than anticipated costs. Prospective payment contrasts with the method of payment originally used under Medicare and Medicaid (as well as other insurance programs) in which institutions were reimbursed for actual expenses incurred. *
Quality of Care
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990, p. 21).
Rural Health Clinic (RHC)
A public or private hospital, clinic, or physician practice designated by the federal government as in compliance with the Rural Health Clinics Act (P.L. 95-210). The practice must be located in a medically underserved area or a health professions shortage area and use physician assistants and/or nurse practitioners to deliver services. A rural health clinic must be licensed by the state and provide preventive services. *
Rural Health Clinics Act
Establishes a reimbursement mechanism to support the provision of primary care services in rural areas. P.L. 95-210 was enacted in 1977 and authorizes the expanded use of physician assistants, nurse practitioners, and certified nurse practitioners; extends Medicare and Medicaid reimbursement to designated clinics; and raises Medicaid reimbursement levels to those set by Medicare. *
A research construct with either or both cognitive and social structural elements that refers to the stocks of resources available through social relationships, as measured by indicators such as civic engagement, norms of reciprocity, and interpersonal trust (Macinko and Starfield, 2001).
The degree of perceived or operationalized social connectedness or integration among a group of people, sometimes measured as social capital (see Kawachi and Kennedy, 1997a).
Sole Community Hospital (SCH)
A hospital (1) that is more than 50 miles from any similar hospital; (2) 25 to 50 miles from a similar hospital and isolated from it at least one month a year (e.g., by snow), or the exclusive provider of services to at least 75 percent of its service area populations; (3) 15 to 25 miles from any similar hospital and isolated from it at least one month a year; or (4) designated as an SCH under previous rules. The Medicare diagnosis related group (DRG) program makes special optional payment provisions for SCHs, most of which are rural, including providing that their rates are set permanently so that 75 percent of their payment is hospital specific and only 25 percent is based on regional DRG rates. *
A physician, dentist, or other health professional who is specially
trained in a certain branch of medicine or dentistry related to specific services or procedures (e.g., surgery, radiology, pathology); certain age categories of patients (e.g., geriatrics); certain body systems (e.g., dermatology, orthopedics, cardiology); or certain types of diseases (e.g., allergy, periodontics). Specialists usually have advanced education and training related to their specialties. *
Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologists, urologists, dermatologists). In the United States, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. *
Services provided by highly specialized providers (e.g., neurologists, thoracic surgeons, intensive care units). Such services frequently require highly sophisticated equipment and support facilities. The development of these services has largely been a function of diagnostic and therapeutic advances attained through basic and clinical biomedical research. *
Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs of these services may be covered through cost shifting. Not all uncompensated care results from charity care. It also includes bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bills. *