Healthcare Policy And Regulation
Expert-defined terms from the Professional Certificate in Consulting for Healthcare Management course at Greenwich School of Business and Finance. Free to read, free to share, paired with a professional course.
Accountable Care Organization (ACO) refers to a network of healthcare providers… #
Accountable Care Organization (ACO) refers to a network of healthcare providers who come together to provide coordinated, high-quality care to patients while reducing costs, related terms include value-based care, population health management, and care coordination, the goal of an ACO is to improve patient outcomes and reduce healthcare spending by promoting preventive care, reducing unnecessary tests and procedures, and improving communication among providers, for example, an ACO might include primary care physicians, specialists, hospitals, and other healthcare providers who work together to provide comprehensive care to patients.
Administrative Simplification refers to the use of standardized electronic trans… #
Administrative Simplification refers to the use of standardized electronic transactions to simplify administrative tasks, such as claims processing and eligibility verification, related terms include HIPAA, electronic data interchange, and operating rules, the goal of administrative simplification is to reduce administrative burdens and costs, improve efficiency, and enhance patient care, for instance, the use of standardized electronic claims processing can reduce errors and improve payment turnaround times.
Adverse Event refers to an unwanted or unexpected occurrence, such as a medical… #
Adverse Event refers to an unwanted or unexpected occurrence, such as a medical error or patient harm, that results in harm to a patient, related terms include patient safety, quality improvement, and root cause analysis, adverse events can be caused by a variety of factors, including human error, equipment failure, or system flaws, and can have serious consequences, such as patient injury or death, for example, a medication error that results in patient harm is considered an adverse event.
Affordable Care Act (ACA) refers to a comprehensive healthcare reform law enacte… #
Affordable Care Act (ACA) refers to a comprehensive healthcare reform law enacted in 2010, related terms include health insurance marketplace, Medicaid expansion, and individual mandate, the ACA aimed to increase healthcare accessibility and affordability, improve healthcare quality, and reduce healthcare spending, for instance, the ACA expanded Medicaid eligibility to millions of low-income individuals and families, and prohibited insurance companies from denying coverage based on pre-existing conditions.
Ambulatory Care refers to medical care provided on an outpatient basis, such as… #
Ambulatory Care refers to medical care provided on an outpatient basis, such as in a physician's office or clinic, related terms include primary care, specialty care, and telehealth, ambulatory care services can include routine check-ups, diagnostic tests, and treatments, and are often provided by primary care physicians, specialists, or other healthcare professionals, for example, a patient may visit a primary care physician for a routine check-up or to receive treatment for a minor illness.
Benefit Design refers to the structure and features of a health insurance plan,… #
Benefit Design refers to the structure and features of a health insurance plan, including the types of services covered, cost-sharing requirements, and network limitations, related terms include premium, deductible, and copayment, the goal of benefit design is to balance the need for comprehensive coverage with the need to control costs, for instance, a health insurance plan may cover preventive services, such as annual physicals and screenings, but require a copayment for specialist visits.
Bundled Payment refers to a payment model in which a single payment is made for… #
Bundled Payment refers to a payment model in which a single payment is made for all services related to a specific episode of care, such as a hospital stay or surgical procedure, related terms include value-based care, episode-based payment, and care coordination, the goal of bundled payment is to incentivize providers to deliver high-quality, cost-effective care, for example, a bundled payment for a surgical procedure might include payment for pre-operative care, the surgery itself, and post-operative care.
Care Coordination refers to the process of organizing and managing patient care… #
Care Coordination refers to the process of organizing and managing patient care activities, including transitions between care settings, related terms include case management, care transitions, and patient navigation, the goal of care coordination is to ensure that patients receive seamless, high-quality care, for instance, a care coordinator might help a patient transition from hospital to home care, or coordinate appointments and tests with multiple providers.
Case Management refers to the process of assessing, planning, and coordinating c… #
Case Management refers to the process of assessing, planning, and coordinating care for patients with complex or chronic conditions, related terms include disease management, care coordination, and patient education, the goal of case management is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for example, a case manager might work with a patient with diabetes to develop a care plan, coordinate appointments and tests, and provide education on self-management.
Certification refers to the process of verifying that a healthcare provider or o… #
Certification refers to the process of verifying that a healthcare provider or organization meets certain standards or criteria, related terms include accreditation, licensure, and credentialing, certification can be voluntary or mandatory, and can be used to demonstrate expertise, quality, or compliance with regulations, for instance, a hospital might seek certification from a national accrediting organization to demonstrate its commitment to quality and patient safety.
Chronic Care Management refers to the process of managing and coordinating care… #
Chronic Care Management refers to the process of managing and coordinating care for patients with chronic conditions, such as diabetes or heart disease, related terms include disease management, care coordination, and patient education, the goal of chronic care management is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for example, a chronic care manager might work with a patient with diabetes to develop a care plan, coordinate appointments and tests, and provide education on self-management.
Clinical Decision Support (CDS) refers to the use of computer #
based systems to provide healthcare providers with clinical decision-making support, related terms include electronic health record, clinical guidelines, and order sets, the goal of CDS is to improve patient care, reduce errors, and enhance provider decision-making, for instance, a CDS system might provide alerts and reminders to healthcare providers about medication interactions or allergies.
Community Health refers to the health and well #
being of a defined population, such as a geographic community or vulnerable population, related terms include public health, health disparities, and health equity, the goal of community health is to promote health, prevent disease, and reduce health disparities, for example, a community health initiative might focus on improving access to healthy food, promoting physical activity, or providing health education and outreach.
Compliance refers to the process of adhering to laws, regulations, and standards… #
Compliance refers to the process of adhering to laws, regulations, and standards, related terms include regulatory requirements, accreditation, and audit, compliance is critical in healthcare to ensure patient safety, quality care, and financial integrity, for instance, a healthcare organization might establish a compliance program to ensure adherence to HIPAA regulations and prevent fraud and abuse.
Consumer #
Directed Health Plan (CDHP) refers to a type of health insurance plan that allows consumers to make decisions about their healthcare spending, related terms include health savings account, high-deductible plan, and consumer engagement, the goal of CDHPs is to encourage consumers to take a more active role in their healthcare decisions, for example, a CDHP might allow consumers to use a health savings account to pay for healthcare expenses.
Continuity of Care refers to the process of ensuring that patients receive seaml… #
Continuity of Care refers to the process of ensuring that patients receive seamless, uninterrupted care, related terms include care coordination, care transitions, and patient navigation, the goal of continuity of care is to ensure that patients receive high-quality, coordinated care, for instance, a healthcare provider might use an electronic health record to share patient information and coordinate care with other providers.
Coordinated Care refers to the process of organizing and managing patient care a… #
Coordinated Care refers to the process of organizing and managing patient care activities, including transitions between care settings, related terms include care coordination, case management, and patient navigation, the goal of coordinated care is to ensure that patients receive high-quality, seamless care, for example, a coordinated care team might include healthcare providers, social workers, and patient navigators who work together to provide comprehensive care.
Cost #
Sharing refers to the process of dividing healthcare costs between patients and payers, related terms include copayment, deductible, and coinsurance, the goal of cost-sharing is to balance the need for comprehensive coverage with the need to control costs, for instance, a health insurance plan might require patients to pay a copayment for prescription medications.
Credentialing refers to the process of verifying the qualifications and crede… #
Credentialing refers to the process of verifying the qualifications and credentials of healthcare providers, related terms include licensure, certification, and privileging, credentialing is critical in healthcare to ensure patient safety and quality care, for example, a hospital might verify the credentials of a physician before granting privileges to practice.
Data Analytics refers to the process of analyzing and interpreting data t… #
Data Analytics refers to the process of analyzing and interpreting data to inform healthcare decisions, related terms include health information technology, electronic health record, and population health management, the goal of data analytics is to improve patient care, reduce costs, and enhance operational efficiency, for instance, a healthcare organization might use data analytics to identify trends in patient outcomes or resource utilization.
Disease Management refers to the process of managing and coordinating care for p… #
Disease Management refers to the process of managing and coordinating care for patients with chronic conditions, related terms include case management, care coordination, and patient education, the goal of disease management is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for example, a disease management program might include patient education, medication management, and care coordination.
Electronic Health Record (EHR) refers to a digital version of a patient's medica… #
Electronic Health Record (EHR) refers to a digital version of a patient's medical record, related terms include health information technology, clinical decision support, and interoperability, the goal of EHRs is to improve patient care, reduce errors, and enhance provider decision-making, for instance, an EHR might include patient demographics, medical history, and test results.
Evidence #
Based Practice (EBP) refers to the use of research-based evidence to inform healthcare decisions, related terms include clinical guidelines, quality improvement, and patient safety, the goal of EBP is to improve patient outcomes, reduce costs, and enhance quality of care, for example, a healthcare provider might use evidence-based guidelines to develop a treatment plan for a patient with a specific condition.
Health Information Exchange (HIE) refers to the electronic sharing of health… #
Health Information Exchange (HIE) refers to the electronic sharing of health information between healthcare providers and organizations, related terms include interoperability, electronic health record, and health information technology, the goal of HIE is to improve patient care, reduce errors, and enhance provider decision-making, for instance, an HIE might enable healthcare providers to access patient information from other providers or organizations.
Health Insurance refers to a type of insurance that covers the cost of medica… #
Health Insurance refers to a type of insurance that covers the cost of medical care, related terms include health insurance marketplace, Medicaid, and Medicare, the goal of health insurance is to protect individuals and families from financial risk, for example, a health insurance plan might cover preventive services, such as annual physicals and screenings.
Health Information Technology (HIT) refers to the use of technology to ma… #
Health Information Technology (HIT) refers to the use of technology to manage and process health information, related terms include electronic health record, clinical decision support, and health information exchange, the goal of HIT is to improve patient care, reduce errors, and enhance provider decision-making, for instance, HIT might include electronic prescribing, telehealth, or patient portals.
Health Reform refers to the process of changing or improving the healthcare</… #
Health Reform refers to the process of changing or improving the healthcare system, related terms include Affordable Care Act, health insurance marketplace, and Medicaid expansion, the goal of health reform is to improve healthcare accessibility, affordability, and quality, for example, the Affordable Care Act expanded Medicaid eligibility and prohibited insurance companies from denying coverage based on pre-existing conditions.
Healthcare Access refers to the ability of individuals to obtain healthcare</… #
Healthcare Access refers to the ability of individuals to obtain healthcare services, related terms include health insurance, primary care, and specialty care, the goal of healthcare access is to ensure that individuals have access to necessary healthcare services, for instance, a healthcare organization might provide sliding-scale fees or charity care to individuals who are uninsured or underinsured.
Healthcare Disparities refer to differences in healthcare access, quality… #
Healthcare Disparities refer to differences in healthcare access, quality, or outcomes between different populations, related terms include health equity, health disparities, and cultural competence, the goal of addressing healthcare disparities is to promote health equity and reduce disparities, for example, a healthcare organization might provide culturally sensitive care or targeted outreach to underserved populations.
Healthcare Policy refers to the laws, regulations, and guidelines that govern th… #
Healthcare Policy refers to the laws, regulations, and guidelines that govern the healthcare system, related terms include health reform, health insurance marketplace, and Medicaid expansion, the goal of healthcare policy is to improve healthcare accessibility, affordability, and quality, for instance, a healthcare policy might aim to increase funding for community health centers or expand Medicaid eligibility.
Healthcare Quality refers to the degree to which healthcare services meet… #
Healthcare Quality refers to the degree to which healthcare services meet established standards, related terms include quality improvement, patient safety, and clinical guidelines, the goal of healthcare quality is to ensure that patients receive high-quality, safe care, for example, a healthcare organization might use quality metrics to monitor and improve patient outcomes.
Healthcare Regulation refers to the laws, regulations, and guidelines that gover… #
Healthcare Regulation refers to the laws, regulations, and guidelines that govern the healthcare system, related terms include healthcare policy, licensure, and accreditation, the goal of healthcare regulation is to ensure patient safety, quality care, and financial integrity, for instance, a healthcare regulation might require healthcare providers to obtain licensure or certification.
Medicaid refers to a joint federal #
state program that provides health insurance coverage to low-income individuals and families, related terms include Medicaid expansion, health insurance marketplace, and Affordable Care Act, the goal of Medicaid is to provide healthcare access to vulnerable populations, for example, Medicaid might cover preventive services, such as annual physicals and screenings.
Medicare refers to a federal program that provides health insurance cover… #
Medicare refers to a federal program that provides health insurance coverage to individuals aged 65 and older, related terms include Medicaid, health insurance marketplace, and Affordable Care Act, the goal of Medicare is to provide healthcare access to older adults, for instance, Medicare might cover hospital stays, physician visits, and prescription medications.
Medical Home refers to a model of primary care that emphasizes patient #
centered, comprehensive, and coordinated care, related terms include primary care, care coordination, and patient navigation, the goal of the medical home model is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for example, a medical home might include a team of healthcare providers who work together to provide comprehensive care.
Network refers to a group of healthcare providers who have agreed to prov… #
Network refers to a group of healthcare providers who have agreed to provide care to patients at a negotiated rate, related terms include health insurance, provider network, and referral, the goal of a network is to provide patients with access to a range of healthcare services, for instance, a health insurance plan might include a network of primary care physicians, specialists, and hospitals.
Patient #
Centered Care refers to a model of care that emphasizes patient needs, preferences, and values, related terms include patient engagement, patient education, and shared decision-making, the goal of patient-centered care is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for example, a healthcare provider might involve patients in decision-making about their care.
Patient Engagement refers to the process of involving patients in their care<… #
Patient Engagement refers to the process of involving patients in their care, related terms include patient-centered care, patient education, and shared decision-making, the goal of patient engagement is to improve patient outcomes, reduce costs, and enhance patient satisfaction, for instance, a healthcare provider might use patient portals or mobile apps to engage patients in their care.
Patient Safety refers to the prevention of harm or injury to patients, re… #
Patient Safety refers to the prevention of harm or injury to patients, related terms include quality improvement, adverse event, and near miss, the goal of patient safety is to ensure that patients receive safe, high-quality care, for example, a healthcare organization might use safety protocols to prevent medication errors or falls.
Pay #
for-Performance (P4P) refers to a payment model that ties payment to performance metrics, such as quality or cost, related terms include value-based care, quality improvement, and cost reduction, the goal of P4P is to incentivize providers to deliver high-quality, cost-effective care, for instance, a P4P program might reward providers for meeting quality targets or reducing costs.
Population Health refers to the health and well #
being of a defined population, related terms include public health, health disparities, and health equity, the goal of population health is to promote health, prevent disease, and reduce health disparities, for example, a population health initiative might focus on improving access to healthy food, promoting physical activity, or providing health education and outreach.
Primary Care refers to the first level of contact between patients and the he… #
Primary Care refers to the first level of contact between patients and the healthcare system, related terms include primary care physician, specialty care, and referral, the goal of primary care is to provide patients with access to comprehensive, coordinated care, for instance, a primary care physician might provide routine check-ups, diagnose and treat illnesses, and refer patients to specialists.
Quality Improvement (QI) refers to the process of identifying and addressing opp… #
Quality Improvement (QI) refers to the process of identifying and addressing opportunities for improvement in healthcare, related terms include patient safety, quality metrics, and performance improvement, the goal of QI is to improve patient outcomes, reduce costs, and enhance quality of care, for example, a healthcare organization might use QI initiatives to reduce hospital readmissions or improve patient satisfaction.
Reimbursement refers to the process of paying healthcare providers for th… #
Reimbursement refers to the process of paying healthcare providers for their services, related terms include payment model, fee-for-service, and value-based care, the goal of reimbursement is to ensure that healthcare providers are fairly compensated for their services, for instance, a reimbursement model might pay providers based on the quality of care they provide.
Risk Management refers to the process of identifying and mitigating risks … #
Risk Management refers to the process of identifying and mitigating risks in healthcare, related terms include patient safety, quality improvement, and compliance, the goal of risk management is to minimize harm to patients, providers, and organizations, for example, a healthcare organization might use risk management strategies to prevent medical errors or reduce liability.
Telehealth refers to the use of technology to deliver healthcare s… #
Telehealth refers to the use of technology to deliver healthcare services remotely, related terms include telemedicine, remote monitoring, and virtual care, the goal of telehealth is to improve access to healthcare services, reduce costs, and enhance patient convenience, for example, a telehealth program might enable patients to receive virtual consultations or monitoring from home.
Value #
Based Care refers to a payment model that ties payment to value metrics, such as quality or cost, related terms include pay-for-performance, quality improvement, and cost reduction, the goal of value-based care is to incentivize providers to deliver high-quality, cost-effective care, for instance, a value-based care model might reward providers for meeting quality targets or reducing costs.
Value #
Based Payment (VBP) refers to a payment model that ties payment to value metrics, such as quality or cost, related terms include pay-for-performance, quality improvement, and cost reduction, the goal of VBP is to incentivize providers to deliver high-quality, cost-effective care, for example, a VBP model might reward providers for meeting quality targets or reducing costs.
Vulnerable Population refers to a group of individuals who are at risk for he… #
Vulnerable Population refers to a group of individuals who are at risk for health disparities or poor health outcomes, related terms include health disparities, health equity, and cultural competence, the goal of addressing the needs of vulnerable populations is to promote health equity and reduce disparities, for instance, a healthcare organization might provide targeted outreach or culturally sensitive care to vulnerable populations.