Healthcare Policy and Regulation
Expert-defined terms from the Advanced Professional Diploma in Healthcare Economics course at UK School of Management. Free to read, free to share, paired with a globally recognised certification pathway.
Healthcare Policy and Regulation Glossary #
Healthcare Policy and Regulation Glossary
A #
A
Accountable Care Organization (ACO) #
Accountable Care Organization (ACO)
- An ACO is a group of healthcare providers that work together to coordinate car… #
The goal of an ACO is to improve the quality of care while reducing costs by focusing on preventative care and better management of chronic conditions.
Accreditation #
Accreditation
- Accreditation is a process by which healthcare organizations are evaluated aga… #
Accreditation can be voluntary or mandatory depending on the type of organization.
Adverse Event #
Adverse Event
- An adverse event is any unintended harm caused to a patient during the course… #
Adverse events can range from minor complications to serious injuries or even death.
B #
B
Beneficiary #
Beneficiary
- A beneficiary is a person who is eligible to receive benefits from a healthcar… #
This term is commonly used in the context of Medicare and Medicaid programs.
Block Grant #
Block Grant
- A block grant is a type of funding provided by the federal government to state… #
Block grants give states more flexibility in how they use the funds, but they may also result in reduced federal oversight.
C #
C
Certificate of Need (CON) #
Certificate of Need (CON)
- A Certificate of Need is a regulatory process used by some states to determine… #
CON laws aim to prevent the overuse of healthcare services and control costs.
Clinical Practice Guidelines #
Clinical Practice Guidelines
- Clinical practice guidelines are evidence-based recommendations for healthcare… #
Guidelines are developed by expert panels and are intended to improve the quality of care.
Consumer #
Directed Health Plans
- Consumer-directed health plans are insurance plans that give individuals more… #
These plans typically have high deductibles and are paired with health savings accounts to help cover out-of-pocket costs.
D #
D
Drug Formulary #
Drug Formulary
- A drug formulary is a list of prescription medications that are covered by a h… #
Formularies are typically divided into tiers based on cost and may require patients to pay different copayments depending on the tier.
E #
E
Electronic Health Record (EHR) #
Electronic Health Record (EHR)
- An electronic health record is a digital version of a patient's medical histor… #
EHRs allow for the sharing of information between different providers and can improve coordination of care.
Employee Retirement Income Security Act (ERISA) #
Employee Retirement Income Security Act (ERISA)
- ERISA is a federal law that sets standards for private employer-sponsored heal… #
ERISA preempts state laws and regulations related to employee benefits, which can impact the regulation of health insurance.
Essential Health Benefits #
Essential Health Benefits
- Essential health benefits are a set of ten categories of services that health… #
These benefits include preventive care, prescription drugs, and maternity care, among others.
F #
F
Fee #
for-Service
- Fee-for-service is a payment model in which healthcare providers are paid for… #
This model has been criticized for incentivizing overutilization of services and driving up healthcare costs.
Formularies #
Formularies
- Formularies are lists of prescription medications that are covered by health i… #
Formularies may require patients to try lower-cost medications before more expensive drugs are covered, a process known as step therapy.
G #
G
Gatekeeper #
Gatekeeper
- A gatekeeper is a healthcare provider, typically a primary care physician, who… #
Gatekeepers help coordinate care and reduce unnecessary referrals.
Global Budget #
Global Budget
- A global budget is a fixed amount of money allocated to a healthcare organizat… #
Global budgets can help control costs but may also limit access to care.
H #
H
Health Information Exchange (HIE) #
Health Information Exchange (HIE)
- Health information exchange is the electronic sharing of patient information b… #
HIE can improve care coordination and reduce duplication of tests and treatments.
Health Insurance Marketplace #
Health Insurance Marketplace
- The health insurance marketplace is a platform where individuals and small bus… #
Marketplaces were established under the Affordable Care Act to increase access to coverage.
Health Maintenance Organization (HMO) #
Health Maintenance Organization (HMO)
- An HMO is a type of managed care organization that requires patients to see he… #
HMOs typically require patients to select a primary care physician who coordinates their care.
I #
I
Inflation Factor #
Inflation Factor
- The inflation factor is a measure of how much prices for goods and services in… #
The inflation factor is used to adjust payment rates for healthcare services.
Interoperability #
Interoperability
- Interoperability is the ability of different healthcare systems and software t… #
Interoperability is essential for improving care coordination and patient outcomes.
J #
J
Joint Commission #
Joint Commission
- The Joint Commission is an independent organization that accredits and certifi… #
Joint Commission accreditation is a recognized marker of quality in healthcare.
K #
K
Key Performance Indicators (KPIs) #
Key Performance Indicators (KPIs)
- Key performance indicators are specific metrics used to evaluate the performan… #
KPIs can include measures of quality, safety, efficiency, and patient satisfaction.
L #
L
Licensure #
Licensure
- Licensure is the process by which healthcare professionals are granted permiss… #
Licensure requirements vary by state and typically include education, training, and examination.
M #
M
Medicaid #
Medicaid
- Medicaid is a joint federal and state program that provides health insurance t… #
Medicaid covers a wide range of services, including hospital care, physician visits, and prescription drugs.
Medicare #
Medicare
- Medicare is a federal health insurance program for individuals aged 65 and old… #
Medicare is divided into several parts that cover hospital care, medical services, and prescription drugs.
N #
N
Network Adequacy #
Network Adequacy
- Network adequacy refers to the sufficiency of healthcare providers within an i… #
Regulators may set standards for network adequacy to ensure that patients have access to care.
O #
O
Outcomes #
based Payment
- Outcomes-based payment is a payment model that ties reimbursement for healthca… #
Providers may receive bonuses for meeting quality targets or penalties for poor performance.
P #
P
Patient #
Centered Medical Home (PCMH)
- A patient-centered medical home is a model of primary care that focuses on tea… #
PCMHs aim to improve quality, access, and efficiency of care.
Pay #
for-Performance
- Pay-for-performance is a reimbursement model that rewards healthcare providers… #
Providers may receive bonuses or penalties based on their performance.
Population Health Management #
Population Health Management
- Population health management is an approach to healthcare that focuses on impr… #
This may involve preventive care, chronic disease management, and addressing social determinants of health.
Preauthorization #
Preauthorization
- Preauthorization is the process by which a healthcare provider obtains approva… #
Preauthorization helps ensure that care is medically necessary and appropriate.
Q #
Q
Quality Improvement #
Quality Improvement
- Quality improvement is a systematic approach to assessing and improving the qu… #
Quality improvement initiatives may focus on patient outcomes, safety, and efficiency.
Quality Measures #
Quality Measures
- Quality measures are specific indicators used to assess the quality of care pr… #
Measures may include clinical outcomes, patient experience, and adherence to best practices.
R #
R
Reimbursement #
Reimbursement
- Reimbursement is the process by which healthcare providers are compensated for… #
Reimbursement rates can vary based on the type of service, payer, and payment model.
Regulation #
Regulation
- Regulation refers to the rules and guidelines established by governments or re… #
Regulations may cover areas such as licensure, accreditation, patient safety, and reimbursement.
S #
S
Scope of Practice #
Scope of Practice
- Scope of practice refers to the specific duties and responsibilities that heal… #
Scope of practice may vary by state and specialty.
Single #
Payer System
- A single-payer system is a healthcare financing model in which a single govern… #
Single-payer systems are designed to achieve universal coverage and control costs.
Stakeholder #
Stakeholder
- A stakeholder is an individual or group with a vested interest in the healthca… #
Stakeholders in healthcare may include patients, providers, insurers, regulators, policymakers, and advocacy groups.
T #
T
Telemedicine #
Telemedicine
- Telemedicine is the use of technology to deliver healthcare services remotely,… #
Telemedicine can improve access to care, particularly in rural or underserved areas.
U #
U
Utilization Review #
Utilization Review
- Utilization review is the process by which insurance plans evaluate the medica… #
Utilization review aims to ensure that care is delivered efficiently and effectively.
V #
V
Value #
Based Care
- Value-based care is a healthcare delivery model that focuses on improving pati… #
Providers are incentivized to deliver high-quality, efficient care rather than simply providing more services.
W #
W
Wellness Program #
Wellness Program
- A wellness program is a health promotion initiative designed to improve the ov… #
Wellness programs may include activities such as fitness challenges, smoking cessation programs, and stress management workshops.
X #
X
XML (Extensible Markup Language) #
XML (Extensible Markup Language)
- XML is a markup language used to encode and structure data in a format that is… #
XML is commonly used in healthcare for exchanging clinical information between different systems and applications.
Y #
Y
Yield Management #
Yield Management
- Yield management is a pricing strategy used in healthcare to optimize revenue… #
Yield management can help healthcare organizations maximize revenue while ensuring access to care.
Z #
Z
Zero #
Based Budgeting
- Zero-based budgeting is a budgeting approach in which all expenses must be jus… #
This method requires organizations to evaluate the necessity and value of every expense, which can help identify cost-saving opportunities.