"REFORMSPEAK": SOME TERMS
YOU SHOULD KNOW
Fee for Service.
Global Budget. This is the annual, government-established target or spending limit for the country’s health expenditures. In its most extreme form, specific limits would be set for each state as well as for the nation.
Health Maintenance Organization (HMO). An HMO is a medical-care-provider corporation organized to deliver both office-based medical care and necessary hospitalization for subscribers who pay one prepaid monthly or annual fee (packages vary). HMOs have their own staff of primary-care doctors and nurses, and expensive visits, procedures, and hospitalization are restrained. Subscribers who seek care outside the HMO will have to pay for bills they incur. HMOs may be for-profit or nonprofit, and can be set up by government, insurance companies, unions, or other groups. HMOs are the oldest type of managed care.
Independent Practice Association (IPA). An IPA contracts with doctors who are in private practice to care also for some patients in different HMOs and other health plans, presumably for less cost.
Managed Care. This is any system that controls costs by monitoring and controlling decisions made by doctors and hospitals under various types of health planes. HMOs and PPOs are two types. Managed care may set up specific guaranteed services of doctors and hospitals to subscribers based on fixed prepaid fees or premiums. A key component of any type of managed-competition plan, managed care is usually profit motivated but may also reduce unnecessary or risky treatments.
Managed Competition. This is an untested theory combining health care services and financing mechanisms. It is tied to employment and based on the profit-making insurance principle, but with vastly expanded regional markets. A few very large health-insurance plans would be forced to compete for large pools of subscribers in each region. Groups of employers or other subscriber offering benefits, variously called health insurance purchasing cooperatives, or alliances (HIPCs, HIPAs), would "shop" for the best plan. Insurers would be obliged to offer (defined) basic coverage packages to everyone in a prepaid managed-care system with global budgets (package price set in advance) and capitation (a fixed fee to care for each person for a fixed time). Theoretically, the best plan would be the cheapest and would win the competition, keeping prices down and avoiding price control.
PAC Money. Political action committees, special interest groups, give funds to members of Congress to finance their campaigns, securing their loyalty in key legislation battles. (see box, "Political Action Committee [PAC] Contributions and Women")
Play or Pay. This is a "carrot and stick" approach to employers that would require them to either provide health-insurance coverage for their employees ("play") or else "pay" the federal government, which would provide it through payroll taxes.
Primary Care. Primary care is generally defined by health experts to mean health or medical care given by a generalist, someone with broad training who is skilled in recognizing special problems and who will refer a patient to specialists if needed. Nurses with additional training, like nurse practitioners, midwives, and physician’s assistants, now function as primary care practitioners in doctor’s offices, public health systems, and managed care programs, as do many physicians, such as family-practice doctors, internists, and geriatricians. The obstetrician-gynecologist, a surgical specialist, is not trained as a primary-care provider and should not be so designated, although many women use them for primary care.
Preferred Provider Organization (PPO). In a PPO, which is one of several managed-care approaches, doctors and hospitals form corporations to give volume discounts to insurance companies to help lower copayments for subscribers who choose from a large list of providers in private practice. PPOs are rarely nonprofit.
Provider. Any health worker or health facility eligible (by license or other mechanism) to receive payment for a medical visit or service, regardless of who pays the bill.
Public Interest. This describes the viewpoint of consumers or citizens, especially to benefit or protect the most vulnerable members of the public, including the poor, the elderly, people with disabilities.
Single Payer. This is a principle similar to public utilities in which one national, centralized nonprofit utility, or a government agency like the Social Security Administration, would be responsible for both collecting and disbursing the money needed to pay medical-care bills. Canada works on this principle and covers everyone for less, with agreed fee schedules for providers and systemwide access for consumers. A single payer would replace the approximately twelve hundred (mostly profit-making) U.S. insurance companies now handling medical claims. Two independent federal agencies agree this saves the most money and is the fairest way to expand coverage. As we go to press, the Health Security Act of 1993 is the most popular single-payer bill before Congress.
Utilization Review. This is the practice of regularly examining all the processes of medical care—tests, treatments, hospitalizations, and other services—so as to limit the unnecessary ones.