| Show 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 where institutions were reimbursed for actual expenses incurred public health The science dealing with the protection and improvement of community health by organized community effort Public health activities are generally those which are less amenable to being undertaken by individuals or which are less effective when undertaken on an individual basis and do not typically include direct personal health services Public health activities include immunizations sanitation preventive medicine quarantine and other disease control activities occupational health and safety programs assurance of the healthfulness of air water and food health education epidemiology and others quality of care Can be defined asmeasure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other untoward outcomes given the existing state of medical science and art Quality is frequently described as having three dimensions quality of input resources certification and or training of providers quality of the process of services delivery the use of appropriate procedures forgiven condition and quality of outcome of service use actual improvement in condition or reduction of harmful effects rate band The allowable variation in insurance premiums as defined in state regulations Acceptble variation may be expressed asratio from highest to lowest g 1 or aspercent from the community rate 20 Usually based on risk factors such as age gender occupation or residence reinsurance The resale of insurance products to secondary market thereby spreading the costs associated with underwriting resource-based relative value scale RBRVS Established as part of the Omnibus Reconciliation Act of 1989 Medicare payment rules for physician services was altered by establishing an RBRVS fee schedule This payment methodology has three components relative value for each procedure geographic adjustment factor anddollar conversion factor risk adjustmentprocess by which premium dollars are shifted fromplan with relatively healthy enrollees to another with sicker members Itintended to minimize any financial incentives health plans may have to select healthier than average enrollees In this process health plans which attract higher risk providers and members would be compensated for any differences in the proportion of their members that require high levels of care compared to other plans risk-bearing entity An organization that assumes financial responsibility for the provision ofdefined set of benefits by accepting prepayment for some or all of the cost of care riskbearing entity may be an insurer health plan or self-funded employer orPHO or other form of PSN risk selection Digital image 2005 Marriott Library University of Utah Al rights reserved |
