| OCR Text |
Show community. Similar to the Usual, Customary, and Reasonable system used by private insurers. defined benefit Funding mechanisms for pension plans that can be applied to health benefits. Typical pension approaches include: (1) pegging benefits to a percentage of an employee's average compensation over his/her entire service or over a particular number of years; (2) calculation of a flat monthly, payment; (3) setting benefits based upon a definitive amount for each year of service, either as a percentage of compensation for each year of service or as a flat dollar amount for each year of service defined contribution Funding mechanism for pension plans that can also be applied to health benefits based on a specific dollar contribution, without defining the services to be provided. Deinstitutionalization Policy which calls for the provision of supportive care and treatment for medically and socially dependent individuals in the community rather than in an institutional setting. Diagnosis Related Groups (DRGs) Groupings of diagnostic categories drawn from the International Classification of Diseases and modified by the presence of a surgical procedure, patient age, presence or absence of significant comorbidities or complications, and other relevant criteria. DRGs are the case-mix measure used in Medicare's perspective payment system. antecedents of disease in human populations. Epidemiology utilizes biology, clinical medicine, and statistics in a effort to understand the etiology (causes) of illness and/or disease. The ultimate goal of the epidemiologist is not merely to identify underlying causes of disease but to apply findings to disease prevention and health promotion. expenditure target (ET) A mechanism to adjust fee updates (or the fees themselves) based on how actual expenditures in an area compare to a target for those expenditures. experience rating A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group. gatekeeper The primary care practitioner in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non routine services. The goal is to guide the patient to appropriate services while avoiding unnecessary and costly referrals to specialists. global budgeting A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system. epidemiology The study of patterns of determinants and global fee A total charge for a specific set of services, such as obstetrical services that encompass 135 |
