Glossary

HPIO has created what it hopes is an exhaustive list of terms most often heard in conversations about health policy. To suggest the addition of new terms, please contact nwiselogel@hpio.net

Scroll down to see all of the definitions or click a letter below to go to that section of the glossary. If you are using a PC, you may also use the F3 key or control+f function to search for a term.

A  B  C  D  E  F  G  H  I  K  L  M  O P  Q R  S  T  U  V W

A

Act – A bill passed by the legislature. (An act becomes law if it is signed by the governor or ten days after the governor takes no action.)

Affordable Care Act (ACA) – The health care reform law enacted in March 2010. The law was enacted in two parts: the Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.

Accountable Care Community (ACC) – A broadened concept of accountable care organizations (see below) that includes other entities, such as community-based prevention organizations, local health departments, or social service providers, in addition to health care providers, in the group held accountable for performance

Accountable Care Organization (ACO) – A group of health care providers who provide coordinated care, chronic disease management, and thereby improve the quality of care patients receive. The organization’s payment is tied to achieving health care quality goals and outcomes that result in cost savings.

Advance Directive – A legal document detailing individuals’ health care wishes, including the person to whom they give the legal authority to act on their behalf and what types of treatment they do and do not want to receive in the event they are unable to speak or communicate.

Adverse Selection – People with a higher-than-average risk of needing health care are more likely than healthier people to seek health insurance. Health coverage providers strive to maintain risk pools of people whose health, on average, is the same as that of the general population. Adverse selection results when the less healthy people disproportionately enroll in a risk pool.

Advocacy — Advocacy is any action that speaks in favor of, recommends, argues for a cause, supports or defends, or pleads on behalf of others. Policy advocacy includes many different activities designed to build  support for an issue or advance policy change, including educating the public and policymakers, letters to the editor, “call to action” email alerts, visiting elected officials, testifying for a legislative committee,  attending rallies, etc. Lobbying is a specific form of policy advocacy (see Lobbying).

Issue advocacy — An organization communicating positions on issues of social, economic or philosophical concern. Advocacy might include education or attempting to influence the public on health, social or economic subjects. The term is commonly used to mean all policy-related activities that are not intended to intervene in an election for or against a candidate for public office.
Legislative advocacy — Efforts to change policy through the legislative branch of government. This may include lobbying or other communications with the legislative branch that do not meet the definition of lobbying.
Media advocacy — The process of disseminating policy-related information through the
communications media, especially where the aim is to effect action, a change in policy, or to
alter the public’s view of issues. The strategic use of media as a resource for advancing a social or public policy initiative.

Aged, Blind, Disabled (ABD) – A Medicaid designation that assists with medical expenses for poor individuals who are aged 65 years or older, blind or disabled (disability as classified by the Social Security Administration for an adult or child).

Appropriation – Spending authority granted by the General Assembly, usually to a state agency.

B

Best available research evidence ― Evidence used to determine whether or not a prevention program, practice, or policy is actually achieving the outcomes it aims to and in the way it intends. The more rigorous a study’s research design, the more compelling the research evidence, indicating whether or not a program, practice, or policy is effectively preventing violence.

Biennium – A two-year period. Each Ohio General Assembly meets for one biennium and each state budget lasts one biennium. For example, the current biennium runs from January 2013 to December 2014.)

Bundled Payments – Use of a single payment for all services related to a treatment or condition, possibly spanning multiple providers in multiple settings. (Also referred to as case rates or episode-based payment).

Bill – A formal written document proposing to make a change in law by amending or repealing an existing provision of law or enacting a new provision.

Budget Bill – The spending proposal for the state submitted by the Governor and considered by both houses of the legislature. Ohio’s budget bill is for a two-year period (see: biennium).

C

Capitation – A method of payment for health services in which an individual or institutional provider is paid a fixed amount for each person served without regard to the actual number or nature of services provided to each person in a set period of time.

Case Management – A process where a health plan identifies covered individuals with specific health care needs (usually for individuals who need high-cost or extensive services or who have a specific diagnosis) and devises and carries out a coordinated treatment plan.

Catastrophic Coverage – A coverage option with limited benefits and a high deductible, intended to protect against medical bankruptcy due to an unforeseen illness or injury. These plans are usually geared toward young adults in relatively good health. While catastrophic plans do not generally cover preventive care, catastrophic coverage plans under health reform will be required to exempt some preventive care services from the deductible.

Categorically Needy – Medicaid’s eligibility pathway for individuals who can be covered. There are more than 25 eligibility categories organized into five broad groups: children, pregnant women, adults with dependent children, individuals with disabilities and the elderly. Persons not falling into one of these groups (notably childless adults) cannot qualify for Medicaid no matter how low their income. The ACA simplifies Medicaid eligibility, expanding coverage to all adults up to 138% of FPL (133% + 5% income disregard). This will extend eligibility to an estimated 560,000 Ohioans.

Centers for Medicare and Medicaid Services (CMS) – The federal agency within the Department of Health and Human Services that directs the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act). Formerly the Health Care Financing Administration (HCFA). www.cms.gov

Certificate of Need (CON) – A certificate issued by a  governmental body to an individual or organization  proposing to construct or modify a health facility, acquire major new medical equipment, modify a health facility or offer a new or different health service. CON is intended to control expansion of facilities, services and costs by preventing excessive or duplicative development of facilities and services.

Children’s Health Insurance Program (CHIP) – Enacted in 1997, CHIP is a federal-state program that provides health care coverage for uninsured low-income children who are not eligible for Medicaid. States have the option of administering CHIP through their Medicaid programs or through a separate program (or a combination of both). The federal government matches state spending for CHIP but federal CHIP funds are capped. Formerly known as SCHIP, or State Children’s Health Insurance Program, the name was changed when the program was reauthorized in 2009.

Clinical preventive services – Prevention services provided to individual patients in a healthcare setting.

Co-Insurance – A method of cost-sharing in health insurance plans in which the plan member is required to pay a defined percentage of their medical costs after the deductible has been met.

Consolidated Omnibus Budget Reconciliation Act (COBRA) – A 1986 act containing certain health benefit  provisions that amend ERISA, the IRS code and the Public Health Service Act to enable qualified individuals who lose their job to maintain the group coverage in which they were enrolled for an additional 18 months after leaving employment. Individuals are required to pay the standard premium of their previously provided plan. Applies to firms with more than 20 employees.

Community-based prevention programs – Prevention programs delivered in a community setting (such as home, school, child care, workplace, or neighborhood) to program participants as individuals, families, or communities.

Community-centered health homes – An emerging health model to bridge clinical services with community-based prevention programs and population-level policy strategies.   A provider practice that addresses the factors outside the healthcare system that impact patient health outcomes by advocating for policy, system and environmental change.

Consumer-Driven Health Care – Most commonly used to describe the combination of a high-deductible health insurance plan with a tax-preferred savings account used to pay for routine health care expenses.

Contextual evidence ― Contextual Evidence refers to information about whether or not a strategy “fits” with the context in which it is to be implemented. In other words, contextual evidence provides prevention practitioners with information on whether a strategy is feasible to implement, is useful, and is likely to be accepted by a particular community.

Community Rating – A method for setting premium rates under which all policy holders are charged the same premium for the same coverage. “Modified community rating” generally refers to a rating method under which health insuring organizations are permitted to vary premiums based on specified demographic characteristics (e.g. age, gender, location), but cannot vary premiums based on the health status or claims history of policy holders. Under health reform, beginning in 2014, health plans will be required to adopt modified community rating. Variations in premiums will only be allowed for differences in geography, family structure, age (limited to a 3 to 1 ratio) and tobacco use (limited to a 1.5 to 1 ratio).

Co-Payment – A fixed dollar amount paid by an individual at the time of receiving a covered health care service from a participating provider. The required fee varies by the service provided and by the health plan.

Cost-Shifting – Recouping the cost of providing uncompensated care by increasing revenues from some payers to offset losses and lower net payments from other payers. For example, hospitals may increase charges for some payers to offset losses due to uncompensated or indigent care or lower payments (e.g., Medicaid or Medicare) from other payers.

Credible ― The source of the information contributes to how worthy it is of belief when compared to external (who and where it comes from) and internal (independent knowledge of the subject) criteria.

Creditable Coverage – Health insurance that must meet minimum standards.

Crowd-Out – A phenomenon whereby new public programs or expansions of existing public programs designed to extend coverage to the uninsured prompt some privately insured persons to drop their private coverage and take advantage of the expanded public subsidy.

D

Deductible – A set amount of medical expenses a patient must pay before being eligible for benefits under an insurance program.

Department of Health and Human Services (HHS) – HHS is the U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. Many HHS-funded services, including Medicare, are provided at the local level by state or county agencies or through private sector grantees. The department’s programs are administered by 11 operating divisions, including eight agencies in the U.S. Public Health Service and three human services agencies.

Diagnostic Related Group (DRG) – A system used to classify patients (especially Medicare beneficiaries) for the purpose of reimbursing hospitals. Under the system, hospitals are paid a fixed fee for each case in a given category, regardless of the actual costs.

Disease Management – A process of identifying and delivering within selected patient populations (e.g., patients with asthma or diabetes) the most efficient, effective combination of resources, interventions or pharmaceuticals for the treatment or prevention of a disease.

Disproportionate Share Hospital Program (DSH) – A federal program that works to increase health care access for the poor. Hospitals that treat a “disproportionate” number of Medicaid and other indigent patients qualify for higher Medicaid payments based on the hospital’s estimated uncompensated cost of services to the uninsured.

Doughnut Hole – A gap in prescription drug coverage under Medicare Part D, where beneficiaries enrolled in Part D plans pay 100% of their prescription drug costs after their total drug spending exceeds an initial coverage limit until they qualify for catastrophic coverage. The coverage gap will be gradually phased out under health reform, so that by 2020, beneficiaries will only be responsible for 25% of all prescription drug costs up to the catastrophic level.

Dual Eligible – A person who is eligible for two health insurance plans, often referring to a Medicare beneficiary who also qualifies for Medicaid benefits.

E

Electronic Medical Record (EMR) – An individual medical record that has been digitized and stored electronically.

Emergency Medical Service (EMS) – Services utilized in responding to the perceived individual need for immediate treatment for medical, physiological, or psychological illness or injury.

Emergency Medical Treatment and Active Labor Act (EMTALA) – A  United States Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) requiring hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay.

Employee Retirement Income Security Act (ERISA) – A federal act passed in 1974 that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA are exempt from state insurance laws.

Environmental change — Physical or material changes to the economic, social, or physical environment (such as water fluoridation, removing lead from paint, and improving the built environment with sidewalks and bike lanes).

Essential Benefits – As specified in the ACA, plans in the health insurance exchange are required to offer coverage for “essential benefits” that must include: emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, preventive and wellness services and chronic disease management, and pediatric services (including pediatric oral and vision care).

Evidence-based practice ― Evidence-based practice involves making decisions on the basis of the best available scientific evidence, using data and information systems systematically, applying program-planning frameworks, engaging the community in decision making, conducting sound evaluation, and disseminating what is learned. Note: This is the definition was adopted by the Public Health Accreditation Board (PHAB).

Evidence-based prevention strategies ― Programs or policies that have been evaluated and demonstrated to be effective in preventing health problems based upon the best-available research evidence, rather than upon personal belief or anecdotal evidence.

Evidence-based public health ― The process of integrating science-based interventions with community preferences to improve the health of populations.

Experiential evidence ― The collective experience and expertise of those who have practiced or lived in a particular setting. It also includes the knowledge of subject matter experts. This insight, understanding, skill and expertise is accumulated over time and is often referred to as intuitive or tacit knowledge.

F

Federal Medical Assistance Percentage (FMAP) – The statutory term for the federal Medicaid matching rate—i.e., the share of the costs of Medicaid services or administration that the federal government bears. The American Recovery and Reinvestment Act (ARRA) provided a temporary increase in the FMAP (also known as enhanced FMAP or eFMAP) through December 31, 2010, and additional legislation partially extends this funding through June 30, 2011.

Federal Poverty Level (FPL) – Annually updated guidelines established by the U.S. Department of Health and Human Services to determine eligibility for various federal and state programs. In 2014, the FPL for a family of four is $23,850.

Federally-Qualified Health Center (FQHC) – A health center in a medically under-served area or population that is eligible to receive cost-based Medicare and Medicaid reimbursement and provides direct reimbursement to nurse practitioners, physician assistants and certified nurse midwives. FQHCs are sometimes referred to as CHCs (Community Health Centers). A CHC is an ambulatory health care program usually serving a catchment area that has scarce or non-existent health services or a population with special needs.

Fee-for-Service – A traditional method of paying for medical services under which doctors and hospitals are paid for each service they provide. Bills are either paid by the patient, who then submits them to the insurance company, or are submitted by the provider to the patient’s insurance carrier for reimbursement.

Fidelity ― The degree to which a program, practice, or policy is conducted in the way that it was intended to be conducted. This is particularly important during replication, where fidelity is the extent to which a program, practice, or policy being conducted in a new setting mirrors the way it was conducted in its original setting.

Fiscal year (FY) – A 12-month budget and accounting period that is named for the year in which it ends. The state’s fiscal year begins on July 1. Note that different entities (school districts, municipalities, the federal government) can have different fiscal years.

Flexible Spending Account (or a Section 125 option) – An employer-sponsored benefit plan that enables employees to use pretax (tax free) dollars to pay for medical expenses or the cost of care for children or elderly dependents, up to legislated limits and within specific guidelines.

Formulary – see Preferred Drug List

Fully insured plan – An insurance plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims and for all incurred administrative costs.

G

Grandfathered Plan – A health plan that was in place on March 23, 2010, when the health reform law was enacted, is exempt from complying with some parts of the health reform law, so long as the plan does not make significant changes to its policy. Once a health plan makes changes to its policy, the policy becomes subject to all the requirements of health reform.

Grey literature ― Electronic and print format documents produced by government agencies, academic institutions and other organizations not controlled by commercial publishing.

Guaranteed Issue – Requires insurers to offer and renew coverage, without regard to health status, use of services, or pre-existing conditions. This requirement ensures that no one will be denied coverage for any reason. Beginning in 2014, the health reform law will require guarantee issue and renewability.

H

Health — A state of complete physical, social, and mental wellbeing, and not merely the absence of disease or infirmity.

Health disparities — Differences in health status among distinct segments of the population including differences that occur by gender, race or ethnicity, education or income, disability, or living in various geographic localities.

Health equity — Equal opportunity for members of all populations to disease prevention, healthy outcomes, or access to health care, regardless of race, gender, nationality, age, ethnicity, religion, sexual orientation, immigration status, language skills, healthy status, or socioeconomic status.

Health Impact Pyramid — Introduced by Thomas Frieden in 2010, the Health Impact Pyramid describes the impact of different types of public health strategies and provides a framework for identifying activities with the greatest potential for improving population health. The pyramid has five levels: 1) Socioeconomic factors, 2) Changing the context to make individuals’ default decisions healthy, 3) Long-lasting protective factors, 4) Clinical interventions, and 5) Counseling and education. Activities toward the base of the pyramid require minimal individual effort and have the greatest leverage for improving population health, while activities toward the top of the pyramid require increased individual effort and reach smaller segments of the population.

Health in All Policies – A collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas.

Health Information Exchange (HIE) – Health Information Exchange is the transmission of healthcare-related data among facilities, health information organizations and government agencies according to national standards.

Health Information Technology (HIT) – The secure sharing of medical information to assist health care providers in managing patient care. HIT includes the use of electronic medical records (EMRs) instead of paper medical records to maintain people’s health information.

Health Insurance Exchange – A way to pool risk, the Health Insurance Exchange is a competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges offer a choice of health plans that meet certain benefits and cost standards. The Exchange can set standards beyond those required by the federal government, accept bids, and negotiate contracts with insurers. An example of this arrangement is the Commonwealth Connector, created in Massachusetts in 2006. Under the ACA, states will have the option to either establish their own exchanges or participate in a national exchange starting in 2014.

Health Insurance Exchange Navigators – Health Insurance Exchanges will be required to contract with professional associations and local organizations to provide Exchange Navigator services. These services include providing education and information about qualified health plans that is culturally and linguistically appropriate; distributing fair and impartial information about enrollment; facilitating enrollment in health plans; and providing referrals for any enrollee with a grievance, complaint, or question regarding a health plan.

Health Insurance Exchange Plans – The Health Insurance Exchanges established under the ACA must offer four levels of coverage (bronze, silver, gold, platinum plans) based on the plan’s actuarial value.

Health Insurance Portability & Accountability Act (HIPAA) – Passed by Congress in 1996, HIPAA includes various health insurance coverage and patient privacy protections. The privacy rules were established to protect patients’ privacy through the strict enforcement of confidentiality of medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Health insuring corporation (HIC) – See health maintenance organization

Health Maintenance Organization (HMO) – Known as health insuring corporations (HICs) in Ohio, HMOs are  health  insurance plans that provide a coordinated array of preventive and treatment services for a fixed payment per month. HMOs provide services through a panel of health care providers. Enrollees receive medically necessary  services regardless of whether the cost of those services exceeds the premium paid on the enrollees’ behalf.

Health Professional Shortage Area (HPSA) – HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups or medical or other public facilities.

Health promotion — The process of enabling people to increase control over, and to improve their health.

Health Reimbursement Account (HRA) – A tax-exempt account that can be used to pay for current or future qualified health expenses. HRAs are established benefit plans funded solely by employer contributions, with no limits on the amount an employer can contribute. HRAs are often paired with a high-deductible health plan, but do not have to be. Also know as a Health Reimbursement Arrangement.

Health Resources and Services Administration (HRSA) – An agency of the U.S. Department of Health and Human Services (HHS), HRSA is the primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable.

Health Savings Account (HSA) – An HSA is a tax exempt savings account for medical expenses. Funds can be withdrawn from an HSA to meet the deductible of the HDHP (see below) and pay for other medical services and supplies.

High Deductible Health Plan (HDHP) – An HDHP is an inexpensive health insurance plan that generally does not pay for the first several thousand dollars of health care expenses (i.e., the “deductible”) but will generally cover medical care after the deductible is met. HDHPs may have first dollar coverage (no deductible) for preventive care and apply higher out-of-pocket limits (and co-pays and coinsurance) for non-network services.

High-Risk Pool – A subsidized health insurance pool organized by some states as an alternative for individuals who have been denied health insurance because of a medical condition, or whose premiums are rated significantly higher than the average due to health status or claims experience. Under federal health reform, Ohio has established a high-risk pool that is being administered by Medical Mutual of Ohio. (http://www.ohiohighriskpool.com/)

Home and Community-Based Services (HCBS) – Any care or services provided in a patient’s place of residence or in a non-institutional setting located in the immediate community.

Hospice – A facility or program designed to care for patients in the terminal phase of an illness.

Hospital community benefit requirements – Federal Internal Revenue Service requirements that nonprofit hospitals must meet to maintain their nonprofit status.

I

Implementation guidance ― Resources such as training, coaching, technical assistance, manuals/guides, curricula, policy templates, or other documentation that help practitioners to implement a strategy as intended. Implementation guidance is typically created by the original developers of a program in order to facilitate replication.

Individual Mandate – The requirement that all individuals must obtain health care insurance or pay a penalty. The individual mandate will  be in place by 2014, although some exceptions do apply (financial hardship, religious reasons). The penalty, in the form of a tax, will be $95 per individual or up to 1% taxable income in 2014, whichever is lower. It increases to $325 or up to 2% taxable  income in 2015 and $695 or up to 3% taxable income in 2016.

Investment for health — Resources which are explicitly dedicated to the production of health and improved health outcomes. They may be invested by public and private agencies as well as by people as individuals and groups. Investment for health strategies are based on knowledge about the determinants of health and seek to gain political commitment to health public policies

K

Katie Beckett Children – Disabled children who qualify for home care coverage under a special provision of Medicaid, named after a girl who remained institutionalized solely to continue Medicaid coverage before the provision’s enactment. Also known as a “Deeming Waiver.”

L

Legislation — Action by a legislative body, including the “introduction, amendment, enactment, defeat or repeal of Acts, bills, resolutions, or similar items.” It includes actions by Congress, a state legislature, a similar local legislative body, or any actions by the general public in a referendum question, initiative petition, or proposed constitutional amendment. Note that judicial, executive, and administrative bodies, including special purpose bodies like school and zoning boards, are not legislative bodies.

Lobbying — Lobbying is an attempt to influence specific legislation by communicating views to legislators or asking people to contact their legislators. See also direct lobbying and grassroots lobbying.

Direct lobbying — Occurs when an organization communicates with a legislator or legislative staff member (or any other government employee who may participate in the formulation of the legislation, but only if the principal purpose of the communication is to influence legislation) about a specific piece of legislation and reflects a view on that legislation. Direct Lobbying also encompasses any communication with the general public expressing a view about a ballot initiative, referendum, bond measure, or similar procedure.
Grassroots lobbying — A communication with the general public that reflects a view on specific legislation and includes a call to action that encourages people to contact their legislative representatives or staff in order influence that legislation.

Long-Term Care (LTC) – A set of health care, personal care and social services provided to persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis.

M

Managed Care – health care systems that integrate the financing and delivery of appropriate health care services to covered individuals.  Managed care systems arrange with selected providers to furnish a comprehensive set of health care services.

Media framing — The process of selecting and organizing information in order to present relevant events and suggest what is at issue in a manner than makes sense to media producers and audiences.

Medicaid – A federally-aided, state-administered and jointly-funded health insurance program that provides medical benefits to qualified indigent or low-income persons in need of health and medical care. The program is subject to broad federal guidelines and states determine the benefits covered and methods of administration.

Medical Home – An approach to providing comprehensive primary care that facilitates partnerships between individual patients, and their personal providers, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need it in a culturally and linguistically appropriate manner.

Medical Loss Ratio (MLR) – The percentage of premium dollars an insurance company spends on medical care, as opposed to administrative costs or profits. The health reform law requires insurers in the large group market to have an MLR of 85% and insurers in the small group and individual markets to have an MLR of 80%.

Medicare – A federally funded health insurance plan that provides hospital, surgical and medical benefits to elderly persons over 65 and certain disabled persons. Medicare Part A provides basic hospital insurance, and Medicare Part B provides benefits for physicians’ professional services. Medicare Part C (Medicare Advantage Plan) allows those covered to combine their coverage under Parts A and B but is provided by private insurance companies. Medicare Part D helps pay for medications doctors prescribe for treatment.

Message framing — The way a story is told – its selective use of particular symbols, metaphors, and messengers, for example – and to the way these cues, in turn, trigger the shared and durable cultural models that people use to make sense of their world. Reframing changes the lens through which a person can think about an issue, so that different interpretations and outcomes become visible to them.

Mid-Biennium Budget Review (MBR) – A review of state agencies’ budgets and spending, conducted halfway through the two-year main operating budget cycle.

O

Ohio Revised Code (ORC) – Compilation of all current statutes of the Ohio General Assembly of a permanent and general nature.

P

Patient Centered Medical Home – A provider practice that receives additional payments in exchange for the delivery of care coordination services that are not currently provided or reimbursed.

Patient Self Determination Act (PSDA) – A federal law passed by the U.S. Congress in 1990, mandates that most hospitals provide patients with information on state laws regarding their right to refuse medical treatment and document their preferences through an advance directive.

Pay-for-Performance (P4P) – A health care payment system in which providers receive incentives for meeting or exceeding quality and cost benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay for performance programs is to improve the quality of care over time.

Peer-reviewed literature ― Articles and reports that have gone through a formal process to assess quality, accuracy and validity.

Pharmaceutical Assistance Program – A program to provide pharmaceutical coverage to those who cannot afford or have difficulty obtaining prescription drugs. Several states, including Ohio, operate state-funded pharmaceutical assistance programs which primarily provide benefits to low-income elderly or persons with disabilities who do not qualify for Medicaid. (http://www.rxforohio.org/)

Pharmacy Benefit Manager (PBM) – Companies that manage drug benefit coverage for employees and health plan members.

Policy — Laws, regulations, rules, protocols, mandates, resolutions, and ordinances designed to guide or influence behavior. Public policy refers to legislative (laws, ballot measures), legal (court decisions), fiscal (government budgets), and regulatory actions (including administrative rules and executive orders). Organizational policy refers to internal standards and protocols established by public or private organizations, such as workplace or school wellness policies.

Policy agenda — A set of policies or issues to be addressed or pursued by an individual, group, or
organization. Agenda setting refers to the process of placing issues on the policy agenda for public
consideration and intervention.

Policy analysis — The use of reason and evidence to select the best policy among a number of alternatives to address a particular policy problem.

Policymaker — A person with power to influence or determine policies and practices at a national, state, regional, or local level. Public policymakers include elected and appointed officials and leaders of public agencies. State-level public policymakers include legislators, the governor, state agency leaders, and state boards. Local level public policymakers include mayors, county commissioners, city council members, public boards and commissions, and school superintendents.

Policy, system and environmental change (PSEC) — Policy, system and environmental change is a way to modify the environment to make healthy choices practical and available to all community members. See Ohio Wellness and Prevention Network’s “What is ‘Policy, System, and Environmental Change’?” fact sheet.

Population-based prevention policies — Policy change strategies designed to reach all residents of a geographic area or all people in a community setting (such as a school or workplace) in order to modify the environment to make healthy choices practical and available to all community members. See also, policy, systems and environmental change.

Population health — The health outcomes of a group of individuals, including the distribution of such outcomes within the group. The field of population health focuses on the determinants of health (including medical care, public health interventions, social environment, physical environment, genetics, and individual behavior) and the policies and programs that influence those determinants and reduce health disparities among population groups.

Preferred Drug List (PDL) – A list of prescription drugs which are covered by a health plan or other payer (e.g., Medicaid).  Also known as a formulary.

Preferred Provider Organization (PPO) – A health insurance plan in which health care providers agree to provide services to members at a negotiated price. Covered individuals (members) receive all medically necessary services regardless of whether the cost of the services exceeds the premium paid, although members do have cost sharing obligations.

Prevention — A systematic process that promotes healthy behaviors and reduces the likelihood or frequency of an incident, condition, or illness. Ideally, prevention addresses health problems before they occur, rather than after people have shown signs of disease or injury. There are two commonly used systems for classifying levels of prevention. The first is based on the timing of prevention activity relative to the onset of the health problem: Primary, Secondary, and Tertiary. The second classification was developed in the field of substance abuse prevention and refers to the level of risk in the population addressed: Universal, Selected, and Indicated. For more details, see Ohio Wellness and Prevention Network’s Prevention Policy and Advocacy Glossary.

Prevention organization — Any organization that is working to promote health and prevent illness and disability. This includes government public health agencies, community-based organizations, trade associations, coalitions, health care providers, employers, philanthropies, grass-roots groups and others who are working in the areas of prevention, wellness, population health or health promotion.

Primary Care Provider (PCP) – In insurance terms, a physician selected by or assigned to a patient who provides general care and supervises the patient’s access to other medical services.

Primordial prevention – An approach to prevention that targets underlying health determinants via modifying social policies so as to improve health in general .

Prior Authorization – Under a system of utilization review, a requirement imposed by a health plan or third party administrator that a provider justify the need for delivering a particular service in order to receive reimbursement. Prior authorization may apply to all services or only to those that are potentially expensive and/or overused.

Public health — The science and art of promoting health, preventing disease, and prolonging life through the organized efforts of society. Public health organizations include government agencies at the federal, state, and local levels, as well as nongovernmental organizations that are working to promote health and prevent disease and injury within entire communities or population groups.

Public policy — Public policy is a series of governmental decisions and actions that are intended to address a perceived public problem. They can be expressed as local, state or federal governmental action, such as legislation, appropriations, administrative practices and court decisions.

Q

Quasi-experimental designs ― Experiments based on sound theory, and typically have comparison groups (but no random assignment of participants to condition), and/or multiple measurement points (e.g., pre-post measures, longitudinal design).

Quaternary prevention ― The avoidance of unnecessary or excessive medical interventions.  For the purposes of this publication, quaternary prevention is included within the category of treatment.

R

Randomized control trial ― A trial in which participants are assigned to control or experimental (receive strategy) groups at random, meaning that all members of the sample must have an equal chance of being selected for either the control or experimental groups (i.e. flipping a coin, where “heads” means participants are assigned to the control group and “tails” means they are assigned to the experimental group). This way, it can be assumed that the two groups are equivalent and there are no systematic differences between them, which increases the likelihood that any differences in outcomes are due to the program, practice, or policy and not some other variable(s) that the groups differ on.

Regulation — A rule or order that has the force of law that originates from the executive branch (usually from an agency), and deals with the specifics of a program.

Rigorous ― Extremely thorough adherence to strict rules or discipline to ensure as accurate results as possible.

Rule – Statements adopted by an agency to make the law it administers more specific or to govern the agency’s organization or procedure. Administrative rules are not enacted by the legislature; instead the legislature gives agencies the authority to establish its own rules. These administrative rules have the force and effect of law.

Rural Health Clinic – A public or private hospital, clinic, or physician practice designated by the federal government as in compliance with the Rural Health Clinics Act (Public Law 95-210). The practice must be located in a medically under¬served area or a Health Professional Shortage Area (HPSA) and use physician assistants and/or nurse practitioners to deliver services.

Rural Health Network – Refers to any variety of organizational arrangements to link rural health care providers in a common purpose.

S

Safety Net – The safety net is made up of providers and institutions that provide low cost or free medical care to medically needy, low income or uninsured populations.

Self-insured plan – A group health plan in which the employer assumes the financial risk for providing health care benefits to its employees. Also called a ‘self-funded’ plan.

Social determinants of health — Conditions in the environments in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. In addition to the social, economic and physical conditions of a person’s environment, social determinants also include patterns of social engagement and sense of security and well-being. Examples of resources that can influence (or, “determine”) health outcomes include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services and environments free of life-threatening toxins.

Spectrum of prevention — A framework for developing effective and sustainable primary prevention programs. The spectrum consists of six levels of prevention activities that are most effective when implemented together as part of a comprehensive prevention strategy: 1) Strengthening individual knowledge and skills, 2) Promoting community education, 3) Educating providers, 4) Fostering coalitions and networks, 5) Changing organizational practices, 6) Influencing policy and legislation.

Supplemental Security Income (SSI) – A federally funded cash assistance program for low-income elderly, blind and disabled individuals who have little or no income with basic needs, such as food, clothing and shelter. Once eligible for SSI, these individuals are also eligible for Medicaid.

System change — System change involves change made to rules and practices within an organization, institution or system (such as school, transportation, park, food distribution or health care systems).

Systematic reviews ― A literature review that attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria. Systematic reviews of randomized controlled trials are considered to the “gold standard” of evidence.

T

Trauma System – A trauma system is an organized, coordinated effort in a defined geographic area that delivers the full range of emergency care to all injured patients and is integrated with the local public health system.

Treatment – What a health care provider does to relieve, reduce, or eliminate harm once it has become manifest in an ailment.

Triple Aim – A term used to describe an approach for enhancing health system performance.  The goals of the Triple Aim, as conceptualized by the Institute for Healthcare Improvement are: improve the patient experience of care, improve health of populations, and reduce the per capita cost of health care.

U

Uncompensated Care – Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers.

Underinsured – People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay.

Uninsured – People who lack public or private health insurance.

Upstream prevention – Health improvement approaches that address the causes of health problems rather than just the symptoms.  Upstream strategies often involve non-clinical/community-based programs and policies that address the social determinants of health.

Utilization – Commonly examined in terms of patterns or rates of use of a single service or type of service (e.g., hospital care, physician visits, and prescription drugs). Use is also expressed in rate per unit of population at risk for a given period of time.

Utilization Review – The critical examination, usually conducted by an insurer or third party administrator, of the necessity and/or appropriateness of the health care services provided to an individual patient.

V

Value-Based Purchasing – A payment reform under which hospitals and other providers are provided bonuses based upon their performance against quality measures. The health reform law establishes a value-based purchasing program in Medicare for hospitals and requires the development of similar programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers, and the testing of pilot programs for other providers.

W

Wellness — Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the full potential of the individual physically, psychologically, socially, spiritually and economically, and the fulfillment of one’s role expectations in the family, community, place of worship, workplace and other settings.