As with all technical areas there is a language used by people in that field which can be difficult for others to understand. In healthcare financing the terms come from a combination of health economics and actuarial science. This is a growing document and it will be expanded during the course of the policy brief series as needed. The IMSA NHI glossary is organised into subject areas and related concepts are defined together.
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- Clinical and financial risk assessment and management of healthcare with a view to facilitating appropriateness and cost-effectiveness of relevant healthcare services within what is affordable.
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- Management of patients with chronic diseases. The management includes medical treatment and monitoring, medication, education and lifestyle management.
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- A listing of prescribed medications. Under a closed formulary, benefits are only provided for medicines in the formulary. Under an open formulary benefits are available for other drugs based on the cost of the formulary drug.
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- A requirement in a policy contract that requires notification of the risk taker before accessing certain benefits. This usually applies to hospitalization under a medical scheme contract.
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- A set of guidelines in relation to the optimal sequencing of diagnostic testing and treatment for specific conditions.
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- Health Maintenance Organisation (HMO)
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- Is a medical care organisation designed to deliver and finance health care services. An HMO provides comprehensive health care services to its Members for fixed, prepaid Premiums. HMO models differ according to the type of relationship they have with Providers and Members. Some models are:
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- HMO’s employ medical specialists to provide health care to their Members. All premiums and other revenues accrue to the HMO’s which compensate the medical specialists by salary.
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- HMO’s contract with medical specialists organised as a partnership or professional corporation. The HMO compensates the medical group at a negotiated per capita rate and the group is responsible for compensating the medical specialists in the group.
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- Individual Practice Association
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- HMOs contract with an IPA entity to provide health care services in return for a Capitation fee. The IPA in turn contracts with medical specialists who continue in their existing individual or group practices.
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- Preferred Provider Organisation (PPO)
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- Is a program where contracts are established with providers of medical care in order to reduce the cost of medical care. Providers under such contracts are referred to as preferred providers. Usually better benefits are available for services received from preferred providers. Members may be allowed benefits for services from non-participating providers on an indemnity basis subject to limits or co-payments. The participating providers may be paid on a fee for service or capitation basis.
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