malpractice — professional misconduct or failure to apply ordinary skill in the performance of a professional act. A practitioner is liable for damages or injuries caused by malpractice. For some professions such as medicine, malpractice insurance can cover the costs of defending suits instituted against the professional and/or any damages assessed by the court, usually up to a maximum limit. To prove malpractice, a patient must demonstrate some injury that was caused by negligence.
managed care — the body of clinical, financial and organizational activities designed to ensure the provision of appropriate health care services in a cost-efficient manner. Managed care techniques are most often practiced by organizations and professionals that assume risk for a defined population (e.g., health maintenance organizations).
management services organization — an organization that provides administrative and practice management services to physicians, which may be owned by a hospital, a group of hospitals or investors. Large group practices may also establish management services organizations to sell management services to other physician groups.
Medicaid (Title XIX) — a federally aided, state-operated and -administered program that provides medical benefits for certain indigent and low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for low-income people. It does not cover all of low-income individuals, however, but only persons who meet specified eligibility criteria. Subject to broad federal guidelines, states determine the benefits covered, program eligibility, rates of payment for providers and methods of administering the program.
Medi-Cal — the name given to California’s Medicaid program.
medical audit — detailed retrospective review and evaluation of selected medical records by qualified professional staff. Medical audits are used in some hospitals, group practices and occasionally in private, independent practices for evaluating professional performance by comparing it with accepted criteria, standards and current professional judgment. A medical audit is usually concerned with the care of a given illness and is undertaken to identify deficiencies in that care in anticipation of educational programs to improve it.
medically indigent — persons who cannot afford needed health care because of insufficient income and/or lack of adequate health insurance.
medically needy — persons who are categorically eligible for Medicaid and whose income, less accumulated medical bills, is below state income limits for the Medicaid program.
medically underserved area — a whole county, a group of contiguous counties, a group of county or civil divisions, or a group of urban census tracts in which residents have a shortage of personal health services. The term is used to give priority for federal assistance.
medically underserved population — a population experiencing a shortage of personal health services. A medically underserved population may or may not reside in a particular medically underserved area or be defined by its place of residence. Thus, migrants, Native Americans and inmates of a prison or mental hospital may constitute such a population. The term is defined and used to give priority for federal assistance.
Medicare (Title XVIII) — A U.S. health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited into special trust funds for use in meeting the expenses incurred by the insured. Medicare consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B).
Medicare approved charge — the amount Medicare approves for payment to a physician. Typically, Medicare pays 80 percent of the approved charge, and the beneficiary pays the remaining 20 percent. Physicians may bill beneficiaries for an additional amount (the balance) not to exceed 15 percent of the Medicare approved charge.
mental disorders — health conditions characterized by alterations in thinking, mood or behavior or some combination thereof, associated with distress or impaired functioning.
mental health — the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity. From early childhood until late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience and self-esteem.
mental health services — services, as defined under some state laws and federal statutes, that include the following with regard to mental health: inpatient care, outpatient care, day care and other partial hospitalization and emergency services; specialized services for the mental health of children; specialized services for the mental health of the elderly; consultation and education services; assistance to courts and other public agencies in screening catchment area residents; follow-up care for catchment area residents discharged from mental health facilities or who would require inpatient care without such halfway house services; and specialized programs for the prevention, treatment and rehabilitation of alcohol and drug abusers.
mental illness — the term that refers collectively to all mental disorders.
morbidity — the extent of illness, injury or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.
mortality rate — used to describe the relation of deaths to the population in which they occur. The mortality rate (or death rate) expresses the number of deaths in a unit of population within a prescribed time and may be expressed as crude death rates (e.g., total deaths in relation to total population during a year) or as death rates specific for diseases and, sometimes, for age, sex or other attributes (e.g., number of deaths from cancer in white males in relation to the white male population during a given year).
network — an affiliation of health care providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services.
nurse — an individual trained to care for the sick, aged or injured. A nurse can be defined as a professional qualified by education and authorized by law to practice nursing. There are many different types, specialties and grades of nurses.
nurse practitioner — a registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities and other health care institutions. Nurse practitioners generally function under the supervision of a physician but not necessarily in his or her presence. They are usually salaried rather than reimbursed on a fee-for-service basis, although supervising physicians may receive fee-for-service reimbursement for their services.
nursing homes — a wide range of institutions that provide various levels of maintenance and personal or nursing care to people who are unable to care for themselves and who have health problems that range from minimal to very serious. The term includes both free-standing institutions and identifiable components of other health facilities that provide nursing care and related services, personal care and residential care. Nursing homes include skilled nursing facilities and extended care facilities but not boarding homes.
Obamacare — See Affordable Care Act.
occupancy rate — a measure of the use of an inpatient health facility determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
occupational health services — health services concerned with the physical, mental and social well-being of an individual in relation to his or her working environment and with the adjustment of individuals to their work. The term applies to more than the safety of the workplace and includes health and job satisfaction. In the U.S., the principal federal statute concerned with occupational health is the Occupational Safety and Health Act administered by the Occupational Safety and Health Administration and the National Institute of Occupational Safety and Health.
open enrollment — a method for assuring that insurance plans, especially prepaid plans, do not exclusively select good risks. Under an open enrollment requirement, a plan must accept all who apply during a specific period each year. It also prevents a person from enrolling in a plan to get services covered and then drop the plan when services are no longer needed.
oral health — the state of being free from chronic mouth and facial pain, oral and throat cancer, oral sores, birth defects such as cleft lip and palate, gum disease, tooth decay, tooth loss and other diseases and disorders that affect the mouth.
outcomes research — research on measures of changes in patients’ health status and satisfaction resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of the many other factors that influence patients' health and satisfaction.
outpatient — a patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. Usually, the term does not include people receiving services from a physician's office or other program that does not provide inpatient care.
participating physician — a physician who signs an agreement to accept assignment on all insurance claims for one year from a particular insurance plan or program, such as Medicaid.
passive intervention — a health promotion and disease prevention initiative that does not require the direct involvement of the individual (e.g., fluoridation programs). Most often, these types of initiatives are government sponsored.
patient-centered medical home — a health care delivery model whereby a patient’s treatment is coordinated through his or her primary care physician to ensure that the patient receives the necessary care when and where it is needed in a manner that the patient can understand.
peer review — the evaluation by practicing physicians or other professionals of the effectiveness and efficiency of services ordered or performed by other members of the profession. Frequently, peer review refers to the activities of professional review organizations and to the review of research by other researchers.
physical environment — encompasses all the physical places and spaces where community residents interact, such as houses, schools, stores, clinics, office buildings, streets, parks, playgrounds, churches, malls, fields, restaurants and public transportation. Projects to improve a community’s physical environment as it relates to health and safety include neighborhood clean-up and beautification projects; identifying and ameliorating unsafe buildings and streets; creating safe, common spaces in which children, youth and families can gather, work and play together; and improving access to health and social services.
physician assistant — a specially trained and licensed or otherwise credentialed individual who performs tasks that might otherwise be performed by a physician, under the direction of a supervising physician.
point-in-time count — a one-time count of all homeless people in a defined area. The U.S. Department of Housing and Urban Development requires that communities receiving federal funds from the McKinney-Vento Homeless Assistance Grants program conduct a point-in-time count in the last week of January at least every other year.
point of service — a health insurance benefits program in which subscribers can select among different delivery systems (e.g., health maintenance organizations, preferred provider organizations or fee-for-service arrangements) when in need of health care services, rather than making the selection among delivery systems at time of open enrollment at place of employment.
pre-existing condition — a medical condition developed prior to issuance of a health insurance policy.
preferred provider organization — formally organized medical entity, such as a hospital or physician, that provides health care services to purchasers, usually at discounted rates in return for expedited claims payment and a somewhat predictable market share. In this model, consumers have a choice of using providers in or out of the health insurance network; however, financial incentives are built in to benefit structures to encourage utilization of providers within the network.
prepayment — usually refers to any payment to a provider for anticipated services, such as an expectant mother paying in advance for maternity care. Sometimes prepayment is distinguished from insurance as referring to payment to organizations that, unlike insurance companies, take responsibility for arranging for, and providing, needed services as well as paying for them, such as health maintenance organizations, prepaid group practices and medical foundations.
prevailing charge — a charge set at a percentile of customary charges of all physicians in the locality and used as one of the factors determining a physician's payment for a service under Medicare.
prevalence — the number of cases of disease, infected persons or persons with some other attribute present at a particular time and in relation to the size of the population from which drawn. It can be a measurement of morbidity at a moment in time, e.g., the number of cases of hemophilia in the country as of the first of the year.
preventive medicine — care that has the aim of preventing disease or its consequences, including health care programs aimed at warding off illnesses (e.g., immunizations), detecting diseases (e.g., Pap smears) and inhibiting further deterioration of the body (e.g., exercise or prophylactic surgery). Preventive medicine developed following discovery of bacterial diseases and was concerned in its early history with specific medical control measures taken against the agents of infectious diseases. Preventive medicine is also concerned with general preventive measures aimed at improving the healthfulness of the environment. In particular, the promotion of health through altering behavior, especially using health education, is gaining prominence as a component of preventive care.
primary health care — basic or general health care focused on the point at which a patient ideally first seeks assistance from the medical care system. Primary care is considered comprehensive when the primary care provider takes responsibility for the overall coordination of the care of the patient's health problems, be they biological, behavioral or social. The appropriate use of consultants and community resources is an important part of effective primary care. Such care is generally provided by physicians but is increasingly provided by other personnel, such as nurse practitioners and physician assistants.
provider — hospital, licensed health care professional, group of hospitals or group of health care professionals that provides health care services to patients. May also refer to medical supply firms and vendors of durable medical equipment.
public health — the science dealing with the protection and improvement of community health by organized community efforts. Public health activities are generally those that are less amenable to being undertaken by individuals, or that 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; and epidemiology.
public health approach — an approach that takes into account not only the individual, but also the agents of disease and physical and social environments.