Capitation---a method of reimbursing Doctors. A pre-determined fee, usually payed monthly, to give a patient total health care for a pre-determined period of time, usually one, year.Then, there is no limit to the amount of care the patient may request. The Doctor must respond as often as the patient demands.

Cherry-Picking---refers to health insurance companies that try to insure only healthy people. Sicker patients are turned down and forced to look elsewhere. This is designed to result in a bigger profit for the insurance company that does "cherry-picking".

Consumers---people who require health care

Co-pay---refers to the amount of money the insured patient must pay [out of pocket] to the Primary Care Doctor before he can be seen at the Doctor's office. The purpose of such a payment [usually $5 to $15] is to discourage the patient from making frivolous [unnecessary] visits to see the doctor .

Cost Effective---usually refers to the question,"are we saving enough lives to justify the cost?"

DRG's---a designated reimbursement scheme [payment formula] started by the government as a way to pay providers for the care of seniors. It's a fixed amount of money to be paid regardless of the actual cost of the care a patient should have. For example: the quicker the hospital discharges the patient the more profit or loss they take for a given treatment to that patient. This has resulted in some patients being discharged too soon---Some have had to return to the hospital, others have not survived. {see also, Utilization Control]

Elective Care---may be for a surgery [like a hernia repair or to remove varicose veins], or a hospital admission for the treatment of a patient's Diabetes. In cases that are not felt to be an emergency, cases that can be scheduled at a "convenient" time for everyone involved.

Exclusions---a term used in health care insurance policies that notify you of the diseases that you already have or may get in the future that they will not cover.Some insurance companies may exclude you from coverage from diseases you had in the past even though you may be completely cured. Read this part of your policy very carefully. There are cases where the insurance company will only take you if you are totally healthy...also called "Cherry Picking".

Formulary of drugs---refers to prescription drugs covered by your insurance policy. In managed care plans, usually refers to Generic drugs, with name-brand drugs provided at additional cost[to the patient] if ordered by the Doctor.

GAG Rule---a clause written into too many Physician contracts that force the Doctor to remain silent about methods of care that are not provided by your insurance policy, even when that other method would be better for you.

Gatekeeper---your primary care physician [PCP].The Doctor assigned to you by your HMO who must see you first except in an emergency. The Gatekeep or PCP must approve your seeing a specialist before the insurance carrier will pay the bill. Before recent laws were passed, making it illegal, your PCP was often rewarded [in money] by the insurance company for reducing the number of patients he/she referred to a specialist.In short, the PCP is in control of how much and how good your health care will be.

Health Care Delivery---refers to the method in which health care is provided eg.private insurance or managed care. HMO is one type of managed care, then there is government controlled care such as single payer or socialized medicine. Medicare and Medicaid are forms of government controlled care

Health Savings Accounts [HSA]---are allowed in the new Medicare law. In order to appreciate the significance of this development I urge you to read the definition of MSA's [further down this list] then return to this discussion to appreciate the generous changes to be found in HSA's that may benefit you or your family.

The new HSA's will apply to all age groups, except for Seniors already enrolled in Medicare. It is designed for those who wishes to manage their own health care, individual or family. The amount of the annual deductible is increased to $2600 dollars for an individual subscriber or $5100 per family.  To qualify one MUST purchase the lower cost catastrophic policy. Drug coverage will be a question that each subscriber will have to settle, depending on their needs. The annual rollover, like an IRA, is tax-free and could be substantial and amount to a large sum of money available upon retirement.

The key here is that you, together with your Doctor help, become the manager of your own health care. Further information can be obtained from www.webmd.com or www.aapsonline.org

Hippa Rules---new regulations concerning the privacy of a patient's medical records [approx 1400 pages written by former Sec of Health under Pres. Clinton,Donna Shalalah and 450 pages added for Pres Bush] which give the Sec. of Health unlimited control of medical records and eliminates the need for the individual to sign a release of their records to designated/proper authorities.

Hold Harmless Clause---a clause in a Physicians contract that holds them legally responsible for a bad outcome, in your care, even when the insurance company controlled the kind of care they would pay for.

Hormone Replacement Therapy [HRT}
refers to the Post Menopausal use of Estrogen alone for the women whose Uterus has been removed or the use of Estrogen together with Progesterone for the Post Menopausal women with her Uterus still in her body.[Progesterone protects the Uterus from developing Cancer of the Uterus]
The hormones are valuable in that they protect the women from developing Osteoporosis [called weakening of the bones] which makes Hip Fractures more common. It has been shown that the death rate from Fractured Hips in older women is ten times greater than the death rate from Cancer of the Uterus.
Estrogen also protects women from Strokes, Heart Attacks, Alzheimers Disease and Cancer of the Colon. Numerous studies, over the past 50 years have failed to find a link between the use of Estrogen and an increase in the incidence of Breast Cancer. The greatest disadvantage to the use of Estrogen in older women, in my opinion, is that their is nothing like it for the older men.

IPA---Independent Practice Association is a group of Doctors who contract with HMO's and other managed care insurance companies to take care of their patients at whatever reimbursement [pay]schedule they decide upon. IPA"s usually work for HMO's.

HMO---Health Maintainance Organization is a prepaid form of health care whereby you choose a primary care doctor[PCP] from the approved list provided by the insurance company. Your PCP is in charge of your health care and must approve your visit to any specialist or health care facility on the approved list. If he does not approve your visit to a specialist, emergency room, laboratory you will have to pay the bill from your own pocket.

Maloccurance---is the charge when a patient has an unexpected complication or bad result from either medical or surgical treatment despite there being no evidence of incompetence.

Malpractice---is the charge when a doctor injures or kills a patient because of his/her incompetence

Medically Underinsured---people with inadequate insurance coverage in the event of a serious[expensive]illness or injury.

Medically Uninsured---people without
health care insurance.

MEDICARE---health insurance provuded by the federal government for senior citizens

MEDICAID---health insurance provided by the federal and state governments for the care of the poor. Some seniors may qualify for both Medicare and Medicaid insurance.

Medigap Insurance--An Insurance policy that pays the part of your bill not covered by Medicare. Medicare usually covers 80% of the service you receive with restrictions on the number of Pap Smears and Mammograms for female patients. There are other restrictions for both male and female patients. Medigap insurance helps you pay for these uncovered items. It wont cover them all but it sure helps.

MSA...Medical savings account. A new law allows the setting up of a medical IRA for individuals or families. [$1500 for individuals and $3500 for families can be placed in a tax free account each year] It allows MSA members to go to any Doctor they choose and pay out of pocket only what's in the account for that year [not previously rolled- over money] They need only purchase high deductible health insurance that comes into effect if their out-of-pocket expenses exceed the amount set aside for that year.  This type of health insurance runs about $2000 a year. It give the MSA member freedom to choose their Doctor and covers expensive health care bills if they get one. Money not spent in the year rolls over and remains in the tax-deductible medical IRA. Contact a major Health insurance Agent or Company such as Blue Cross/Shield: Aetna or Cigna for details or search for MSA on the Internet at www.aapsonline.org. Must be set up according to Federal Government rules.

Osteoporosis: a weakening of the bones most commonly seen in post menopausal women due to the loss of bone Calcium. It can be prevented by the taking of Estogen tablets {HRT} with or without the addition of Progesterone as decided by the Doctor. May also be treated by new medicines such as Fosamax or Evista. Talk to your Doctor about this condition

Patient Bill of Rights---a name for legislation moving in Congress designed to protect people who purchase health insurance. It would guarantee that the insurance company keep the promises set out in the insurance policy. It would allow people to appeal in the event they are dissatified with an insurance company decision concerning their care. It would support a patient's request for a second opinion should the insurance company deny a request for an exam by a specialist. Coverage for the cost of drugs is a difficult point that is causing a delay in the passage of such a Law. Such a law will likely demand that decisions concerning a patient's care be made only by a licensed physician. All good ideas, it will be interesting to see what actually is covered when such a law is passed. The insurance companies are fighting this one The President also wants managed care patients to have the right to sue an HMO for malpractice. This will cuase premiums to go even higher and could bankrupt the HMOS in which event Government controlled [single payer] insurance will likely take over. Having travelled the world to look at government systems, I can tell you that would be worse than what we have now. Changes in our HMOs must be done carefully by experts who know what they're doing--the Nation's Physicians who up to now have largely been ignored in the planning stages of managed care.

Percentage of GNP [%GDP more commonly used]---usually refers to the amount of money a nation spends on health care.

Pre Authorization---refers to the permission your Doctor must obtain from the Plan Administration before you can get certain Laboratiry tests, specified X-Ray procedures, or to enter the Hospital when you're sick or even when you go into labor to have your baby. If you don't get permission in advance they wont pay your bill.

Pre-Existing Condition---a clause in your policy that notifies you that it will not cover the cost of care for a problem you had in the past even though you may be totally cured at the time you buy tha policy. See also Exclusions and Cherry Picking which amount to the same thing...a way of controlling how much health insurance coverage your really going to get.

Providers---persons or places that deliver health care

PPO---Prudent Provider Organization provides all of your health care at a discounted rate which is negotiated by the insurance company with Doctors, hospitals, drug stores and laboratories.The patient may see any physician who is listed in the PPO Directory

PPS--Prospective Payment System--new government designation for a method of paying for Nursing Home patients. Amounts to a set payment fee per day for each patient covered by government insurance. Hope it will improve care???

Second Opinion---The medical opinion of another Doctor, if you disagree or are uncomfortable with the diagnosis and treatment you are advised to have, for your problem, by the first Doctor you see.A second opinion by a Doctor outside of your insurance plan can be valuable.

Right to Appeal---the right guaranteed to you to seek other opinions on the insurance companies decision to limit or not allow the treatment that your second opinion recommends.

Third Party Payer---whoever pays the bills usually the health care insurer, can be an insurance company or the government either state or federal.

Two Tier System of HealthCare--seen in any nation with National Health Insurance. One tier for the average citizen who cant afford anything else and the second tier for those willing to pay "out of pocket" for prompt, private and personal care when needed. Only Canada, as far as I can learn, tried to prevent the second tier but Canadians patients buy insurance in America and get their care in the U.S.

Utilization Control---limiting the amount of or the cost of the care available..

Waiting Period---the length of time you must pay for the insurance before your coverage begins.