Glossary

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California Affordable Basic Health Care Act of 1992: A reform proposed by the California Medical Association that would require all employers in the state to provide basic health insurance for workers and their families.
California Medical Injury Compensation Reform Act of 1975: California statute often held up as a model for federal legislation. Its key features are a $250,000 cap for noneconomic damages (such as "pain and suffering"), a cap on attorney fees, and empowering defendants to disclose information about damages that were covered by insurance.
California Public Employees' Retirement System: The nation's largest public pension system - administers pension and health care benefits to California public employees.
Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes: A national quality-improvement initiative to increase the practice of evidenced-based medicine for patients with unstable angina or non-ST-segment-elevation myocardial infarction (heart attack).
Capacity: The availability of health care resources, including both labor and facilities/equipment. Available resources are those existing in a given geographic area and meeting regulatory requirements for service delivery. Also included is the ability of a health system to respond to a sudden need for services.
Capitation: A flat, periodic payment to a health plan, health care system or health care provider for each enrolled individual (per capita). The recipient of the payment assumes the risk that the payment will cover the costs of providing health care for all enrolled individuals for the agreed upon period of time.
Care management: Coordinating, facilitating, and tracking a patient's use of health and social services over time. May involve assessing patient's adherence to treatment plans, conducting patient education on self-care, coordinating referrals, and communicating with health care providers.
Caregiver: An individual who provides care for a disabled or ill family member or friend.
Case management: Directing patients to the most appropriate amount, duration, and type of health and social services and monitoring outcomes. When used in connection with managed care, covers the activities associated with evaluating the patient's needs, planning treatment, referring, and following up, so that care is continuous and comprehensive.
Case mix: The distribution of patients by type and level of illness within a facility, physician's practice, or other medical care organization. Variables such as age, gender, diagnosis, and health status are used to classify patients into groups. Case mix adjustment is a method used to control for differences in the mix of patients that may affect the resources required to deliver care.
Case-Mix Groups: A classification system used by the Centers for Medicare & Medicaid Services (CMS) to group similar types of patients for payment purposes.
Catastrophic coverage: Also referred to as major medical plans. Health insurance designed to protect against major financial loss. Covers major medical and hospital expenses, usually with higher than normal deductibles, but does not cover routine care or prescription drugs.
Causal/causality: Refers to a cause-effect relationship. For example, a causal model attempts to discover whether an observed association between an exposure (e.g., cigarette smoking) and a health condition (e.g., high blood pressure) arises because the exposure causes the condition or whether the association is related to other factors.
Certificate of Need: Under state law, programs that require health care institutions to seek and receive state permission to build new facilities, expand existing facilities, and in some cases, make major acquisitions of new technology (such as MRI equipment).
Child Health Plus: A New York state program implemented in 1991 to provide health insurance to children; believed to have been a model for the nationwide State Children's Health Insurance Program (SCHIP).
Chronic care: Concerned with long-term medical care (care usually lasting more than 90 days), especially for individuals with chronic physical or mental impairment.
Chronic Care Model: A widely used conceptual framework developed by Ed Wagner and colleagues in The Robert Wood Johnson Foundation Improving Chronic Care Initiative. The model focuses on six fundamental areas making up a system that encourages high-quality chronic disease management. Organizations must focus on these six areas, as well as develop productive interactions between patients and providers.
Chronic disease: A condition with one or more of the following characteristics: it is permanent; it leaves residual disability; it is caused by nonreversible pathological alteration; it requires special rehabilitative training for the patient; and it may be expected to require a long period of supervision, observation, or care.
Claims data: Information derived from health care providers' claims submitted to third-party payers (such as the government and private insurance companies). Claims data are often used to evaluate health care utilization and cost.
Cleveland Health Quality Choice Program: Established in 1989 as a voluntary, collaborative effort between hospitals, physicians, and purchasers in the Cleveland metropolitan area to assess the quality and efficiency of care in 31 hospitals. Its objective is to produce high-fidelity comparative hospital outcomes data.
Clinical Antipsychotic Trials of Intervention Effectiveness: A major NIH-funded research program studying treatment effectiveness and outcomes in schizophrenia and Alzheimer's disease.
Clinical waste: The production of clinical services that provide marginal or no benefit over less costly alternatives. A clinical service might be considered wasteful even if it has positive health effects, if the costs of the service outweigh the benefits.
Clinician: A health professional engaged in the care of patients, as distinguished from health professionals whose sole activities are in areas such as research or administration.
Closed formulary: A structure for pharmaceutical benefits that excludes coverage of certain medications, such as brand-name drugs.
Closed staffing model: An arrangement in which no new applicants are accepted to an organization's medical staff unless a vacancy exists or is anticipated; an organization-physician contract in which a physician or physician group provides administrative and clinical services on an exclusive basis (and other physicians are excluded from practicing that specialty in that institution for the period of the contract).
CMS-HCCs: see HCCs
Coinsurance: A health insurance policy provision under which the insured pays all costs until a stated dollar requirement is met within the policy year (the deductible), and thereafter the insurer and the insured share costs according to a specific formula (stated percentage per visit or for an established number of supplies).
Collateral source rule: Within medical malpractice litigation, the rule allows defendants to argue that portions of a plaintiff's alleged economic damages are actually covered by insurance, workers' compensation, or other sources and therefore, any tort award against the defendant should be reduced accordingly.
Commercially-insured: Generally, all forms of insurance provided by non-governmental entities, whether individual or group.
Commonwealth Care: A program run by the Commonwealth of Massachusetts to provide qualified residents with affordable health insurance if they do not have it.
Commonwealth Connector: An independent state agency, authorized under the Massachusetts Health Reform Law of 2006, that helps Massachusetts residents find health insurance coverage and avoid penalties under the individual mandate.
Community Health Center: A provider of care that acts as a "safety net" to provide health services for the needy of the community. If "federally qualified," a community health center is guaranteed federal cost-based payment.
Community rating: A method of determining premiums for health insurance, in which a premium is based on the average cost of the actual or anticipated health services used by all subscribers in a specific geographic area or industry. The intent of community rating is to spread the cost of illness evenly over all subscribers to an insurance plan, rather than charging the sick more than the healthy.
Community Tracking Study: A set of periodic surveys and site visits of a set of nationally representative communities conducted by the Center for Studying Health System Change that has allowed researchers to analyze information about local health markets and the nation as a whole. It includes surveys of physicians, households, and employers.
Comparative effectiveness: A process by which the relative clinical effectiveness of different treatment options (e.g., drugs, devices, surgical interventions) for a particular medical condition is assessed. In order to standardize the outcomes, researchers often use quality-adjusted life years (QALY) as an outcome measure.
Compliance: Adherence to a prescribed course of treatment or action, such as patient compliance with a treatment regimen or physician compliance with generally accepted medical practice.
Computerized decision support: Computer software that assists clinicians in clinical decisionmaking at the point of care. (See also decision support).
Computerized Physician Order Entry: A computer-based system of ordering medications and often other tests. Basic CPOE ensures standardized, legible, complete orders and therefore reduces errors due to poor handwriting and ambiguous abbreviations.
Confounding factor: In statistical analysis, an extraneous variable that distorts the true relationship between or among the variables of interest. Extraneous to the study question, confounding factors can hide a true correlation or give the appearance of a correlation when none actually exists.
Congestive Heart Failure: Medical condition in which the heart is unable to maintain adequate circulation of blood in the tissues of the body.
Congressional Budget Office: An organization created by the Congressional Budget Act of 1974 that provides the U.S. Congress with analyses of alternative fiscal, programmatic, and budgetary issues.
Consolidated Omnibus Budget Reconciliation Act of 1985: The Consolidated Omnibus Budget Reconciliation Act, Pub. Law No. 99-272 (1985), included provisions requiring every hospital that participates in Medicare and has an emergency room to treat any patient in an emergency condition or active labor, regardless of ability to pay (referred to as EMTLA). COBRA also requires employers to offer a continuation of benefits to specified workers and families after termination of employment.
Consumer Assessment of Healthcare Providers and Systems: A national project that measures (with standardized questionnaires and reporting instruments) what patients experience, think and know about their health care. The goal of CAHPS?is to produce valid, reliable, meaningful, and comparable data on patients' experiences with their health insurance company and care providers. It is used to report information on Medicare beneficiaries' experiences with managed care plans.
Consumer financial risk: The amount of money spent out-of-pocket on health care by individuals and families relative to disposable income. It is the extent to which health care expenses can be expected to place individuals and/or households at risk for not meeting essential financial demands.
Consumer Price Index: A measure of the changes in the prices paid by urban consumers for a representative market basket of goods and services.
Consumer-directed health plan: Although insurance carriers and employers offer several variants in the private health insurance market, these plans generally include three basic components-a health plan with a high deductible; an associated tax-advantaged account to pay for medical expenses under the deductible (either a tax-advantaged health reimbursement account or a health savings account); and decision-support tools to help enrollees evaluate health care treatment options, providers, and costs. (See also HDHP, HRA, HSA).
Continuation of benefits: Access to health benefits (for a stated period of time) provided to enrolled members who have lost their employment or finalized a divorce that causes a loss of health insurance benefits. Required by a provision of COBRA.
Continuity of care: The degree to which the care of a patient occurs without interruption and is coordinated among practitioners, among organizations, and over time.
Continuous eligibility: A provision of the Balanced Budget Act of 1997 that allows a state to implement rules in its State Children's Health Insurance Program (SCHIP) that qualify children for 12 straight months.
Continuous enrollment: The ability to ensure no lapse in health insurance coverage during life transitions.
Control group: A group used as a standard of comparison in an experiment; this group does not receive the experimental treatment and is compared with the treated group to determine whether the treatment had an effect.
Convenience sample: For research purposes, identifying a sample of individuals who are chosen because they are easy to find and/or enroll in a study. A convenience sample is therefore not necessarily representative of the whole - so that the findings of the study may be biased in unknown ways.
Copayment: The fixed sum a beneficiary pays for health services, regardless of the actual charge, with the insurer paying the remainder.
Coronary: Refers to the heart. See Acute Myocardial Infarction (AMI)
Coronary Artery Bypass Graft: The surgical bypassing of obstructed heart arteries with grafts; such surgery is commonly measured in quality improvement initiatives. Also referred to as heart bypass and bypass surgery.
Cost-benefit ratio: The total expected costs of a course of action compared with the total expected benefits (expressed in monetary terms), adjusted for the time value of money (reflecting the fact that costs and benefits may occur at different times).
Cost-effectiveness analysis: An analytic tool used to compare the costs and outcomes of two or more programs or interventions. The costs and effects are calculated and presented in a ratio of incremental cost to incremental effect.
Cost-shifting: The practice of charging certain patients, groups or classes of patients higher rates to recoup losses sustained when a provider receives inadequate reimbursement for other patients. A strategy used by payers in which payment methods are established that do not meet the full cost of care delivered by a provider, thus forcing the provider to cover these costs through higher charges to other patients.
Council on Graduate Medical Education: Authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues, and financing policies and to recommend appropriate federal and private-sector efforts to address identified needs.
Coverage: The guarantee against specific losses provided under the terms of an insurance policy. Sometimes it is also used interchangeably with 'benefits' and also used to refer to insurance or an insurance contract.
Coverage determination: When a payer limits coverage to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.
Coverage with Evidence Development: A Center for Medicare & Medicaid Services (CMS) rule that allows the Medicare program to document appropriateness of items or services not currently included as benefits but that may be appropriate for some individuals, in order to inform future benefit determinations and to improve clinical evidence around those items or services.
Coverage with Study Participation: A component of the Centers for Medicare & Medicaid Services (CMS) Coverage with Evidence Development (CED) rule that allows CMS to determine that an item or service is only reasonable and necessary when it is provided within a research setting in which there are added safety, patient protections, monitoring, and clinical expertise.
CQI: see RAND Community Quality Index
Credentialing: The process of determining eligibility for hospital medical-staff membership, and privileges to be granted to, physicians and other health care professionals in light of their academic preparation, licensing, training, and performance.
Critical access hospital: A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
Critical care unit: see ICU (intensive care unit)
Crowd out: In health economics, used to describe the effect that new or expanded public health insurance programs have on the demand for private health care insurance, that is, the likelihood that persons with private insurance will switch to the new public program.
Cultural competency: Possessing relevance and sensitivity to the ethnic and cultural background of patients in any component of service delivery, the setting in which health services are delivered, and/or and the means and methods of communication with patients (e.g., educational materials, questionnaires).
Current Population Survey: A monthly survey of about 50,000 households conducted by the U.S. Bureau of the Census for the Bureau of Labor Statistics. Conducted for more than 50 years, the survey is the primary source of information on the labor-force characteristics of the U.S. population. Estimates obtained include employment, unemployment, earnings, and hours of work.
Custodial care: Non-skilled, personal care, such as help with activities of daily living (ADL): bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom.

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