ABPS Administrative Medicine key terms

A group of doctors, hospitals, and other providers that jointly takes responsibility for the cost and quality of care for a defined patient population, sharing in savings or losses against a spending benchmark.

An organization that combines hospitals, physician groups, and often insurance or post-acute services under common ownership or contractual control, coordinating care across the continuum for a population.

The full range of health services a person may need over time, from prevention and primary care through acute treatment, rehabilitation, long-term care, and end-of-life services.

Deliberately organizing patient care activities and sharing information among participants to achieve safer, more effective, and more efficient care across settings and over time.

A primary care model in which a physician-led team provides continuous, comprehensive, coordinated care, emphasizes access and quality measurement, and is often recognized through formal accreditation standards.

A state regulatory program requiring providers to obtain government approval before building facilities or buying major equipment, intended to control costs and avoid duplicative services.

A federal law requiring Medicare-participating hospitals to provide a medical screening examination and stabilizing treatment to anyone presenting with an emergency condition, regardless of ability to pay.

Federal legislation that sets national standards for protecting individually identifiable health information and for the portability of health coverage when people change or lose jobs.

Individually identifiable health information held or transmitted by a covered entity or its business associate, in any form, that relates to a person's past, present, or future health, care, or payment.

A HIPAA principle requiring covered entities to limit uses, disclosures, and requests for protected health information to the least amount reasonably needed to accomplish the intended purpose.

A federal statute prohibiting physicians from referring Medicare patients for designated health services to entities in which the physician or an immediate family member has a financial relationship, unless a regulatory exception applies.

A federal criminal law making it illegal to knowingly offer, pay, solicit, or receive remuneration to induce referrals for items or services reimbursed by federal health care programs.

A regulatory provision that describes a payment practice which, although it might otherwise implicate the anti-kickback statute, is protected from prosecution when all stated conditions are met.

A doctrine in many states restricting who may employ physicians or practice medicine for profit, generally requiring medical services to be delivered by licensed physicians rather than lay corporations.

The governing rules adopted by a hospital's organized medical staff that define membership categories, credentialing and privileging processes, peer review, and due process rights for physicians.

The process of verifying a clinician's education, training, licensure, certification, and experience to confirm eligibility for medical staff membership or participation in a payer network.

The process by which a hospital or health system authorizes a credentialed clinician to perform specific procedures or provide particular services, based on documented competence and institutional capability.

A structured, confidential process in which physicians evaluate the clinical performance and quality of care of colleagues, used for credentialing, privileging, and quality improvement purposes.

A payment approach that adjusts reimbursement to providers based on performance on quality, cost, and patient experience measures rather than volume of services alone.

A reimbursement model that ties a portion of provider payment to achievement of specified quality, efficiency, or patient experience targets, rewarding measured performance rather than service volume.

A payment arrangement in which a provider organization receives a portion of the difference between actual spending for its population and a benchmark, contingent on meeting quality requirements.

The sum of all health care spending for a defined population over a period, including inpatient, outpatient, pharmacy, and post-acute costs, often compared with a risk-adjusted benchmark.

A statistical method that adjusts payments or benchmarks for differences in the health status and expected costs of patient populations, so providers are not penalized for caring for sicker patients.

A payment method that pays a provider a fixed amount per enrolled person per period, regardless of how many services that person actually uses, shifting financial risk to the provider.

Health services provided free or at reduced charge to patients who cannot pay, often tracked as part of a nonprofit hospital's community benefit obligation.

The combined value of charity care and bad debt a provider absorbs for services that are not reimbursed by patients or insurers.

A rapid-cycle improvement method in which a change is planned, tested on a small scale, studied for results, and then acted on through adoption, adaptation, or abandonment.

A structured retrospective method for identifying underlying system failures that contributed to an adverse event, with the goal of redesigning processes to prevent recurrence.

An unexpected occurrence involving death, serious physical or psychological harm, or the risk thereof, which signals a need for immediate investigation and response.

A clearly identifiable, serious adverse event that is largely preventable and should never occur in a health care setting, such as wrong-site surgery or transfusion of the wrong blood type.

A quantified indicator, often expressed as a rate or ratio, used to assess the structure, process, or outcomes of care and to compare performance over time or across organizations.

Comparing an organization's performance on selected measures against internal targets, peer organizations, or national standards to identify gaps and prioritize improvement work.

A strategic management framework that tracks performance across financial, customer, internal process, and learning perspectives to keep leaders focused on multiple goals at once.

A written document that sets an organization's mission, long-range goals, chosen strategies, and the resources and accountability needed to achieve them over a defined horizon.

A planning exercise that inventories an organization's internal strengths and weaknesses and its external opportunities and threats to inform strategy selection.

The legal obligation of board members to act in the organization's best interest with loyalty and reasonable care, including oversight of finances, mission, and executive performance.

A situation in which a person's outside financial or personal interests could improperly influence decisions made in their organizational role, requiring disclosure and often recusal or management.

Health information technology features that give clinicians patient-specific knowledge and alerts at the point of care to support decisions and reduce errors.

An electronic system that lets clinicians enter orders for medications, tests, and other services directly, often paired with decision support to catch errors before they reach patients.

A digital, longitudinal record of a patient's health information that is created and shared across care settings and supports clinical documentation, ordering, and reporting.

The electronic movement of health information among organizations according to national standards, enabling clinicians to access patient data across separate care settings.

The ability of different information systems to exchange data and use the exchanged information without special effort, a prerequisite for coordinated care across organizations.

A shortfall in the supply of primary care clinicians relative to population need, often measured by designated shortage areas and associated with reduced access and worse outcomes.

A federal designation for a geographic area, population group, or facility with too few primary care, dental, or mental health providers relative to the population served, used to target incentives.

A recruitment incentive in which a health care organization or government program repays part of a clinician's educational debt in exchange for a commitment to practice in an underserved setting.

A syndrome of emotional exhaustion, depersonalization, and reduced sense of accomplishment related to work, associated with lower quality, higher turnover, and reduced patient satisfaction.

A contract defining a physician's duties, compensation, benefits, call obligations, restrictive covenants, and termination terms, which must comply with applicable fraud and abuse rules.

The price at which a willing buyer and willing seller would exchange services or property in an arm's-length transaction, used to validate compensation arrangements under fraud and abuse rules.

The process of informing a patient about the nature, risks, benefits, and alternatives of a proposed intervention and obtaining their voluntary agreement to proceed.

A patient's ability to understand relevant information, appreciate the consequences, reason about options, and communicate a choice regarding their own medical care.

A written statement, such as a living will or durable power of attorney for health care, made by a person in advance to direct care if they later lose decision-making capacity.

A systematic process of assessing population health needs and existing resources to set priorities and guide investment in facilities, services, and workforce.

A legal protection that exempts certain provider collaborations from federal antitrust liability, typically requiring state action or active state supervision of the arrangement.