Reasonable access to high-quality, core health-care facilities and medical services independent of financial or other barriers

The requirement that one justify one's actions and conduct. Ex ante accountability means that actions or conduct are justified in terms of achieving certain explicit aims - the criteria are laid down in advance. Ex post accountability means that actions or conduct are justified by giving good reasons after the event - criteria for performance emerge and are tested during the process of justification.

A disproportionately high enrollment of low-risk individuals into a health plan, often referred to as "cream skimming" or selection bias; see also risk selection.

The level and mix of health services delivered to a patient according to that patient's individual health-care needs and the prevailing professional view based on clinical efficacy studies

A recent term used in Canadian health planning to describe a narrower set of services than those defined as "core" health care.

Services that meet established standards for quality health and provide maximum value to the consumer and the taxpayer

Note: Currently, there is no clear differentiation between the term "basic" and "core". Both imply health-care services that should be insured for all citizens, but that there are some definite limitations and citizens will have to pay for some care. The term "basic" reflects the emphasis or approach of the province or territory using it.

The target billings for individual physicians = roster size X age sex-adjusted capitation rate (usually billed in office based setting).

A population-based method of funding health care in which health-care dollars are linked to defined populations, that may also be used as a method of remunerating providers.

Capitation has three crucial elements:

1. care is prepaid at a predetermined rate;

2. the recipient of the capitated payments may be at financial risk if expenditures exceed payments, and as a result has an incentive to manage care in a cost-effective manner; and

3. payment is tied to a specific, defined population of patients.

Under the terms of a capitated payment arrangement, a provider, group of providers or health-care organization agrees to accept a fixed, prospective payment amount per member of a defined patient population, per unit time.

In return for this payment, for a specified period, the provider, group of providers, or health-care organization agrees to provide any of a number of specified services to any member of the defined patient population, on an as-required basis.

Capitated payment arrangements may be further defined as either indirect or direct:

indirect	Under indirect capitation the "per capita" payments represent a block funding arrangement to a group of providers or health-care organization.
direct	Direct capitation is a non-fee-for-service method of remunerating individual providers for services rendered.
sub-capitation	Sub-capitation arrangements can also exist, under which a capitated provider group contracts with another health-care organization, provider group, or individual provider to provide a sub-set of its defined services, also on a capitated basis.

A process whereby covered persons with specific health-care needs are identified and a plan that efficiently uses health-care resources is formulated and implemented to achieve the optimum patient outcome in the most cost-effective manner.

Wherever practicable, Canadian consumers and health-care providers should have reasonable choice as to health-care setting, mode of delivery (type and location of practice) and method of health-care financing

The structure of a health-care system which has minimal (if any) overlap with the current health-care system. Two systems which cover a different range of services/ resources/ patients are said to be complementary

A broad range of services that covers most, if not all, health-care needs. These services may or may not be funded/insured by a government plan.

Services that are available to everyone as funded/insured by a government plan. Alternate funding sources for these services are not necessarily excluded.

See also: Health care

Those health services which must be available or accessible to every resident of the province

Core services refer to general categories of health services. They do not refer to the type and level of specific services provided within those categories

An EPO is a more rigid type of Preferred Provider Organization (PPO) that requires the employee to use only designated providers or sacrifice reimbursement altogether. PPOs encourage employees to use "preferred" providers through more generous reimbursement, but will still reimburse for non-preferred providers. EPOs are similar to Health Maintenance Organizations (HMOs) in that only the use of designated providers is reimbursed.

Relative health benefits received by combining the various human and other health resources to address changing health needs (i.e., designing programs and delivering services so as to maximize "value for money"). It also encompasses appropriateness in terms of the level and mix of health services delivered to a patient according to that patient's individual health-care needs and the prevailing professional view based on clinical efficacy studies

Reflects the level of benefit expected when health-care services are applied under "ideal" conditions of use or the results of using a technology applied by the most skilled practitioners in the best possible circumstances

Refers to the administrative, technical and allocative components of the health-care system where administrative efficiency refers to administering programs and collecting revenue at minimum cost; technical efficiency involves the production of health-care services, which, like any other production process, involves maximizing outputs with available resource inputs; and allocative efficiency refers to optimizing health-care resources allocated across competing needs both within any category of health spending (e.g., clinical services), as well as across categories of expenditure (e.g., capital and operating). Allocative efficiency is improved where a particular payment modality encourages optimal use of physician and non-physician resources in the production of health (not just health care)

Quality may also be considered as one component of efficiency. If resources are allocated efficiently and used in an efficient manner, it will lead to the production of a high-quality service

Efficiency may also be considered in the context of juxtaposing questions of individual professional accountabilities with collective and individual resource allocation/utilization decisions

The principle of equal rights for all persons; like equality before the law, equality of access to health care requires that essential hospital and medical services be available to all Canadians, regardless of income or other considerations.

The total number of persons registered in a health plan.

See also: Roster and Lock-in

A record of the number and types of services rendered to patients during a specified period.

Refers to the degree that institutional structures (i.e., legislation) do not allow for pluralistic funding mechanisms for services that are publicly funded

A method of providing funds for the purpose of contracting for referred care on behalf of a rostered population of patients. This approach to funding rose to prominence in the United Kingdom following a 1989 proposal for National Health Service reform, and is also in use in New Zealand. It is often referred to as GP Fundholding in the UK

Under fundholding, the budget for a specified set of services is transferred prospectively from the administrative body responsible for purchasing health-care services for a designated geographic area, to a fundholding practice, together with authority for purchasing on behalf of patients registered with the practice.

Under the GP Fundholding Model, in exchange for receiving this budget and purchasing authority, the fundholder practice agrees to assume responsibility for providing or paying for all covered services needed by their patients (including payment for care supplied by other providers), and contracts independently with hospitals, and other service providers and organizations for this purpose, casting the General Practitioner in the role of gatekeeper.

A health-care professional who coordinates, manages and authorizes all health-care services provided to a covered beneficiary. The health-care professional may be a nurse, a social worker, a physician's assistant or a physician (e.g., internist, family/general practitioner, pediatrician, and in some cases, obstetrician/gynaecologist). Gatekeepers are frequently used by managed care plans as a method for controlling costs by controlling referrals to specialists and utilization of resources.

Process of matching patients' needs with the judicious use of medical services, in order to ensure appropriate use of health-care resources and to protect patients from possible adverse effects of inappropriate care. The "gatekeeper" is typically the provider of first contact.

A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity

Health is the integration of the total individual body, mind, and spirit in the functioning process

Health is the perfect continuing system of adjustment of an organism to its environment... Health is the capacity of the organism to maintain a balance in which it may be reasonably free from pain, discomfort, disability or limitation of them, including social capacity

Health is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and, on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, as well as physical capacity

Aims at the health protection of the population of a given area and at maintaining and improving the health status of that population. It is concerned with the promotion of health - not only physical health (including dental health and physical fitness) but mental health. It is also, in consequence, concerned with sickness or morbidity (both acute and chronic disease); and, inevitably with mortality. It extends from the cradle to the grave, from maternity care to geriatrics and the problems of old age; indeed it begins earlier than the cradle, with family planning and with the considerations of fertility and infertility

A prepaid health-care plan that provides or arranges comprehensive health services for its enrolled members. HMOs .may be organized differently.

The process of enabling individuals and communities to increase their control over and improve their health.

See also: Prevention

A contractual relationship between an insurer and another party under which the insurer agrees to reimburse or otherwise provide compensation for a loss, should one occur, in exchange for the payment of a fee

Hospital services, physician services and surgical-dental services provided to insured persons, but does not include any health services that a person is entitled to and eligible for under any other Act of Parliament or under any Act of the legislature of a province that relates to workers' or workmen's compensation

Note: Health-care services that are provided by other health-care practitioners (e.g., optometrists or chiropractors) can also be considered insured if the province permits this by law; such services must also be insured by the province.

Health services that a resident of a province or territory is entitled to receive under its insured health scheme. Note: Most provincial/territorial insurance acts now refer to these services as "insured professional services."

A group of hospitals, physicians and ancillary providers that have joined to create a system which provides comprehensive health-care services through a coordinated, client-centered continuum designed to improve health-care services in specified geographic markets and within economic limits (e.g., capitation).

Lock-in refers to the period of time an individual is required to, or agrees to remain registered with a particular provider, group of providers or health-care organization. In general, as more financial risk is assumed by the recipient of the prospective capitation payments for a patient population, more stringent restrictions are required on patient choice in obtaining non-emergent services outside of the provider practice, group or organization with which they are rostered or enrolled.

A comprehensive approach to the planning, management and coordination of health care in a cost-effective manner, with provisions for patient education, provider practice standards and guidelines, utilization review, monitoring of quality of care, cost containment and quality assurance initiatives, and increasingly, outcomes assessment. In the contemporary fiscal context, the principles of managed care underpin all service delivery decisions, and form an integral component of all patient-physician interactions.

A health-care plan which integrates the financing and delivery of care so as to maximize the value of its services within a fixed budget, and typically:

1. Provides a comprehensive set of health-care services to a defined set of members.

2. Is financed by predetermined monthly premiums.

3. Contracts with selected physicians and other health-care providers to provide services to its members.

4. Employs utilization and quality assurance controls by which contracting providers agree to abide.

5. Employs financial incentives to encourage members to use the plan's providers and facilities.

6. May be organized so providers assume some financial risk for the plan's costs.

7. May provide for decisions regarding the coordination and management of patient care to be made by a member of the managed care organization other than a physician (for example, a case manager).

In the United States, managed care plans typically take the form of a:

1. Health Maintenance Organization (HMO);

2. Preferred Provider Organization (PPO); or

3. Point of Service Plan

In the Canadian context a variety of alternative delivery and payment models have evolved which could be considered examples of managed care organizations:

4. Health Service Organizations (HSOs) - Community or hospital-based organizations that are funded through a capitation system and provide primary care to an identified population. The majority of HSOs in Ontario are physician owned and operated.

5. Comprehensive Health Organizations (CHOs) - Non-profit organizations which undertake to provide or to purchase a full range of health and related (both primary and referral) services to an identified population. A management team operates the CHO with direction from a community board.

6. Community Health Centres (CHCs) - In addition to providing primary care services for an identified population, CHCs provide a range of other ancillary services such as social work, chiropody, counselling, dentistry, housing coordination and job training, with an emphasis on prevention and health promotion, in addition to treatment. CHCs are owned by non-profit community boards, and the providers who work in them are typically paid by salary.

7. Local Community Services Centres (CLSCs) - The Quebec version of a CHC, CLSCs are funded on a capitation basis for a defined geographic area, to price a mix of primary care and social services to a specific community. Providers are typically paid by salary, and physicians form only a small part of the CLSC staff. CLSCs are publicly owned.

A situation where a number of health-care plans compete for members. The plans may include various types of managed care plans as well as conventional insurance plans. Competition is based on the premiums, covered services, access to services (availability and types of providers), and the perceived quality of care.

The ability to choose from an array of health services, and determine who will provide them and in what location

Services that a qualified physician determines are required to assess, prevent, treat, rehabilitate or palliate a given health concern or problem as supported by professional experience and consensus and/or scientific evidence that is available.

Note: Alternatively, they may be defined as medical practice that has a reasonable chance to prevent, diagnose or treat disability/dysfunction/disease and improve or maintain health status (demonstrate a net health gain) as supported by professional experience and scientific evidence. It should be recognized that there are other subsets of health-care services that are also necessary and may be determined by other health-care professionals such as nurses, dentists, psychologists, etc. The term "medically necessary" is often used independently in the Canada Health Act to refer to the determination made by a qualified physician to deliver these health services. Within the Canada Health Act, there is some confusion as to the scope of this term.

Involves the deduction or rescindment of all or some part of the prospective capitation payment for an enrolled patient who seeks non-emergent care outside of the rostered practice, where that care could otherwise have been provided within the practice in which they are enrolled.

In jurisdictions outside of Canada, the patient is most often required to pay personally for services obtained outside of the rostered practice.

A defined group of providers, typically linked though contractual arrangements, that provides either specific benefits or a full range of services.

A contractual arrangement between independent or institutionally-based providers and another entity (often an employer or insurance company) to deliver health services to a defined population at established fees. The PPO contains a panel of physicians and health-care institutions that constitute the preferred providers. Health-care services are delivered on a fee-for-service basis at established rates, usually discounted from the physician's usual and customary rates. Economic incentives encourage PPO members to use the preferred panel.

Any activity undertaken by a person believing themselves to be healthy, for the purpose of preventing disease or detecting it in an asymptomatic stage.

See also: Health promotion

That level of care where the health system is entered and basic services are received. As the first level of contact, it is intended to be the point from which all subsequent health services are mobilized and coordinated. The most frequently cited definition of primary health care is that of the World Health Organization, as articulated in its Alma Ata declaration of 1978:


Essential health care based on practical, scientifically sound and socially-acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It is the first level of contact of the individual, the family and the community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health process. Primary health care addresses the main health problems in the community, providing promotive, preventative, curative, supportive and rehabilitative services accordingly.

Primary medical care, provided by physicians, is the principal component of primary health care.

Covers services not currently insured by a government plan.

Since the inception of Medicare programs, private insurers have been limited to providing supplementary benefits, like semi-private or private accommodation, drugs, eyeglasses, dental care and uninsured services

The process of transferring responsibility from the public sector to the private sector.... The process of reducing or changing the involvement of public agencies or governments in one or more of the following functions or activities: financing services and facilities, owning facilities, regulating the provision of services, providing services, or administering elements of the health-care system.

This is done with the goal of giving transactors greater responsibility, flexibility and incentives to improve the overall efficiency of the system

The ability to achieve desirable objectives using legitimate means. The objective specified is almost always an achievable state of health

Delivering high-quality care and providing individuals with the information necessary to make informed choices Quality assurance/Quality management

A formal set of activities to review and affect the quality of services provided. Quality assurance includes assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative and support services.

Care or service with characteristics that meet specified requirements and, given the state of knowledge and available resources, fulfil reasonable expectations for maximizing benefits and minimizing risk to the health and well-being of the customer

The assessment of health care in relation to three aspects: structure, process and outcome. Structure encompasses the key features of the setting in which health care is provided, such as facilities and equipment, and human resources. Process includes the activities involved in providing and receiving care, such as the practitioner's activities in diagnosing conditions and prescribing treatments. Outcome involves the study of the effects of health care on the health status of patients

Level of performance or accomplishment that characterizes the health care provided

Coordinated specialty care beyond the primary, including the services of medical specialists, supplemental or allied health-care professionals, diagnostic and institutional facilities, as may be necessary.

A funding and payment model for primary care service provision, reimbursed via FFS payment to a Bench Mark Threshold determined individually by an age/gender adjusted capitation rate applied to a rostered practice.

The process of deciding which health-care procedures and treatments are approved and funded and which patient will receive them

In the United States, the balance of spending on health care against other important national priorities is referred to as wise allocation of resources

The possibility, under the terms of a capitated payment arrangement, of having to provide services to a patient or patient population at a cost that exceeds the amount received under capitation to care for the patient or population.

A defined account (e.g., by size, geographic location and claim dollars that exceed "x" level per individual, etc.) to which revenue and expenses are posted. A risk pool attempts to define expected claim liabilities of a given defined account as well as required funding to support the claim liability.

The list of the patients registered with a given provider or provider organization, in respect of whom said provider or provider organization is receiving capitation payments.

Refers to the situation where the demand for a quantity of a good or a service far exceeds the amount which the economy's resources can produce

Reorganization of individual physician practices into single, larger practices where decision-making, administrative function, and clinical activities are centralized and services are provided in one or more locations.

Insurance for providers under capitation contracts whereby a third party agrees to share or assume treatment costs that exceed a pre-defined threshold amount; a means of limiting the provider's financial risk for individual patients should the cost of their care exceed a pre-determined upper limit.

A non-physician health-care provider licensed by a specific professional body to practice within a defined health-care domain; also known as ancillary or Allied Health-care Providers (AHPs). Examples include licensed practical nurses, midwives, nurses, Nurse Practitioners (NPs), pharmacists, Physician Assistants (PAs), physiotherapists. The scope of the services a supplementary provider may participate in providing varies in accordance with the regulatory statutes of the jurisdiction in which the provider is licensed.

Refers to insured coverage for health-care services which are not wholly insured by the provincial/territorial health insurance plan and which constitute core health services provided under uniform terms and conditions to all residents of a province in conformance with the Canada Health Act

See also: Complementary health-care system

The organization and method of financing the system needs to ensure that core health insurance benefits are to be commensurate with collective or individual ability to pay through insurance or

The requirement that all bona fide residents of Canada be entitled to reasonably comparable levels of core health insurance benefits according to uniform terms and conditions, where core benefits are defined in terms of the most recent evidence available on clinical efficacy and cost-effectiveness

Access by all citizens and legal residents to health care without financial or other barriers

See also: Accessibility

The requirement that all bona fide residents of Canada be entitled to publicly financed core health insurance benefits according to uniform terms and conditions, where core benefits are defined in terms of the most recent evidence available on clinical efficacy and cost-effectiveness

In order to satisfy the criterion respecting universality, the health-care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions

Programs, protocols and procedures (including the audit and review of encounter data), to assure appropriate placement of patients, so as to receive appropriate services, in a manner coincident with the health system objectives of efficiency, equity and effectiveness.

A subset of utilization management techniques that typically encompasses pre-service (e.g., pre-admission certification) and during service strategies (e.g., concurrent review).

References

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2. Working Group on Health System Financing 1993: Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 113.
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3. Alberta Health Planning Secretariat 1994: Starting Points: Recommendations for Creating a More Accountable and Affordable Health System, Government of Alberta, Edmonton: 15.
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4. Proceedings of the 126th Annual Meeting Including the Transactions of the General Council, Calgary, Alberta, August 22-25, 1993, Canadian Medical Association, Ottawa, 11993: 21.
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5. Working Group on Health System Financing 1993: Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 114.
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6. Saskatchewan Health 1993: A Guide to Core Services for Saskatchewan Health Districts, Government of Saskatchewan, Regina: 3.
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7. Ministry of Health 1993: Planning for Core Services and Standards in British Columbia: An Interim Document, Government of British Columbia, Victoria: 4.
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8. Working Group on Health System Financing 1993: Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 115.
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9. Harrigan M 1992: Quality of Care: Issues and Challenges in the 90s, Canadian Medical Association, Ottawa: 166.
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10. Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 116.
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11. World Health Organization 1961: Constitution of the World Health Organization. In Basic Documents (15th ed), World Health Organization, Geneva: 171.
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14. World Health Organization 1984: Health Promotion: A Discussion Document on the Concept and Principles, Regional Office for Europe, World Health Organization, Copenhagen.
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15. Hogarth J 1978: Glossary of Health Care Terminology, Regional Office for Europe, World Health Organization, Copenhagen.
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16. International Dictionary of Medicine and Biology, John Wiley & Sons, New York, 1986.
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17. Canada Health Act, 1984, c.6, s.1.
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18. Alberta Health Planning Secretariat 1993: Starting Points: Recommendations for Creating a More Accountable and Affordable Health System, Government of Alberta, Edmonton: 13.
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19. Working Group on Health System Financing 1993: Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 55.
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20. Research and Development, Canadian Hospital Association 1985: Privatize Hospitals? CHA, Ottawa: 6.
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21. Canadian Council on Health Facilities Accreditation 1991: Acute Care Hospital Accreditation Guide, CCHFA. Ottawa.
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22. Donabedian A 1988: Quality assessment and quality: unity of purpose, diversity of means. Inquiry, 25(1): 173-192.
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23. White House Domestic Policy Council 1993: The President's Health Security Plan, Random House, New York: 12.
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24. Canadian Hospital Association 1989: Quality Indicators in Health Care Facilities (draft policy statement), CHA, Ottawa.
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25. Donabedian A 1988: The quality of care: how can it be assessed? JAMA; 260: 1743-1748.
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26. Clinical Practice Guidelines Network Workshop, Ottawa, ON, Oct. 31-Nov. 1.
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27. Canadian Medical Association 1991: Quality of Care Program: Program Overview, CMA, Ottawa.
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28. White House Domestic Policy Council 1993: The President's Health Security Plan, Random House, New York: 12.
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29. Working Group on Health System Financing 1993: Toward a New Consensus on Health Care Financing in Canada, Canadian Medical Association, Ottawa: 118.
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30. Proceedings of the 126th Annual Meeting Including the Transactions of the General Council, Calgary, Alberta, August 22-25, 1993, Canadian Medical Association, Ottawa, 1993: 21.
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31. White House Domestic Policy Council 1993: The President's Health Security Plan, Random House, New York: 11.
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