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Quality Assurance Reform Initiative (QARI) — A process developed by the Health Care Financing Administration to develop a health care quality improvement system form Medicaid managed care plans.

quality of care — Can be defined as a measure of the degree to which delivered health services meet established professional standards and judgments of value to the consumer. Quality may also be seen as the degree to which actions taken or not taken maximize the probability of beneficial health outcomes and minimize risk and other untoward outcomes, given the existing state of medical science and art. Quality is frequently described as having three dimensions: quality of input resources (certification and/or training of providers); quality of the process of services delivery (the use of appropriate procedures for a given condition); and quality of outcome of service use (actual improvement in condition or reduction of harmful effects).

rate review — Review by a government or private agency of a hospital's budget and financial data, performed for the purpose of determining the reasonableness of the hospital rates and evaluating proposed rate increases.

referral — The process of sending a patient from one practitioner to another for health care services. Health Plans may require that designated primary care providers authorize a referral for coverage of specialty services.

rehabilitation — The combined and coordinated use of medical, social, educational, and vocational measures for training or retraining individuals disabled by disease or injury to the highest possible level of functional ability. Several different types of rehabilitation are distinguished: vocational, social, psychological, medical, and educational.

reimbursement — The process by which health care providers receive payment for their services. Because of the nature of the health care environment, providers are often reimbursed by third parties who insure and represent patients.

report card —A report presented on quality of health services designed to inform patients and health care purchasers of practitioner and organizational performance.

risk — Responsibility for paying for or otherwise providing a level of health care services based on an unpredictable need for these services.

risk adjustment — A process by which premium dollars are shifted from a plan with relatively healthy enrollees to another with sicker members. It is intended to minimize any financial incentives health plans may have to select healthier than average enrollees. In this process, health plans which attract higher risk providers and members would be compensated for any differences in the proportion of their members that require high levels of care compared to other plans.

risk sharing — The distribution of financial risk among parties furnishing a service. For example, if a hospital and a group of physicians from a corporation provide health care at a fixed price, a risk-sharing arrangement would entail both the hospital and the group being held liable if expenses exceed revenues.

risk selection — Occurrence when a disproportionate share of high or low users of care join a health plan.

rural health network — Refers to any of a variety of organizational arrangements to link rural health care providers in a common purpose.

Rural Health Clinic (RHC) — A public or private hospital, clinic or physician practice designated by the federal government as in compliance with the Rural Health Clinics Act (Public Law 95-210). The practice must be located in a Medically Underserved area or a Health Professions Shortage Area and use a physician assistant and/or nurse practitioners to deliver services. A rural health clinic must be licensed by the state and provide preventive services.

Rural Health Clinics Act — Establishes a reimbursement mechanism to support the provision of primary care services in rural areas. Public Law 95-210 was enacted in 1977 and authorizes the expanded use of physician assistants, nurse practitioners and certified nurse practitioners; extends Medicare and Medicaid reimbursement to designated clinics; and raises Medicaid reimbursement levels to those set by Medicare.

screening — The use of quick procedures to differentiate apparently well persons who have a disease or a high risk of disease from those who probably do not have the disease. It is used to identify high risk individuals for more definitive study or follow-up. Multiple screening (or multiphasic screening) is the combination of a battery of screening tests for various diseases performed by technicians under medical direction and applied to large groups of apparently well persons.

secondary opinions — In cases involving non-emergency or elective surgical procedures, the practice of seeking judgment of another physician in order to eliminate unnecessary surgery and contain the cost of medical care.

secondary care — Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, urologists, dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.

secondary prevention — Early diagnosis, treatment and follow-up. Secondary prevention activities start with the assumption that illness is already present and that primary prevention was not successful and the goal is to diminish the impact of disease or illness through early detection, diagnosis and treatment. For example, blood pressure screening, treatment, and follow up programs.

self-funding / self-insurance — An employer or group of employers sets aside funds to cover the cost of health benefits for their employees. Benefits may be administered by the employer(s) or handled through an administrative service only agreement with an insurance carrier or third-party administrator. Under self-funding, it is generally possible to purchase stop-loss insurance that covers expenditures above a certain aggregate claim level and/or covers catastrophic illness or injury when individual claims reach a certain dollar threshold.

service period — Period of employment that may be required before an employee is eligible to participate in an employer-sponsored health plan, most commonly one to three months.

severity of illness — A risk prediction system to correlate the "seriousness" of a disease in a particular patient with the statistically "expected" outcome (e.g., mortality, morbidity, efficiency of care). Most effectively, severity is measured at or soon after admission, before therapy is initiated, giving a measure of pretreatment risk.

Sexually Healthy Adolescent — A sexually healthy adolescent, as agreed upon by more than 50 national health organizations, has the information needed to make responsible decisions about sexual behavior, an understanding of sexual development and feelings, an ability to maintain personal boundaries and an awareness of possible consequences of his or her decisions.

shared services — The coordinated, or otherwise explicitly agreed upon, sharing of responsibility for provision of medical or nonmedical services on the part of two or more otherwise independent hospitals or other health programs. The sharing of medical services might include an agreement that one hospital provide all pediatric care needed in a community and no obstetrical services while another provide obstetrics and no pediatrics. Examples of shared nonmedical services would include joint laundry or dietary services for two or more nursing homes.

Skilled Nursing Facility (SNF) — A nursing care facility participating in the Medicaid and Medicare programs which meets specified requirements for services, staffing and safety.

skills training — An approach that seeks to train youths in the personal and social skills needed to resist pressures to use violence.

social capital — The degree of social cohesion that exists in communities. It refers to the processes between people that establish networks, norms and social trust, and facilitate coordination and cooperation for mutual benefit.The stronger these networks and bonds, the more likely it is that members of a community will cooperate for mutual benefit. In this way, social capital creates health, and may enhance the benefits of investments for health. Wellness village members are residents who work together to strengthen social cohesion.

social support — The assistance available to individuals and groups from within communities that can provide a buffer against adverse life events and living conditions, and can provide a positive resource for enhancing the quality of life. Social support may include emotional support, information sharing and the provision of material resources and services. Social support is now widely recognized as an important determinant of health and an essential element of social capital.

Sole Community Hospital (SCH) — A hospital that (1) is more than 50 miles from any similar hospital, (2) is 25 to 50 miles from a similar hospital and isolated from it at least one month a year as by snow, or is the exclusive provider of services to at least 75 percent of its service area populations, (3) is 15 to 25 miles from any similar hospital and is isolated from it at least one month a year, or (4) has been designated as an SCH under previous rules. The Medicare DRG program makes special optional payment provisions for SCHs, most of which are rural, including providing that their rates are set permanently so that 75 percent of their payment is hospital-specific and only 25 percent is based on regional DRG rates.

solo practice — Lawful practice of a health occupation as a self-employed individual. Solo practice is by definition private practice but is not necessarily general practice or fee-for-service practice (solo practitioners may be paid by capitation, although fee-for-service is more common). Solo practice is common among physicians, dentists, podiatrists, optometrists, and pharmacists.

specialist — A physician, dentist, or other health professional who is specially trained in a certain branch of medicine or dentistry related to specific services or procedures (e.g., surgery, radiology, pathology); certain age categories of patients (e.g., geriatrics); certain body systems (e.g., dermatology, orthopedics, cardiology); or certain types of diseases (e.g., allergy, periodontics). Specialists usually have advanced education and training related to their specialties.

spend down — The amount of expenditures for health care services, relative to income, that qualifies an individual for Medicaid in states that cover categorically eligible, medically indigent individuals. Eligibility is determined on a case-by-case basis.

Substance Abuse and Mental Health Services Administration (SAMHSA) — The mission of SAMHSA is to provide, through the U.S. Public Health Service, a national focus for the Federal effort to promote effective strategies for the prevention and treatment of addictive and mental disorders. SAMHSA is primarily a grant-making organization, promoting knowledge and scientific state-of-the-art practice. SAMHSA strives to reduce barriers to high quality, effective programs and services for individuals who suffer from, or are at risk for, these disorders, as well as for their families and communities.

Supplemental Security Income (SSI) — A federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act. States may use SSI income limits to establish Medicaid eligibility.

supportive environments for health (see also physical environment) — Environments that offer people protection from threats to health and enable them to expand their capabilities and develop self-reliance in health. They encompass where people live; their local community; their home; where they work and play, including people’s access to resources for health; and opportunities for empowerment.

1. social environment encompasses the level of interaction and relationships among individuals in the community. Relationships and interaction with others provide models for lifestyle change; controls and constraints on behavior; access to information; and a sense of meaning and purpose to life that can help make healthy lifestyle changes seem more attainable. Social support has been defined as the comfort, assistance or information one receives from one’s social network. Natural and professional sources of social support include family, tribe, friends, neighbors, parishioners, classmates, coworkers, merchants, health and social services providers. Vehicles of support can include community affiliations, community activities, religious activities, and organized self-help groups.
   
   Projects to improve the social environment focus on reinforcing social networks and social support within the community and developing the material resources available to the community. Activities can include neighborhood health fairs; community-sponsored sports programs; and exercise groups, peer support and self-help groups.
   
   
2. chemical environment encompasses the composition of manmade and naturally occurring chemicals and toxins in the air, water and ground. Chemical hazards in the environment can cause immediate, dangerous health effects and can also contribute to chronic problems.
   
   Projects to improve the chemical environment include environmental risk assessment of communities; health education and awareness campaigns on lead, pesticides, and air particulates; environmental justice activities that will develop, implement and enforce of environmental laws, regulations and policies; and health advocacy activities that focus on improving waste management and sanitation in communities.

Temporary Assistance for Needy Families (TANF) – Commonly referred to as the federal welfare program, TANF is the replacement for Aid to Families with Dependent Children (AFDC).

technology assessment — A comprehensive form of policy research that examines the technical, economic, and social consequences of technological applications. It is especially concerned with unintended, indirect, or delayed social impacts. In health policy, the term has come to mean any form of policy analysis concerned with medical technology, especially the evaluation of efficacy and safety.

telemedicine  —The use of telecommunications (i.e., wire, radio, optical or electromagnetic channels transmitting voice, data and video) tofacilitate medical diagnosis, patient care, and/or distance learning.

tertiary care — Services provided by highly specialized providers (e.g., neurologists, neurosurgeons, thoracic surgeons, intensive care units). Such services frequently require highly sophisticated equipment and support facilities. The development of these services has largely been a function of diagnostic and therapeutic advances attained through basic and clinical biomedical research.

tertiary prevention — Prevention activities which focus on the individual after a disease or illness has manifested itself. The goal is to reduce long-term effects and help individuals better cope with symptoms.

third-party payer — Any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. Such payments are called third-party payments and are distinguished by the separation among the individual receiving the service (the first party), the individual or institution providing it (the second party), and the organization paying for it (third party).

Third-Party Administrator (TPA) — A fiscal intermediary, a person or an organization that serves as another's financial agent. A TPA processes claims, provides services, and issues payments on behalf of certain private, federal and state health benefit programs or other insurance organizations.

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