Health insurance or medical insurance is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance is risk among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
Mass General Brigham is a Boston-based non-profit hospital and physicians network that includes Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH), two of the nation's most prestigious teaching institutions. It was founded in 1994 with H. Richard Nesson, MD, former president of Brigham and Women's Hospital as CEO of Mass General Brigham and Samuel O. Thier, MD, formerly president of Massachusetts General Hospital as president. According to The Boston Globe, by 2008, Mass General Brigham became Massachusetts' "largest private employer and its biggest healthcare provider, treating more than a third of hospital patients in the Boston metropolitan area".
The Massachusetts health care reform, commonly referred to as Romneycare, was a healthcare reform law passed in 2006 and signed into law by Governor Mitt Romney with the aim of providing health insurance to nearly all of the residents of the Commonwealth of Massachusetts.
Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.
Samuel Osiah Thier is professor of Medicine and Health Care Policy at Harvard University. He earned his medical degree at the State University of New York Upstate Medical University in 1960. He previously served as the president of Brandeis University from 1991–1994 and the president of the Massachusetts General Hospital from 1994-96.
Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.
Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status.
There were a number of different health care reforms proposed during the Obama administration. Key reforms address cost and coverage and include obesity, prevention and treatment of chronic conditions, defensive medicine or tort reform, incentives that reward more care instead of better care, redundant payment systems, tax policy, rationing, a shortage of doctors and nurses, intervention vs. hospice, fraud, and use of imaging technology, among others.
Bundled payment is the reimbursement of health care providers "on the basis of expected costs for clinically-defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement and capitation, given that risk is shared between payer and provider. Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs, especially during the Obama administration (2009–2016). Commercial payers have shown interest in bundled payments in order to reduce costs. In 2012, it was estimated that approximately one-third of the United States healthcare reimbursement used bundled methodology.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
Anthem, Inc., is a provider of health insurance in the United States. It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2018, the company had approximately 40 million members.
Gene Lindsey is former president and CEO emeritus of Atrius Health and Harvard Vanguard Medical Associates and a resident of Wellesley, Massachusetts. As head of an organization with more than 40 years experience as an Accountable Care Organization (ACO), Lindsey has been a leading voice in Massachusetts on healthcare reform and has led several initiatives at Atrius Health, including signing Blue Cross Blue Shield of Massachusetts' Alternative Quality Contract (AQC) and a Toyota Lean Transformation. Lindsey has been featured in numerous news articles and speaks around the United States on healthcare reform and ACOs.
Bluebikes, originally Hubway, is a bicycle sharing system in the Boston metropolitan area. As of July 2021, the system had deployed 393 stations with a fleet of over 3,800 bikes in the 10 municipalities it served. Bluebikes is operated by Motivate and uses technology provided by 8D Technologies and PBSC Urban Solutions for equipment. The bike share program officially launched in Boston as Hubway. From 2012 to 2021, neighboring municipalities of Brookline, Cambridge, Somerville, Everett, Newton, Arlington, Chelsea, Watertown, and Salem joined the system. By 2020, total annual members neared 23,000, and as of 2021, 14 million total rides have been taken.
Cleve L. Killingsworth is a former CEO of Blue Cross Blue Shield of Massachusetts. There, he was dissatisfied with the results of pay for performance initiatives, in that he thought billions more of wasteful medical spending could be reduced with a new payment model. In 2007, he set a 6-month deadline for his staff to come up with a new payment model, which was introduced as the alternative quality contract (AQC) to health care providers.
Atrius Health is an American not-for-profit, 501(c)(3) tax-exempt organization, and the largest independent physician-led healthcare organization in the Northeast. Atrius Health has a system of connected care for adult and pediatric patients in eastern and central Massachusetts. Atrius Health's medical practices work together with the home health and hospice services of its VNA Care subsidiary and in collaboration with hospital partners, community specialists and skilled nursing facilities.
Balance billing, sometimes called surprise billing, is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the insurance pays. It is an especially common problem in the United States with providers who are out of network, and therefore not subject to the rates or terms of providers who are in-network. Balance billing has a variable prevalence by market and specialty.
Cycling in Boston has been a popular activity since the late 19th century for both recreation and commuting, and it has grown in popularity in recent years, aided by improving cycling infrastructure. It is especially prevalent around the campuses of the numerous universities in the city.
Value-Based Insurance Design is a demand-side approach to health policy reform. V-BID generally refers to health insurers’ efforts to structure enrollee cost-sharing and other health plan design elements to encourage enrollees to consume high-value clinical services – those that have the greatest potential to positively impact enrollee health. V-BID also discourages the use of low-value clinical services – when benefits do not justify the cost. V-BID aims to increase health care quality and decrease costs by using financial incentives to promote cost efficient health care services and consumer choices. V-BID health insurance plans are designed with the tenets of "clinical nuance" in mind. These tenets recognize that medical services differ in the amount of health produced, and the clinical benefit derived from a specific service depends on the consumer using it, as well as when and where the service is provided.
The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care, especially those involving chemotherapy, which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.
