Reporting on the business of health care:
Covering the business of health care is a challenge, whether reporting on insurance companies, service providers, consumers, pharmaceutical companies or other aspects. AHCJ member Tammy Worth has written a guide and compiled resources to help reporters tackle this complex topic.
Insurance
Broker – An independent agent who sells insurance products to businesses and individuals.
Deductible – The amount an individual must pay out-of-pocket before an insurer will pay for his or her services.
Group insurance – A majority of people in the United States are covered under this type of plan, one in which an employer, association, or other group provides a health insurance policy to its employees or members.
HMO – A health maintenance organization is a managed care plan in which an individual typically has a primary care provider coordinate their health services among a group of approved providers. Individuals typically pay a copayment for services and the insurer reimburses the providers for the remainder of the agreed-upon fees.
High-deductible health plan – Meant to make consumers participate in their health care decisions by giving them more responsibility for their health costs. These offer high deductibles and low premiums for individuals. They are often coupled with a Health Savings Account that allows individuals to save money tax-free to use for qualified health expenditures.
Individual health insurance – Plans offered to people outside of a group or employer based plan. They are regulated by the state in which they are provided.
Out-of-pocket responsibility – The amount of money an insured individual must pay for deductibles, coinsurance and copayments.
PPO – A preferred provider organization is a type of insurance under which providers offer services to individuals insured under the plan for a discounted fee.
Pay for performance – Where insurers pay providers based on the quality of care offered to patients.
Premiums—the amount of money and individual or employer pays monthly to an insurer to purchase an insurance plan.
Providers
Charge – The amount billed to patients for services provided by a hospital or physician.
Cost – The amount it actually costs a hospital or physician to provide a service, usually less than the amount they charge patients.
Cost shifting – When a health care provider loses funds through uncompensated care then increases the cost of services to others, like insurance providers, to replace the losses.
Uncompensated care – Services provided by hospitals or physicians for which no payment is received. This falls under two categories: bad debt, when services are rendered to a patient and the provider attempts to collect payment unsuccessfully; and charity care, where services are provided and payment is not expected in return.
Government/health policy
COBRA – The Consolidated Omnibus Budget Reconciliation Act provides some workers and their families with the right to continue their health coverage for a limited time after certain events, such as the loss of a job.
Doughnut hole – The gap in Medicare prescription coverage for beneficiaries. Individuals’ pharmaceutical costs are covered currently up to $2,700, then insurance does not begin paying again until an individual pays more than $6,100 for medication.
ERISA The Employee Retirement Income Security Act of 1974 is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry. The law provides protection for individuals in these plans.
Employer mandate – A federal mandate that would make employers provide health insurance to workers or pay a fee to help them purchase another plan.
HIPAA – The Health Insurance Portability and Accountability Act includes protections so group health plan participants cannot be excluded for pre-existing conditions or health status and allows workers the right to continue a plan should they switch employment. It also requires that providers collect certain health information and sets rules to protect patient privacy.
Medicaid – A program providing health insurance predominately for low-income individuals that is paid for by state and federal funds and overseen by the states.
Medicare – A federal program that provides insurance for elderly (aged 65 and older) and permanently disabled individuals.
Public option – A health plan that would be provided by the federal government to compete with private insurance companies.
SCHIP – The State Children’s Health Insurance Program provides federal funds for states to spend on health coverage for children in low-income families that make too much money for Medicaid.
Pharmaceuticals
Consumer-directed advertising – Using mass media to market products (such as pharmaceuticals) directly to consumers. The messages in the ads must meet federal guidelines.
Generics – According to the Kaiser Family Foundation, approximately 75 percent of prescription medications on the market today have a generic counterpart.
Off-label usage – When a medication is utilized for purposes that it was not approved for by the FDA: the use of Botulinum Toxin Type A for cosmetic purposes instead of its initial purpose of reducing muscle spasms.
PBM – A pharmacy benefit manager is an organization that works under contract to manage prescription drug plans for employers or insurers.
