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D . . .
Days or Visits Per 1,000
An indicator calculated by taking the total number of days (for
inpatient, residential, or partial hospitalization) or visits
(for outpatient) received by a specific group for a specific period
of time (usually one year). This number is then divided by the
average number of covered members or lives in that group during
the same period and multiplied by 1,000. A measure used to evaluate
utilization management performance.
Day Outlier
A patient with an atypically long length of stay compared with
other patients in a particular diagnosis related group.
Deductible
The out-of-pocket expenses that must be borne by an insurance
subscriber before the insurer will begin reimbursing the subscriber
for additional expenses.
Dependent
In a payer's policy of insurance, a person other than the subscriber
eligible to receive care because of a subscriber's contract.
Diagnosis Related Groups (DRGs)
A patient classification scheme used by Medicare and other insurers
that clusters patients into 468 categories on the basis of patients'
illnesses, diseases and medical problems. All Medicare inpatient hospital
operating costs are determined in advance and paid on a per-case basis,
according to fixed amount or weight established for each DRG.
Direct Contracting
Providing health services to members of a health plan by a group
of providers contracting directly with an employer, thereby butting
out the middleman or third party insurance carrier. This can be
provider heaven, since middleman-MCO-is cut out and provider gets
some portion of the money usually made by it. Key is to price
services correctly, since provider is usually at full risk in
this situation. Takes a strong IDS or AHP to pull this off.
Direct Payment Subscriber
A person enrolled in a prepayment plan who makes individual premium
payments directly to the plan rather than through a group. Rates
of payment are generally higher, and benefits may not be as extensive
as for the subscriber enrolled and paying as a member of the group.
Discounted Fee-For-Service
An agreed upon rate for service between the provider and payer
that is usually less than the provider's full fee. This may be
a fixed amount per service, or a percentage discount. Providers
generally accept such contracts because they represent a means
to increase their volume or reduce their chances of losing volume.
Disease Management
A type of product or service now being offered by many large pharmaceutical
companies to get them into broader healthcare services. Bundles
use of prescription drugs with physician and allied professionals,
linked to large databases created by the pharmaceutical companies,
to treat people with specific diseases. The claim is that this
type of service provides higher quality of care at more reasonable
price than alternative, presumably more fragmented, care. The
development of such products by hugely-capitalized companies should
be all the indicator necessary to convince a provider of how the
healthcare market is changing. Competition is coming from every
direction--other providers of all types, payers, employers (who
are developing their own in-house service systems), the drug companies.
Dual Choice (or Multiple Choice; Dual Option)
The opportunity for an individual within an employed group to
choose from two or more types of health care coverage such as
an HMO and a traditional insurance plan. Section 1310 of the HMO
Act provides for dual choice.
Durable Medical Equipment (DME)
Items of medical equipment owned or rented which are placed in
the home of an insured to facilitate treatment and/or rehabilitation.
DME generally consist of items which can withstand repeated use.
DME is primarily and customarily used to serve a medical purpose
and is usually not useful to a person in the absence of illness
or injury.
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