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Refers to a set of medical services that are carved out of the basic arrangement.  In terms of plan benefits, may refer to a set of benefits that are carved out and contracted for separately; for example, mental health/ substance abuse services may be separated from basic medical-surgical services.  May also refer to carving out a set of services from a basic capitation rate with a provider (e.g., capitating for cardiac care but carving out cardiac surgery and paying case rates for that).  Medical services commonly carved out from managed care contracts (exempt from capitation) include out-of-area emergency, out-of-network services in plans that allow members to use not-network providers, mental health substance abuse, vision and dental care.

Utilizes standards and has defined goals of ongoing increases in the level of quality of care given and outcomes. The CQI program may include the establishment of credentialing standards, regular review of practice patterns, study of clinical outcomes, routine utilization review and case management. These may be mandated by third party payors or developed by health care delivery group.

CONTINUUM OF CARE

A comprehensive set of health services ranging from preventive and ambulatory services to acute care to long-term and rehabilitative services. Continuum of care involves coordinating the mix of services that each patient may require. Primary care tends to be the point of access for most patients. If the patient is well, then the health system would ideally place that person along a track geared toward promoting and maintaining wellness. If the patient has one or more chronic illnesses, then the system would ideally enlist tools and techniques to manage those conditions across sites and providers of care. Such a system provides consistency and continuity of care, while encouraging patients toward responsibility for improving or maintaining their health, independence and well-being.

GATEKEEPER

Usually Primary Care Physicians are the "gatekeeper" who serve as the patient’s initial contact for medical care and referrals. He or she decides on what tests to order, when consultation and hospitalization is needed and whether or not to carry out consultant’s recommendations. In the original gatekeeper systems used by HMOs and many PPOs, the patient cannot self-refer to specialists.

MIDLEVEL PRACTITIONER

Physician's assistants, clinical nurse practitioners, nurse midwives and the like.  Non-physicians who deliver medical care, generally under the supervision of a physician but for less cost.

Practitioners who treat a variety of health problems across all patient age groups and who frequently serve as the patient’s first point of contact with the health care system. Typically, Primary Care Physicians include family practitioners, general internists, general pediatricians, and in some cases, obstetricians and gynecologists. PCP’s are the means by which patients gain access to and navigate through a health care system. Often, Managed Care Organizations establish their own criteria for who may provide primary care. Three general approaches may be used to define the category of primary care physicians: by specialty, by historical practice, and by willingness to provide primary care services.