100 Core U.S. Healthcare System Concepts (Part I)

Here is a list of 100 core concepts and important topics for understanding the U.S. healthcare system, especially relevant for technical professionals, policy analysts, health IT experts, and deep subject-matter audiences. They are categorized to reflect clinical, financial, regulatory, technological, and systemic dimensions. In the article below, we define each in a short 3-5 sentence paragraph. Healthcare entrepreneurs should use this framework as a way to determine market segments / trends to analyze for where they might consider building a business.

I. Policy, Regulation, and Governance

1. Affordable Care Act (ACA)

2. Medicare (Parts A, B, C, D)

3. Medicaid & CHIP

4. CMS Innovation Center (CMMI)

5. HIPAA Privacy & Security Rules

6. HITECH Act

7. 21st Century Cures Act

8. Stark Law / Anti-Kickback Statute

9. ERISA (Employee Retirement Income Security Act)

10. No Surprises Act

11. Public Health Emergency (PHE) and Telehealth Waivers

12. FDA Drug and Device Approval Pathways (e.g., 510(k), PMA)

13. Value-Based Care (VBC) Models

14. Accountable Care Organizations (ACOs)

15. MACRA / MIPS / APMs

16. State vs. Federal Roles in Healthcare Regulation

17. CON (Certificate of Need) Laws

18. Medicare Advantage Regulation

19. Veterans Health Administration (VA System)

20. CMS Star Ratings

II. Healthcare Financing & Economics

21. Fee-for-Service (FFS) vs. Capitation

22. Risk Adjustment Models (e.g., HCC Coding)

23. Medical Loss Ratio (MLR)

24. DRGs (Diagnosis-Related Groups)

25. RVUs (Relative Value Units)

26. Bundled Payments

27. Out-of-Pocket Costs and Cost-Sharing

28. Insurance Underwriting (Community vs. Risk Rating)

29. Healthcare Pricing Transparency

30. Reinsurance & Risk Corridors

31. Value-Based Insurance Design (VBID)

32. Health Savings Accounts (HSAs)

33. FQHCs and Federally Subsidized Clinics

34. Pharmacy Benefit Managers (PBMs)

35. 340B Drug Pricing Program

III. Healthcare Delivery Models

36. Integrated Delivery Networks (IDNs)

37. Patient-Centered Medical Home (PCMH)

38. Retail Clinics & Urgent Care

39. Hospital at Home Programs

40. Telehealth & Remote Patient Monitoring

41. Specialty vs. Primary Care Dynamics

42. Emergency Medical Services (EMS)

43. Post-Acute Care Continuum

44. Long-Term Services and Supports (LTSS)

45. Palliative & Hospice Care Models

46. Behavioral Health Integration

47. Community-Based Health Interventions

48. Home Health & Personal Care Services

49. Direct Primary Care (DPC)

50. Concierge Medicine

IV. Digital Health & Health IT

51. Electronic Health Records (EHRs)

52. FHIR APIs & Interoperability

53. TEFCA (Trusted Exchange Framework and Common Agreement)

54. Health Information Exchanges (HIEs)

55. Blue Button 2.0

56. USCDI (U.S. Core Data for Interoperability)

57. ONC Certification Requirements

58. Clinical Decision Support (CDS) Systems

59. Natural Language Processing (NLP) in Healthcare

60. AI/ML in Diagnostic Decision-Making

61. Remote Therapeutic Monitoring (RTM)

62. Digital Therapeutics (DTx)

63. Healthcare Cybersecurity (e.g., ransomware, zero trust)

64. Patient Portals and Consumer Health Apps

65. Mobile Health (mHealth) Regulations

66. e-Prescribing and PDMP Integration

67. Data Provenance and Audit Trails

68. Healthcare Data Standards (LOINC, SNOMED, HL7)

69. EHR Usability & Burnout

70. Health Data Lakes and Interoperability Platforms

V. Public Health and Population Health

71. Social Determinants of Health (SDoH)

72. Population Health Management Platforms

73. Vaccination Infrastructure

74. Syndromic Surveillance Systems

75. Public Health Informatics

76. Behavioral Health Epidemiology

77. Infectious Disease Reporting Systems

78. Environmental Health Policy

79. Substance Use Disorder (SUD) Treatment Systems

80. Mental Health Crisis Response Models

81. School-Based Health Systems

82. Maternal and Infant Health Metrics

83. Food Insecurity and Health Outcomes

84. Rural Health Access and Disparities

85. Opioid Epidemic Response Strategies

VI. Clinical Standards & Outcomes

86. Clinical Quality Measures (CQMs)

87. Evidence-Based Practice Guidelines

88. Precision Medicine & Genomics

89. Clinical Trials Infrastructure (CTMS, eConsent)

90. Patient Safety & Sentinel Event Reporting

91. Care Coordination and Transitions of Care

92. Clinical Workflow Optimization

93. Utilization Management and Prior Authorization

94. Credentialing & Provider Networks

95. Chronic Disease Management Programs

96. Health Literacy and Patient Engagement

97. Clinical Pathways & Standardization

98. Patient-Reported Outcome Measures (PROMs)

99. Readmission Reduction Programs

100. Caregiver Support Infrastructure