Essentials of managed health care /

Essentials of managed health care /

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Bibliographic Details
Edition:4th ed.
Imprint:Gaithersburg, Md. : Aspen Publishers, 2001.
Description:xxvii, 883 p. : ill. ; 26 cm.
Language:English
Subject:
Managed care plans (Medical care) -- Management.
Managed care plans (Medical care) -- Management.
Format: Print Book
URL for this record:http://pi.lib.uchicago.edu/1001/cat/bib/4382789
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Other authors / contributors:Kongstvedt, Peter R. (Peter Reid)
ISBN:0834218623
Notes:Includes bibliographical references and index.
Table of Contents:
  • About the Editor
  • Contributors
  • Preface
  • Acknowledgments
  • Part I. Introduction to Managed Care
  • Chapter 1. An Overview of Managed Care
  • Study Objectives
  • Introduction
  • Managed Care: The Early Years (Pre-1970)
  • The Adolescent Years: 1970-1985
  • Managed Care Comes of Age: 1985 to the Present
  • Future Issues Facing Managed Care
  • Conclusion
  • Study Questions
  • Chapter 2. Types of Managed Care Organizations
  • Study Objectives
  • Types of MCOs
  • HMO Models
  • Conclusion
  • Study Questions
  • Chapter 3. Integrated Health Care Delivery Systems
  • Study Objectives
  • Introduction
  • Highly Integrated Delivery Systems
  • Market Characteristics
  • Types of IDSs
  • IPAs
  • PPMCs
  • Consolidated Medical Groups
  • PHOs
  • MSOs
  • Foundations
  • Staff Model
  • Physician Ownership Model
  • PSOs
  • Virtual Integration
  • Global Capitation
  • Acquisition of Physician Practices
  • Legal Pitfalls for IDSs
  • Critical Success Factors for IDSs
  • Conclusion
  • Study Questions
  • Chapter 4. Elements of the Management Control and Governance Structure
  • Study Objectives
  • Board of Directors
  • Key Management Positions
  • Committees
  • Management Control Structure
  • Conclusion
  • Study Questions
  • Chapter 5. Examining Common Assertions About Managed Care
  • Study Objectives
  • Introduction
  • Managed Care Myths
  • Conclusion
  • Study Questions
  • Part II. The Health Care Delivery System
  • Chapter 6. Primary Care in Managed Health Care Plans
  • Study Objectives
  • Introduction and Definitions
  • Recruiting
  • Nonphysician or Midlevel Practitioners
  • Types of Contracting Situations
  • Credentialing
  • The National Practitioner Data Bank
  • Healthcare Integrity and Protection Data Bank
  • Compensation
  • Orientation
  • Network Maintenance
  • Internet-Based Activities
  • Removing Physicians from the Network
  • Conclusion
  • Study Questions
  • Chapter 7. Compensation of Primary Care Physicians in Managed Health Care
  • Study Objectives
  • Introduction
  • Basic Models of Reimbursement
  • Capitation
  • Withholds and Risk/Bonus Arrangements
  • Capitation Pools for Referral and Institutional Services
  • Full Professional Risk Capitation
  • Reasons To Capitate
  • Problems with Capitation Systems
  • Effect of Benefits Design on Reimbursement
  • Fee for Service
  • A Special Requirement for Reimbursement When Coinsurance Is in Place
  • Out-of-Network Fees
  • Discounts, Negotiated Fee Schedules, Fee Maximums, or Fee Allowances
  • Relative Value Scales
  • Global Fees
  • Problems with FFS in Managed Health Care Plans
  • Legislation and Regulation Applicable to Physician Incentive Programs
  • Civil Liability in Physician Compensation Programs
  • Conclusion
  • Study Questions
  • Chapter 8. Contracting and Reimbursement of Speciality Physicians
  • Study Objectives
  • Introduction
  • How Many Specialty Care Physicians?
  • Primary versus Specialty Care Designation
  • Credentialing
  • Types of Reimbursement Arrangements
  • Organizational Models for Capitating Specialty Services
  • Common Problems with Specialty Capitation
  • Other Forms of Specialty Physician Reimbursement
  • Risk and Reward
  • Conclusion
  • Study Questions
  • Chapter 9. Negotiating and Contracting with Hospitals, Institutions, and Ancillary Services
  • Study Objectives
  • Introduction
  • Hospital Network Development
  • Types of Reimbursement Arrangements
  • Outpatient Procedures
  • Ancillary Services
  • Conclusion
  • Study Questions
  • Part III. Medical Management
  • Chapter 10. Care Management and Clinical Integration Components
  • Study Objectives
  • The Context for Advanced Care Management
  • Defining Advanced Care Management
  • Integrating the Components of Care Management
  • The Role of Physicians in Care Management
  • Building an Advanced Care Management System: A Typical Process
  • Defining the Future State of Care Management
  • Conclusion
  • Study Questions
  • Appendix 10-A. Description of the Components of the Advanced Care Management System
  • Chapter 11. Managing Basic Medical-Surgical Utilization
  • Study Objectives
  • Introduction
  • Return on Investment in Management of Medical Costs
  • Demand Management
  • Measurements of Utilization
  • Variations in Utilization
  • The Role of Electronic Commerce
  • Authorization or Denial of Payment for Services
  • Managing Utilization of Specialty Services
  • The Role of the Primary Care Physician in Specialty Services Management
  • Single Visit Authorizations Only
  • Specialty Physicians As Primary Physicians
  • Prohibition of Secondary Referrals and Authorizations
  • Review of Reasons for Referral
  • Institutional Utilization Management
  • Common Methods for Managing Utilization
  • Alternatives to Acute Care Hospitalization
  • Case Management
  • Conclusion
  • Study Questions
  • Chapter 12. Clinical Services Requiring Authorization
  • Study Objectives
  • Definition of Services Requiring Authorization
  • Definition of Who Can Authorize Services
  • Claims Payment
  • Categories of Authorization
  • Staffing
  • Common Data Elements
  • Methods of Data Capture and Authorization Issuance
  • Authorization System Reports
  • Open Access HMOs
  • Specialty-Physician Based Authorization Systems
  • Non-Physician-Based Authorization Systems
  • Conclusion
  • Study Questions
  • Chapter 13. Case Management and Managed Care
  • Study Objectives
  • The Case Manager's Role
  • Patient Profile: Not Every Case Needs a Case Manager
  • On-Site versus Telephone-Based Case Management
  • Case Managers in Managed Care
  • Case Management Work Format and Process
  • Utilization Review: Preadmission and Concurrent Review and Case Management
  • Preadmission and Concurrent Review Case Management Reports
  • Red Flags: Indicators for Case Management
  • Timing Case Management Intervention
  • Beyond the Case Management Basics
  • A Long-Term Solution to a Long-Term Problem
  • Study Questions
  • Chapter 14. Fundamentals and Core Competencies of Disease Management
  • Study Objectives
  • Definition and Clarification
  • Barriers and Drivers for Disease Management
  • Business Plan
  • Survey of Disease Management Programs
  • Important Linkages
  • Support from Electronic Commerce
  • Conclusion
  • Study Questions
  • Chapter 15. Prescription Drug Benefits in Managed Care
  • Study Objectives
  • Financial Basis for Pharmacy Benefit Management
  • Pharmacy Program Cost Components
  • Principles of Pharmacy Benefit Management
  • Managing the Supply and Demand
  • Pharmacy Information Systems and Health Informatics
  • Pharmacy Benefit Management Companies (PBMs)
  • Pharmacy Benefit Management Program Components
  • Physician Provider Network
  • Pharmacy Provider Network
  • Pharmacy Provider Audits
  • Drug Formulary Management
  • Pharmaceutical Manufacturer Discount and Rebate Contracts
  • Prescription Patient Copayments
  • Role of Pharmacy Programs in Disease Management and Quality Improvement Programs
  • Quality Improvement in Pharmacy Benefit Management
  • Measuring Pharmacy Benefit Management Program Performance
  • Future Changes in Pharmacy Benefit Management
  • Conclusion
  • Study Questions
  • Chapter 16. Managed Behavioral Health Care and Chemical Dependency Services
  • Study Objectives
  • Introduction
  • Historical Perspective
  • Key Treatment Principles
  • Benefit Plan Design
  • Utilization Management
  • Channeling Mechanisms
  • Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives
  • Quality Assurance
  • BH Information Systems
  • Public/Private Systems Integration
  • Emerging Issues
  • Conclusion
  • Study Questions
  • Chapter 17. Quality Management in Managed Care
  • Study Objectives
  • Introduction
  • Traditional Quality Assurance
  • Components of a Quality Management Program
  • A Process Model for a Modern Quality Management Program
  • Conclusion
  • Study Questions
  • Chapter 18. Using Data and Provider Profiling in Medical Management
  • Study Objectives
  • Introduction
  • Use of Data and Information in Medical Management
  • Patient Data Confidentiality
  • Data Elements and the Application of Reports
  • General Types of Reports
  • Provider Profiling
  • Desired Characteristics of Provider Profiles
  • The Need To Adjust for Severity of Illness
  • Selection of a Profiling Vendor
  • The Future of Data Use
  • Conclusion
  • Study Questions
  • Chapter 19. Physician Behavior Change in Managed Health Care
  • Study Objectives
  • Introduction
  • General Aspects of Physician Practice Behavior
  • General Approaches to Changing Behavior
  • Programmatic Approaches to Changing Physician Behavior
  • Addressing Noncompliance by Individual Physicians
  • Conclusion
  • Study Questions
  • Part IV. Operational Marketing and Management
  • Chapter 20. Information Systems in Managed Health Care Plans
  • Study Objectives
  • Introduction
  • Core Managed Care Information System
  • Electronic Data Interchange
  • Privacy and Confidentiality under HIPAA
  • Value-Added Services--The Next Generation
  • HEDIS
  • Information Services Department
  • Conclusion
  • Study Questions
  • Chapter 21. Claims and Benefits Administration
  • Study Objectives
  • Introduction
  • Claims: Positioning, Purpose, and Opportunities
  • Organizational Structure and Staffing
  • Claims Operations Management
  • Productivity
  • Turn Around Time
  • Staff Training and Development
  • Quality
  • Policy and Procedure
  • Coordination with Other Departments/Functions
  • Systems Support
  • Claims Business Functions
  • Other Issues
  • Conclusion
  • Study Questions
  • Chapter 22. Member Services and Consumer Affairs
  • Study Objectives
  • Provision of General Information
  • Conclusion
  • Study Questions
  • Chapter 23. Sales and Marketing in Managed Health Care Plans: The Process of Distribution
  • Study Objectives
  • What Managed Care Organizations Deliver
  • Challenges Facing MCOs
  • An Overview of the Managed Care Market
  • Key Decision Makers and Influencers in the Managed Care Distribution Process
  • The Managed Care Sales Process
  • How the Managed Care Team Delivers
  • The Management of Sales and Marketing Professionals
  • Conclusion
  • Study Questions
  • Chapter 24. The Employer's View of Managed Health Care: Show Me the Value
  • Study Objectives
  • Recent Managed Care Trends Affecting Employers
  • How These Trends Impact Employers Both Large and Small
  • The Large Group Employer: 5,000 Lives Plus
  • The Moderate Group Employer: 500-5,000 Lives
  • The Medium Group Employer: 50-500 Lives
  • The Small Group Employer: 0-50 Lives
  • How Employers Purchase Value (1988-1998)
  • Looking for Value: 2000 and Beyond
  • Future Trends
  • Conclusion
  • Study Questions
  • Chapter 25. The Impact of Consumerism on Managed Health Care
  • Study Objectives
  • Why Is Consumerism a Significant Trend?
  • Who Is the New Health Care Consumer?
  • What Are the Implications of Consumerism?
  • How Can Organizations Develop a Consumer Strategy?
  • What Consumerism Means for the Managed Care Industry
  • Conclusion
  • Study Questions
  • Chapter 26. Accreditation and Performance Measurement Programs for Managed Care Organizations
  • Study Objectives
  • Introduction
  • Oversight by Type of Organization
  • National Committee for Quality Assurance
  • The Utilization Review Accreditation Commission
  • Joint Commission on Accreditation of Healthcare Organizations
  • Conclusion
  • Study Questions
  • Chapter 27. Common Operational Problems in Managed Health Care Plans
  • Study Objectives
  • Introduction and Background
  • Common versus Unique Problems or Events
  • Common Problems in Managed Care Organizations
  • Conclusion
  • Study Questions
  • Chapter 28. Operational Finance and Budgeting
  • Study Objectives
  • Background
  • Financial Statement Components
  • Balance Sheet
  • Regulatory Reporting Considerations
  • Budgeting and Financial Forecasting
  • Conclusion
  • Study Questions
  • Chapter 29. Underwriting and Rating Functions Common to Most Markets
  • Study Objectives
  • Underwriting
  • Rating
  • Conclusion
  • Study Questions
  • Part V. Medicare and Medicaid
  • Chapter 30. Medicare and Managed Care
  • Study Objectives
  • Introduction
  • Organization of the Chapter
  • Who Is Eligible for a Medicare Risk Contract?
  • The Exception in State Licensure: Provider-Sponsored Organizations
  • Other New Options
  • Muddying the Waters: Plans versus Organizations
  • Federal Preemption
  • What the Contract Requires (Finally!)
  • Limitations on Physician Incentive Plans
  • Consumer Protections
  • Provider Protections and Rights: Conscience Protection
  • Information Dissemination
  • Enrollment
  • Marketing Rules
  • Interactions with Your Government
  • The Contracting Process
  • Web Resources and Other Contacts
  • Future Direction of the Program
  • Study Questions
  • Chapter 31. Medicaid Managed Care
  • Study Objectives
  • Introduction
  • Medicaid--Origins and Evolution
  • Medicaid Managed Care--Background and Models
  • Operational Features
  • Successes of Medicaid Managed Care
  • Shortfalls of Medicaid Managed Care
  • The Challenging Contemporary Context
  • Longer Term Questions and Concerns
  • Conclusion
  • Study Questions
  • Part VI. Regulatory and Legal Issues
  • Chapter 32. Legal Issues In Provider Contracting
  • Study Objectives
  • General Issues in Contracting
  • Contract Structure
  • Common Clauses, Provisions, and Key Factors
  • Conclusion
  • Study Questions
  • Appendix 32-A. Sample Physician Agreement
  • Appendix 32-B. Sample Hospital Agreement
  • Chapter 33. Legal Liability Related to Medical Management Activities
  • Study Objectives
  • Obligations To Conduct Medical Management Activities
  • Common Law Medical Management Liability Actions
  • Contract Actions Related to Medical Management Activities
  • Negligence Actions Related to Medical Management Activities
  • Recommendations
  • Conclusion
  • Study Questions
  • Chapter 34. The Health Insurance Portability and Accountability Act of 1996
  • Study Objectives
  • Introduction
  • Overview
  • Provisions: Portability and Access
  • New Access Initiatives
  • Amendments to HIPAA Portability and Access Provisions
  • Provisions: Administrative Simplification
  • HIPAA Administration and Enforcement
  • An Early Report on the Effects of HIPAA Portability and Access Provisions
  • Conclusion
  • Study Questions
  • Chapter 35. State Regulation of Managed Care
  • Study Objectives
  • Introduction
  • State Oversight: The Regulatory Process
  • State Regulation of Other Products
  • Managed Care Legislation
  • Regulation by Market Segment
  • The State Experience--Conclusion
  • Study Questions
  • Chapter 36. Managed Care's Regulatory Evolution: Driving Change in the New Century
  • Study Objectives
  • Forces Driving Federal Health Policy
  • Major Areas of Policy Development
  • Outlook
  • Study Questions
  • Epilogue: Managed Health Care at the Millennium
  • Introduction--The Rollercoaster That Never Stops
  • Using the Magic Eight Ball: The Answer Is Hazy--Try Again Later
  • They Were Right All Along--Managed Health Care Is in Chaos
  • Reversing Entropy with a Little Help from Professor Heisenberg--Predicting, Leading, and Acting in a Chaotic Managed Health Care Environment
  • Handicapping the Field--The Stratification of Predictability
  • Driving the Nitroglycerine Truck on a Foggy Night--Leadership, Strategy, and Action in the Chaotic World
  • Door Number One, Two, or Three--Choosing Strategic Options
  • Conclusion--Shake the Magic Eight Ball and Try Again
  • Glossary of Terms and Acronyms
  • Index
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