Essentials of Managed Health Care

Contributors	p. ix
About the Author	p. xiii
Acknowledgments	p. xv
Preface	p. xvii
Keeping Current	p. xxi
Introduction to Managed Health Care	p. 1
The Origins of Managed Health Care	p. 3
Types of Managed Care Plans and Integrated Healthcare Delivery Systems	p. 19
Elements of the Management Control and Governance Structure	p. 41
Common Myths and Assertions about Health Plans	p. 51
The Healthcare Delivery System	p. 61
Physician Networks in Managed Health Care	p. 63
Basic Compensation of Physicians in Managed Health Care	p. 93
Hospitals, Facilities, and Ancillary Services	p. 135
Performance-Based Incentives in Managed Health Care: Pay-for-Performance	p. 165
Medical Management	p. 187
Managing Basic Medical-Surgical Utilization	p. 189
Fundamentals and Core Competencies of Disease Management	p. 233
Case Management	p. 247
Prescription Drug Benefits in Managed Health Care	p. 269
Introduction to Managed Behavioral Healthcare Organizations	p. 297
The Role of Health Plans in Preventing Disease	p. 317
Quality Management in Managed Care	p. 335
Data Analysis and Profiling in Health Plans	p. 349
Operational Management and Marketing	p. 371
Information Technology in the Healthcare Organization	p. 373
Claims Administration	p. 387
Member Services	p. 443
Healthcare Consumerism	p. 473
Sales and Marketing	p. 491
The Employer's View of Managed Health Care	p. 505
Accreditation and Performance Measurement Programs for Managed Care Organizations	p. 521
Operational Finance and Budgeting	p. 553
Underwriting and Rating Functions	p. 571
Special Markets	p. 581
Medicare and Managed Care	p. 583
Medicaid Managed Care	p. 619
The Military Managed Healthcare System	p. 633
Managed Care in a Global Context	p. 655
Legal and Regulatory Issues	p. 675
Legal Issues in Provider Contracting	p. 677
ERISA	p. 725
HIPAA	p. 753
State Regulation of Managed Care	p. 765
Glossary	p. 789
Index	p. 825
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