Essentials of Managed Health Care

by Kongstvedt, Peter R., Md.

• ISBN13: 9780834218628
• ISBN10: 0834218623
• Additional ISBN(s): 9780763725792
• Edition: 4th
• Format: Paperback
• Copyright: 2000-07-01
• Publisher: JONES & BARTLETT PUB
• More Book Details
• Purchase Benefits

Summary

Brandon/Hill Medical List first-purchase and minimal core selection (#314). Provides practical knowledge and advice to help with the complexities of managed care. Contains learning objectives, a glossary of terms, common acronyms, study questions, tables and charts. Previous edition not cited. Softcover.

Table of Contents

About the Editor	xvii
Contributors	xviii
Preface	xxi
Acknowledgments	xxvii
PART I---INTRODUCTION TO MANAGED CARE	1	(82)
An Overview of Managed Care	3	(14)
Peter D. Fox
Study Objectives	3	(1)
Introduction	3	(1)
Managed Care: The Early Years (Pre-1970)	4	(1)
The Adolescent Years: 1970-1985	5	(4)
Managed Care Comes of Age: 1985 to the Present	9	(4)
Future Issues Facing Managed Care	13	(2)
Conclusion	15	(1)
Study Questions	15	(2)
Types of Managed Care Organizations	17	(14)
Eric R. Wagner
Study Objectives	17	(2)
Types of MCOs	19	(4)
HMO Models	23	(7)
Conclusion	30	(1)
Study Questions	30	(1)
Integrated Health Care Delivery Systems	31	(32)
Peter R. Kongstvedt
David W. Plocher
Jean C. Stanford
Study Objectives	31	(1)
Introduction	31	(2)
Highly Integrated Delivery Systems	33	(1)
Market Characteristics	33	(1)
Types of IDSs	34	(1)
IPAs	35	(1)
PPMCs	36	(4)
Consolidated Medical Groups	40	(1)
PHOs	41	(4)
MSOs	45	(1)
Foundations	46	(2)
Staff Model	48	(1)
Physician Ownership Model	49	(1)
PSOs	50	(2)
Virtual Integration	52	(1)
Global Capitation	52	(2)
Acquisition of Physician Practices	54	(1)
Legal Pitfalls for IDSs	55	(2)
Critical Success Factors for IDSs	57	(3)
Conclusion	60	(1)
Study Questions	61	(2)
Elements of the Management Control and Governance Structure	63	(8)
Peter R. Kongstvedt
Study Objectives	63	(1)
Board of Directors	63	(3)
Key Management Positions	66	(2)
Committees	68	(2)
Management Control Structure	70	(1)
Conclusion	70	(1)
Study Questions	70	(1)
Examining Common Assertions About Managed Care	71	(12)
Richard I. Smith
Daniel Thornton
Terry Sollom
Study Objectives	71	(1)
Introduction	71	(1)
Managed Care Myths	72	(7)
Conclusion	79	(1)
Study Questions	79	(4)
PART II---THE HEALTH CARE DELIVERY SYSTEM	83	(94)
Primary Care in Managed Health Care Plans	85	(18)
Peter R. Kongstvedt
Study Objectives	85	(1)
Introduction and Definitions	85	(1)
Recruiting	86	(2)
Nonphysician or Midlevel Practitioners	88	(1)
Types of Contracting Situations	89	(3)
Credentialing	92	(2)
The National Practitioner Data Bank	94	(1)
Healthcare Integrity and Protection Data Bank	95	(2)
Compensation	97	(1)
Orientation	97	(1)
Network Maintenance	97	(2)
Internet-Based Activities	99	(1)
Removing Physicians from the Network	100	(1)
Conclusion	101	(1)
Study Questions	101	(2)
Compensation of Primary Care Physicians in Managed Health Care	103	(38)
Peter R. Kongstvedt
Study Objectives	103	(1)
Introduction	103	(1)
Basic Models of Reimbursement	104	(2)
Capitation	106	(4)
Withholds and Risk/Bonus Arrangements	110	(1)
Capitation Pools for Referral and Institutional Services	111	(6)
Full Professional Risk Capitation	117	(1)
Reasons To Capitate	118	(1)
Problems with Capitation Systems	118	(2)
Effect of Benefits Design on Reimbursement	120	(3)
Fee for Service	123	(2)
A Special Requirement for Reimbursement When Coinsurance Is in Place	125	(1)
Out-of-Network Fees	125	(1)
Discounts, Negotiated Fee Schedules, Fee Maximums, or Fee Allowances	126	(1)
Relative Value Scales	126	(1)
Global Fees	127	(3)
Problems with FFS in Managed Health Care Plans	130	(1)
Legislation and Regulation Applicable to Physician Incentive Programs	131	(5)
Civil Liability in Physician Compensation Programs	136	(1)
Conclusion	137	(1)
Study Questions	138	(3)
Contracting and Reimbursement of Specialty Physicians	141	(16)
Peter R. Kongstvedt
Study Objectives	141	(1)
Introduction	141	(1)
How Many Specialty Care Physicians?	142	(1)
Primary versus Specialty Care Designation	143	(1)
Credentialing	144	(1)
Types of Reimbursement Arrangements	144	(6)
Organizational Models for Capitating Specialty Services	150	(2)
Common Problems with Specialty Capitation	152	(2)
Other Forms of Specialty Physician Reimbursement	154	(1)
Risk and Reward	155	(1)
Conclusion	155	(1)
Study Questions	156	(1)
Negotiating and Contracting With Hospitals, Institutions, and Ancillary Services	157	(20)
Peter R. Kongstvedt
Study Objectives	157	(1)
Introduction	157	(1)
Hospital Network Development	157	(5)
Types of Reimbursement Arrangements	162	(8)
Outpatient Procedures	170	(1)
Ancillary Services	171	(4)
Conclusion	175	(1)
Study Questions	175	(2)
PART III---MEDICAL MANAGEMENT	177	(262)
Care Management and Clinical Integration Components	179	(18)
David W. Plocher
Wendy L. Wilson
Jacqueline A. Lutz
Ann Huston
Study Objectives	179	(1)
The Context for Advanced Care Management	179	(2)
Defining Advanced Care Management	181	(1)
Integrating the Components of Care Management	182	(3)
The Role of Physicians in Care Management	185	(1)
Building an Advanced Care Management System: A Typical Process	185	(5)
Defining the Future State of Care Management	190	(2)
Conclusion	192	(1)
Study Questions	193	(4)
Description of the Components of the Advanced Care Management System	194	(3)
Managing Basic Medical-Surgical Utilization	197	(38)
Peter R. Kongstvedt
Study Objectives	197	(1)
Introduction	197	(1)
Return on Investment in Management of Medical Costs	198	(1)
Demand Management	198	(4)
Measurements of Utilization	202	(3)
Variations in Utilization	205	(3)
The Role of Electronic Commerce	208	(1)
Authorization or Denial of Payment for Services	208	(1)
Managing Utilization of Specialty Services	209	(2)
The Role of the Primary Care Physician in Specialty Services Management	211	(1)
Single Visit Authorizations Only	212	(1)
Specialty Physicians As Primary Physicians	213	(1)
Prohibition of Secondary Referrals and Authorizations	214	(1)
Review of Reasons for Referral	215	(2)
Institutional Utilization Management	217	(1)
Common Methods for Managing Utilization	217	(10)
Alternatives to Acute Care Hospitalization	227	(3)
Case Management	230	(1)
Conclusion	230	(1)
Study Questions	231	(4)
Clinical Services Requiring Authorization	235	(14)
Peter R. Kongstvedt
Study Objectives	235	(1)
Definition of Services Requiring Authorization	236	(1)
Definition of Who Can Authorize Services	236	(2)
Claims Payment	238	(1)
Categories of Authorization	239	(2)
Staffing	241	(1)
Common Data Elements	242	(1)
Methods of Data Capture and Authorization Issuance	243	(2)
Authorization System Reports	245	(1)
Open Access HMOs	246	(1)
Specialty-Physician Based Authorization Systems	246	(1)
Non-Physician-Based Authorization Systems	247	(1)
Conclusion	247	(1)
Study Questions	247	(2)
Case Management and Managed Care	249	(32)
Catherine M. Mullahy
Study Objectives	249	(1)
The Case Manager's Role	249	(1)
Patient Profile: Not Every Case Needs a Case Manager	250	(2)
On-Site versus Telephone-Based Case Management	252	(1)
Case Managers in Managed Care	253	(1)
Case Management Work Format and Process	254	(9)
Utilization Review: Preadmission and Concurrent Review and Case Management	263	(1)
Preadmission and Concurrent Review Case Management Reports	264	(1)
Red Flags: Indicators for Case Management	264	(7)
Timing Case Management Intervention	271	(4)
Beyond the Case Management Basics	275	(3)
A Long-Term Solution to a Long-Term Problem	278	(1)
Study Questions	278	(3)
Fundamentals and Core Competencies of Disease Management	281	(12)
David W. Plocher
Study Objectives	281	(1)
Definition and Clarification	281	(3)
Barriers and Drivers for Disease Management	284	(1)
Business Plan	285	(1)
Survey of Disease Management Programs	285	(2)
Important Linkages	287	(1)
Support from Electronic Commerce	287	(4)
Conclusion	291	(1)
Study Questions	291	(2)
Prescription Drug Benefits in Managed Care	293	(39)
Robert P. Navarro
Study Objectives	293	(1)
Financial Basis for Pharmacy Benefit Management	294	(3)
Pharmacy Program Cost Components	297	(1)
Principles of Pharmacy Benefit Management	298	(1)
Managing the Supply and Demand	299	(1)
Pharmacy Information Systems and Health Informatics	299	(5)
Pharmacy Benefit Management Companies (PBMs)	304	(3)
Pharmacy Benefit Management Program Components	307	(2)
Physician Provider Network	309	(1)
Pharmacy Provider Network	309	(4)
Pharmacy Provider Audits	313	(1)
Drug Formulary Management	313	(6)
Pharmaceutical Manufacturer Discount and Rebate Contracts	319	(1)
Prescription Patient Copayments	320	(4)
Role of Pharmacy Programs in Disease Management and Quality Improvement Programs	324	(1)
Quality Improvement in Pharmacy Benefit Management	325	(1)
Measuring Pharmacy Benefit Management Program Performance	325	(2)
Future Changes in Pharmacy Benefit Management	327	(1)
Conclusion	328	(1)
Study Questions	328	(4)
Managed Behavioral Health Care and Chemical Dependency Services	332	(29)
Donald F. Anderson
Jeffrey L. Berlant
Katherine O. Sternbach
Danna Mauch
H.G. Whittington
William R. Maloney
Terri Goens
Study Objectives	332	(1)
Introduction	333	(1)
Historical Perspective	333	(4)
Key Treatment Principles	337	(5)
Benefit Plan Design	342	(3)
Utilization Management	345	(1)
Channeling Mechanisms	346	(2)
Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives	348	(2)
Quality Assurance	350	(4)
BH Information Systems	354	(3)
Public/Private Systems Integration	357	(1)
Emerging Issues	358	(1)
Conclusion	359	(1)
Study Questions	359	(2)
Quality Management in Managed Care	361	(18)
Pamela B. Siren
Study Objectives	361	(1)
Introduction	361	(1)
Traditional Quality Assurance	362	(3)
Components of a Quality Management Program	365	(1)
A Process Model for a Modern Quality Management Program	366	(10)
Conclusion	376	(1)
Study Questions	377	(2)
Using Data and Provider Profiling in Medical Management	379	(40)
Peter R. Kongstvedt
Norbert I. Goldfield
David W. Plocher
Study Objectives	379	(1)
Introduction	379	(1)
Use of Data and Information in Medical Management	380	(4)
Patient Data Confidentiality	384	(1)
Data Elements and the Application of Reports	385	(6)
General Types of Reports	391	(4)
Provider Profiling	395	(2)
Desired Characteristics of Provider Profiles	397	(3)
The Need To Adjust for Severity of Illness	400	(9)
Selection of a Profiling Vendor	409	(5)
The Future of Data Use	414	(2)
Conclusion	416	(1)
Study Questions	416	(3)
Physician Behavior Change in Managed Health Care	419	(20)
Peter R. Kongstvedt
Study Objectives	419	(1)
Introduction	419	(1)
General Aspects of Physician Practice Behavior	420	(7)
General Approaches to Changing Behavior	427	(2)
Programmatic Approaches to Changing Physician Behavior	429	(2)
Addressing Noncompliance by Individual Physicians	431	(3)
Conclusion	434	(1)
Study Questions	435	(4)
PART IV---OPERATIONAL MARKETING AND MANAGEMENT	439	(216)
Information Systems in Managed Health Care Plans	441	(20)
James S. Slubowski
Study Objectives	441	(1)
Introduction	441	(1)
Core Managed Care Information System	442	(4)
Electronic Data Interchange	446	(2)
Privacy and Confidentiality under HIPAA	448	(1)
Value-Added Services---The Next Generation	448	(6)
HEDIS	454	(1)
Information Services Department	455	(4)
Conclusion	459	(1)
Study Questions	460	(1)
Claims and Benefits Administration	461	(46)
Robin L. McElfatrick
Robert S. Eichler
Study Objectives	461	(1)
Introduction	462	(1)
Claims: Positioning, Purpose, and Opportunities	462	(3)
Organizational Structure and Staffing	465	(5)
Claims Operations Management	470	(10)
Productivity	480	(2)
Turn Around Time	482	(2)
Staff Training and Development	484	(2)
Quality	486	(2)
Policy and Procedure	488	(3)
Coordination with Other Departments/Functions	491	(1)
Systems Support	491	(4)
Claims Business Functions	495	(7)
Other Issues	502	(4)
Conclusion	506	(1)
Study Questions	506	(1)
Member Services and Consumer Affairs	507	(28)
Peter R. Kongstvedt
Study Objectives	507	(1)
Provision of General Information	508	(25)
Conclusion	533	(1)
Study Questions	533	(2)
Sales and Marketing in Managed Health Care Plans: The Process of Distribution	535	(20)
Gail Marcus
John C. Thomson
Study Objectives	535	(1)
What Managed Care Organizations Deliver	535	(2)
Challenges Facing MCOs	537	(4)
An Overview of the Managed Care Market	541	(1)
Key Decision Makers and Influencers in the Managed Care Distribution Process	541	(5)
The Managed Care Sales Process	546	(3)
How the Managed Care Team Delivers	549	(3)
The Management of Sales and Marketing Professionals	552	(1)
Conclusion	553	(1)
Study Questions	554	(1)
The Employer's View of Managed Health Care: Show Me the Value	555	(11)
Michael J. Taylor
Study Objectives	555	(1)
Recent Managed Care Trends Affecting Employers	555	(1)
How These Trends Impact Employers Both Large and Small	556	(1)
The Large Group Employer: 5,000 Lives Plus	557	(1)
The Moderate Group Employer: 500-5,000 Lives	557	(1)
The Medium Group Employer: 50-500 Lives	558	(1)
The Small Group Employer: 0-50 Lives	558	(1)
How Employers Purchase Value (1988-1998)	559	(2)
Looking for Value: 2000 and Beyond	561	(1)
Future Trends	562	(2)
Conclusion	564	(1)
Study Questions	565	(1)
The Impact of Consumerism on Managed Health Care	566	(21)
Jacqueline A. Lutz
Hindy J. Shaman
Study Objectives	566	(1)
Why Is Consumerism a Significant Trend?	567	(6)
Who Is the New Health Care Consumer?	573	(1)
What Are the Implications of Consumerism?	574	(10)
How Can Organizations Develop a Consumer Strategy?	584	(1)
What Consumerism Means for the Managed Care Industry	584	(1)
Conclusion	585	(1)
Study Questions	585	(2)
Accreditation and Performance Measurement Programs for Managed Care Organizations	587	(22)
Margaret E. O'Kane
Study Objectives	587	(1)
Introduction	587	(2)
Oversight by Type of Organization	589	(1)
National Committee for Quality Assurance	589	(11)
The Utilization Review Accreditation Commission	600	(3)
Joint Commission on Accreditation of Healthcare Organizations	603	(5)
Conclusion	608	(1)
Study Questions	608	(1)
Common Operational Problems in Managed Health Care Plans	609	(19)
Peter R. Kongstvedt
Study Objectives	609	(1)
Introduction and Background	609	(2)
Common versus Unique Problems or Events	611	(1)
Common Problems in Managed Care Organizations	611	(15)
Conclusion	626	(1)
Study Questions	627	(1)
Operational Finance and Budgeting	628	(15)
Dale F. Harding
Study Objectives	628	(1)
Background	629	(1)
Financial Statement Components	630	(6)
Balance Sheet	636	(2)
Regulatory Reporting Considerations	638	(2)
Budgeting and Financial Forecasting	640	(2)
Conclusion	642	(1)
Study Questions	642	(1)
Underwriting and Rating Functions Common to Most Markets	643	(12)
Stephen M. Cigich
Michael G. Sturm
Study Objectives	643	(1)
Underwriting	644	(1)
Rating	645	(8)
Conclusion	653	(1)
Study Questions	653	(2)
PART V---MEDICARE AND MEDICAID	655	(48)
Medicare and Managed Care	657	(27)
Carlos Zarabozo
Jean D. LeMasurier
Study Objectives	657	(1)
Introduction	657	(1)
Organization of the Chapter	658	(1)
Who Is Eligible for a Medicare Risk Contract?	658	(1)
The Exception in State Licensure: Provider-Sponsored Organizations	659	(1)
Other New Options	660	(2)
Muddying the Waters: Plans versus Organizations	662	(8)
Federal Preemption	670	(1)
What the Contract Requires (Finally!)	670	(3)
Limitations on Physician Incentive Plans	673	(1)
Consumer Protections	673	(2)
Provider Protections and Rights: Conscience Protection	675	(1)
Information Dissemination	675	(1)
Enrollment	676	(2)
Marketing Rules	678	(1)
Interactions with Your Government	679	(1)
The Contracting Process	679	(1)
Web Resources and Other Contacts	680	(1)
Future Direction of the Program	681	(1)
Study Questions	682	(2)
Medicaid Managed Care	684	(19)
Robert E. Hurley
Stephen A. Somers
Study Objectives	684	(1)
Introduction	684	(1)
Medicaid---Origins and Evolution	685	(1)
Medicaid Managed Care---Background and Models	686	(2)
Operational Features	688	(5)
Successes of Medicaid Managed Care	693	(3)
Shortfalls of Medicaid Managed Care	696	(2)
The Challenging Contemporary Context	698	(1)
Longer Term Questions and Concerns	699	(2)
Conclusion	701	(1)
Study Questions	701	(2)
PART VI---REGULATORY AND LEGAL ISSUES	703	(119)
Legal Issues in Provider Contracting	705	(38)
Mark S. Joffe
Study Objectives	705	(1)
General Issues in Contracting	706	(1)
Contract Structure	707	(1)
Common Clauses, Provisions, and Key Factors	708	(13)
Conclusion	721	(1)
Study Questions	721	(22)
Sample Physician Agreement	722	(12)
Sample Hospital Agreement	734	(9)
Legal Liability Related to Medical Management Activities	743	(21)
James L. Touse
Study Objectives	743	(1)
Obligations To Conduct Medical Management Activities	744	(1)
Common Law Medical Management Liability Actions	745	(1)
Contract Actions Related to Medical Management Activities	746	(5)
Negligence Actions Related to Medical Management Activities	751	(7)
Recommendations	758	(3)
Conclusion	761	(1)
Study Questions	762	(2)
The Health Insurance Portability and Accountability Act of 1996	764	(22)
Charles N. Kahn III
Dean A. Rosen
Marianne Miller
Kathleen H. Fyffe
Study Objectives	764	(1)
Introduction	764	(1)
Overview	765	(1)
Provisions: Portability and Access	766	(6)
New Access Initiatives	772	(2)
Amendments to HIPAA Portability and Access Provisions	774	(1)
Provisions: Administrative Simplification	775	(3)
HIPAA Administration and Enforcement	778	(2)
An Early Report on the Effects of HIPAA Portability and Access Provisions	780	(3)
Conclusion	783	(1)
Study Questions	784	(2)
State Regulation of Managed Care	786	(24)
Richard I. Smith
Kristin Stewart
Study Objectives	786	(1)
Introduction	786	(1)
State Oversight: The Regulatory Process	787	(8)
State Regulation of Other Products	795	(3)
Managed Care Legislation	798	(7)
Regulation by Market Segment	805	(2)
The State Experience---Conclusion	807	(1)
Study Questions	807	(3)
Managed Care's Regulatory Evolution: Driving Change in the New Century	810	(12)
Frederick B. Abbey
Study Objectives	810	(1)
Forces Driving Federal Health Policy	811	(3)
Major Areas of Policy Development	814	(6)
Outlook	820	(1)
Study Questions	821	(1)
EPILOGUE---MANAGED HEALTH CARE AT THE MILLENNIUM	822	(11)
Peter R. Kongstvedt
Introduction---The Rollercoaster That Never Stops	822	(1)
Using the Magic Eight Ball: The Answer Is Hazy---Try Again Later	823	(1)
They Were Right All Along---Managed Health Care Is in Chaos	823	(2)
Reversing Entropy with a Little Help from Professor Heisenberg---Predicting, Leading, and Acting in a Chaotic Managed Health Care Environment	825	(1)
Handicapping the Field---The Stratification of Predictability	826	(3)
Driving the Nitroglycerine Truck on a Foggy Night---Leadership, Strategy, and Action in the Chaotic World	829	(2)
Door Number One, Two, or Three---Choosing Strategic Options	831	(1)
Conclusion---Shake the Magic Eight Ball and Try Again	832	(1)
Glossary of Terms and Acronyms	833	(22)
Index	855