|
Table
of Contents
PART I - INTRODUCTION
TO MANAGED CARE
CHAPTER 1 - AN
OVERVIEW OF MANAGED CARE
Peter D. Fox
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
Eric R. Wagner
Study Objectives
Types of MCOs
HMO Models
Conclusion
Study Questions
CHAPTER 3 - INTEGRATED
HEALTH CARE DELIVERY SYSTEMS
Peter R. Kongstvedt,
David W. Plocher, and Jean C. Stanford
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
Peter R. Kongstvedt
Study Objectives
Board of
Directors
Key Management
Positions
Committees
Management
Control Structure
Conclusion
Study Questions
CHAPTER 5 - EXAMINING
COMMON ASSERTIONS ABOUT MANAGED
CARE
Richard I. Smith, Daniel
Thornton, and Terry Sollom
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
Peter R.
Kongstvedt
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
Peter R. Kongstvedt
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 SPECIALTY PHYSICIANS
Peter R. Kongstvedt
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
Peter R. Kongstvedt
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
David W. Plocher,
Wendy L. Wilson, Jacqueline A. Lutz, and Ann Huston
Study Objectives
The Context for
Advanced
Defining Advanced
Integrating the
Components
The Role of Physicians
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
Peter R. Kongstvedt
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
Peter R. Kongstvedt
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
Catherine M. Mullahy
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
David W.
Plocher
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
Robert
P Navarro
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
Donald F Anderson,
Jeffrey L Berlant, Katherine O Sternbach, Danna Mauch,
HG Whittington, William
R Maloney, and Terri Goens
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
Pamela B Siren
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
Peter R Kongstvedt,
Norbert I Goldfield, and David W Plocher
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
Peter R
Kongstvedt
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
James S
Slubowski
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
Robin L
McElfatrick and Robert S Eichler
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
Peter R Kongstvedt
Study Objectives
Provision of General
Information
Conclusion
Study Questions
CHAPTER 23 - SALES
AND MARKETING IN MANAGED
HEALTH CARE PLANS: THE PROCESS OF DISTRIBUTION
Gail Marcus
and John C Thomson
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
Michael J Taylor
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
V8-1998)
Looking for Value:
2000 and Beyond
Future Trends
Conclusion
Study Questions
CHAPTER 25 - THE
IMPACT OF CONSUMERISM ON MANAGED HEALTH CARE
Jacqueline
A Lutz and Hindy J Shaman
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
Margaret E
O'Kane
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
Peter R Kongstvedt
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
Dale F Harding
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
Stephen M Cigich
and Michael G Sturm
Study Objectives
Underwriting
Rating
Conclusion
Study Questions
PART V - MEDICARE
AND MEDICAID
CHAPTER 30 - MEDICARE
AND MANAGED CARE
Carlos
Zarabozo and Jean D LeMasurier
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
Robert E Hurley
and Stephen A Somers
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
Mark S Joffe
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
James L Touse
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 6
Charles N Kahn
III, Dean A Rosen, Marianne Miller, and Kathleen H Fyffe
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
Richard I Smith
and Kristin Stewart
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
Frederick B
Abbey
Study Objectives
Forces Driving Federal
Health Policy
Major Areas of Policy
Development
Outlook
Study Questions
EPILOGUE - MANAGED
HEALTH CARE AT THE MILLENNIUM
Peter R Kongstvedt
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
|
