Managed care issues for the gastroenterologist:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
1997
|
| Schriftenreihe: | Gastroenterology clinics of North America
26,4 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XIV S., S. 703 - 965 Ill., graph. Darst. |
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MANAGED CARE ISSUES FOR THE GASTROENTEROLOGBT
CONTENTS
Preface xiii
James T. Frakes
Managed Care: Evolution and Distinguishing Features 703
James T. Frakes
The managed care system of health care delivery has grown
tremendously in popularity in the United States in the past de¬
cade in response to demands by payors for cost containment,
enhanced access, and improved quality. In this article, the evolu¬
tion of managed care is traced to provide a historical perspective.
In addition, characteristic features that distinguish managed care
from traditional fee for service medicine are presented to enhance
an understanding of this health care delivery method. An ap¬
preciation of the history and distinguishing features of managed
care should set the stage for more in depth articles on specific
managed care topics later in this issue. In addition, this under¬
standing should help prepare the gastroenterologist to effectively
function in this system and to successfully care for patients,
manage the risk structure, and succeed professionally under this
changed health care paradigm.
The Current Health Care Environment and Stages of
Market Development 715
Bennett E. Roth
The history of medical payment strategies is reviewed with a
historical perspective on the development of the health care sys¬
tem in the United States. The growth of managed care is dis¬
cussed with sections detailing the effects on and responses of
health care providers, the insurance industry, government, con
GASTROENTEROLOGY CLINICS OF NORTH AMERICA
VOLUME 26 • NUMBER 4 • DECEMBER 1997 V
sumers, and employers. Current status and future market trends
are discussed.
Managed Care Organizations and Products 725
Lisa M. Behnke
Managed health care is propelling the health care industry to¬
ward further consolidation at an unprecedented pace. A thorough
understanding of managed care organizations (MCOs) and prod¬
ucts is essential to physicians who endeavor to play an active
role in the transitional process. This article begins with a survey
of generic differences between the basic types of managed care
organizations and their products. It then moves on to create a
framework for comparison of managed care organizations on the
basis of external environmental factors and internal structural
elements.
Integrated Delivery Systems and the Gastroenterologist 741
Robert A. Ganz
This article describes the current managed care environment for
gastroenterologists, and also explains the various merger and
networking options that are currently available. The article con¬
tains a detailed discussion of regional versus national merger
options. Specific integration models are outlined for forming a
regional, single specialty, gastroenterology network.
Medicare Managed Care: Why is it Coming? 755
Gail R. Wilensky
The fear that managed care is making inroads into Medicare has
struck a note of near panic in the minds of many American
physicians. Making more options available to seniors, including
many types of managed care plans, and reforming the way Medi¬
care makes payments to such plans, however, may be more
attractive to physicians than the continued reliance on the direct
control system that has been traditionally associated with Medi¬
care. This article discusses the changing private sector, the present
structure of Medicare, how plans are paid, what physicians can
expect in the near term, and future fiscal pressures on Medicare.
Medicare Managed Care: How Physicians Can Make it
Better 763
Gary M. Roggin
The federal government is attempting to control anticipated, in¬
creased Medicare health care costs by providing the senior popu¬
lation with incentives to encourage their movement into managed
care programs. For profit corporate HMOs that currently domi¬
nate the managed care arena are coming under increased compet¬
itive pressure at a time when their perception of profiteering is
Vi CONTENTS
undergoing increased public scrutiny. If physicians are to take
advantage of this window of opportunity and successfully enter
the Medicare managed care marketplace, they must identify the
major deficiencies existing in the current model, and fashion a
new product that divests itself of the profit orientation of current
corporate HMOs. A nonprofit version of a highly integrated,
multispecialty provider service organization (PSO) provides an
appropriate model to effectively compete with the corporate
HMO. The ideal physician controlled managed care model must:
develop a responsive policy board structure; create practice
guidelines that decrease variation in physician practice; achieve
an appropriate balance between primary and specialty medical
care; and adopt a quality assurance program that effectively ad¬
dresses both process and outcome data.
Capitation: Theory, Practice and Evaluating Rates for
Gastroenterology 773
Michael L. Weinstein
Capitation reimbursement systems are increasing in many re¬
gions, not only for primary care providers but for specialists as
well. This article discusses the concepts of capitation as it applies
to gastroenterologists. It explains a method to calculate a capi¬
tation rate, and raises the critical issues a provider must under¬
stand before negotiating or participating in a capitation contract.
Physician Profiling and Capitated Income Distribution 785
Bergein F. Overholt
Increasingly, gastroenterologists are addressing the practice is¬
sues of physician profiling and capitation. This article describes a
method to easily create practice generated physician profiles that
are used in quality of care management and contracting decisions.
These profiles are also used as part of a method for capitation
revenue distribution that is described and that has been used by
the author's practice for over 3 years. This capitation revenue
distribution methodology properly rewards the provision of cost
effective care and bonuses desirable to physician patient relation¬
ships, while protecting against under or over utilization.
Evaluating Health Plans and Marketing the
Gastroenterology Practice under Managed Care 799
Robert S. Chang and Joseph E. Geenen
More patients will have managed care in the future. Therefore,
every practice should have a strategy for working with managed
care organizations (MCOs). Learn how to evaluate an MCO and
how to obtain detailed information about MCOs in your area.
Know how to market your practice and build relationships be¬
tween your group and MCOs. Develop a practice profile that
outlines all the benefits that your group can bring to an MCO.
Plan how you will respond when an MCO says, "No."
CONTENTS Vii
Managed Care Contracts and Negotiations 811
Lisa J. Gilden and J. Bryan Thomas Puterbaugh
This article examines the key provisions which should be focused
on when reviewing managed care contracts. It offers guidance on
how gastroenterologists can negotiate more favorable terms and
avoid common contracting pitfalls. The article also highlights
specific issues applicable to capitated and other risk sharing ar¬
rangements.
Medical Information Systems and Their Importance in
Managed Care 823
Randall S. Hawkins
The increasing emphasis on managed care has added a new class
of information management responsibilities to providers' clinical
obligations. Fiscal constraints have placed a premium on opera¬
tional efficiency, and managing payer and patient expectations
requires ready access to increasing amounts of information. Pro¬
vider groups may benefit from an understanding of the tools that
are becoming available to address their emerging information
management tasks. Modern information applications of potential
use to providers are outlined. The data acquisition and decision
support features of provider workstations are described. A sim¬
plified schema is presented to assist caregivers in identifying their
information management needs and in crafting a strategy for
addressing them. Recent technological trends (including the
growing impact of Internet based tools) are highlighted.
Treatment and Referral Guidelines in Gastroenterology 845
Gregory Zuccaro, Jr.
Treatment and referral guidelines are an integral part of clinical
practice. There are numerous practice guidelines available to the
clinician. The recommendations within quality practice guidelines
should summarize current relevant literature and expert opinion.
Practice guidelines should assist the clinician in providing appro¬
priate, cost effective care. Guidelines may also be used within
health care organizations to facilitate the continued quality im¬
provement process.
Quality and Outcomes Management in Gastroenterology 859
John F. Johanson
Quality and outcomes management is a rapidly expanding disci
pline that is being applied to medical practice in an attempt to
improve quality while reducing health care expenditures. Despite
ongoing educational efforts, outcomes management remains
poorly understood, particularly among gastroenterologists. As
managed care increases its role in health care delivery, outcomes
management will become an even more important issue. This
Viii CONTENTS
article reviews the discipline of quality and outcomes manage¬
ment by addressing three simple questions: What is outcomes
management, why is it important, and how do you do it?
Disease Management Strategies and the Gastroenterologist 873
Christopher J.N. Rail, Amit D. Munshi, and David S. Stasior
Best medical practice for a specific disease state results from
sustainable quality improvement. This process requires ongoing
systematic measurement of the local current process of care with
integration of therapeutic algorithms aimed at reducing clinical
variability and cost while sustaining quality and patient satisfac¬
tion. The dynamic application of these principles is disease man¬
agement. This article reviews the transition from total quality
management in industry to disease management in health care,
and describes disease management efforts in peptic ulcer disease.
Managed Care and Risk Management 895
Peter A. Plumeri
The era of managed care medicine has brought with it new and
interesting legal risks. This article presents the physician with an
introduction to managed care and risk management. Medical
malpractice, as it involves managed care organizations, is intro¬
duced, and several risk management strategies are developed to
help the practicing physician. The topic of managed care organi¬
zation liability is addressed, and special attention is given to
developing Employee Retirement Insurance and Security Act
(ERISA) issues.
Academic Medicine Under Managed Care 911
M. Brian Fennerty
Academic gastroenterology divisions have come under siege both
financially and professionally. This article will deal with the foun¬
dation of this assault on our way of life as well as deal with some
of the mechanisms used to survive and even thrive in these
difficult times. Some divisions may fail to survive, but the future
for most appears to be robust given changes in our structure and
approach to teaching, research, and clinical practice.
Glossary of Managed Care Terms 923
James T. Frakes
The terminology of managed care and healthspeak are confusing
and foreign sounding to many physicians. The acronyms have
been described as "thick alphabet soup." A glossary of these terms
and acronyms is presented to aid the reader in understanding
the articles in this issue.
CONTENTS ix
Cumulative Index 1997 945
Subscription Information Inside Back Cover
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| title | Managed care issues for the gastroenterologist |
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