HMO rate setting & financial strategy:
Gespeichert in:
| 1. Verfasser: | |
|---|---|
| Format: | Buch |
| Sprache: | English |
| Veröffentlicht: |
Ann Arbor, Mich.
Health Administration Press
1990
|
| Schriftenreihe: | Health Administration Press perspectives
|
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XXII, 354 S. graph. Darst. |
| ISBN: | 0910701490 |
Internformat
MARC
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| 650 | 4 | |a Health maintenance organizations |z United States |x Finance | |
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Datensatz im Suchindex
| _version_ | 1805086881409400832 |
|---|---|
| adam_text |
Table of Contents
Foreword by Gino A. Nalli xiii
Preface xvii
Acknowledgments xxi
Part I The Current Competitive Environment
Chapter 1 Introduction and Background 3
1.1 Introduction 3
1.2 The Debate over Premium Rate Setting 5
1.3 The Health Maintenance Organization Amendments
of 1988 6
1.4 National Health Policy in the 1980s 6
1.5 Increased Competition in Health
Care Markets 11
1.6 Outline 15
Chapter 2 History of HMOs 25
2.1 Introduction 25
2.2 Prepaid Group Practice Plans 26
2.3 The Health Maintenance Organization Act
of 1973 , 27
2.4 Development of the HMO Industry:
1973 1988 31
Chapter 3 Key Features of the HMO Concept 45
3.1 Introduction 45
3.2 Differences between HMOs and Other Forms
of Health Insurance 49
3.3 HMO Cost Containment Methods 51
v
v' Table of Contents
3.4 HMO Risk Sharing Models 58
Chapter 4 The Debate between HMOs and Employers . 69
4.1 Introduction 69
4.2 Key Issues of Concern to Employers 70
4.3 Premium Rate Setting: The HMO Perspective 81
4.4 The Health Maintenance Organization Amendments
of 1988 88
4.5 Summary 101
Part II HMO Rate Setting
Chapter 5 Rating and Underwriting 113
5.1 Introduction to Rating 114
5.2 Underwriting for Group Health Insurance 123
5.3 The Statistical Nature of the
Underwriting Process 128
5.4 Marketing, Underwriting, and Rating 134
5.5 HMO Underwriting Methods 137
Chapter 6 Community Rating 143
6.1 Introduction 143
6.2 Federal Legislation and Regulations 144
6.3 Community Rating Methods 147
6.4 Community Rating by Class 174
Chapter 7 Alternative Rating Methods 195
7.1 Introduction 195
7.2 Adjusted Community Rating 199
7.3 Kaiser Permanente's Adjusted
Community Rating System 206
7.4 Experience Rating 213
7.5 Group Specific Rating 218
7.6 Rating and Data Analysis Strategies 232
Chapter 8 Selection Bias and Premium Rate Setting 245
8.1 Introduction 245
8.2 What Is Selection Bias? 247
8.3 HMOs and "Skimming" 252
Appendix Selection Bias: An Overview 258
Table of Contents vii
Part III HMO Competitive Strategy
Chapter 9 Issues, Trends, and Goals Affecting
HMO Competitive Strategy 295
9.1 Introduction 295
9.2 Current Issues Affecting HMO
Competitive Strategy 297
9.3 Forecast of Trends 299
9.4 Immediate Goals for HMOs 300
9.5 Financial Strategies 307
9.6 Other HMO Competitive Strategy Issues 313
9.7 Conclusion 324
Epilogue 333
Glossary of HMO Actuarial Terminology 341
Index 345
About the Author 354
List of Figures
5 1 Distribution of Actual to Expected Costs by Size of Group:
50 Members 130
5 2 Distribution of Actual to Expected Costs by Size of Group:
100 Members 131
5 3 Distribution of Actual to Expected Costs by Size of Group:
500 Members 132
5 4 Distribution of Actual to Expected Costs by Size of Group:
1,000 Members 133
5 5 Distribution of Actual to Expected Costs by Size of Group:
2,500 Members 134
5 6 Distribution of Actual to Expected Costs by Size of Group:
5,000 Members 135
6 1 Overview of Premium Rate Setting Practices 151
viii
List of Tables
2 1 Selected HMO Organizations from 1900 to 1970 28
2 2 Growth of HMO Industry 31
2 3 1980 HMO Membership 33
2 4 HMO Plan Characteristics, January 1988 35
2 5 HMO Enrollment Growth (Number of Members Added) and
Growth Rate for Calendar Years 1981 to 1987 36
2 6 30 Largest Plans Ranked by Enrollment, January 1988 37
2 7 HMO Membership Growth by Model Type,
June 1980 to January 1988 38
2 8 HMOs and Enrollment by State Headquarters, January 1988 40
2 9 Number of TEFRA Risk HMOs and Enrollees, June 1985
to December 1986 41
2 10 Number of Risk HMOs by Model Type, June 1985 to
December 1986 42
2 11 Kaiser Permanente Medical Care Program Total Enrollment,
by Region 42
2 12 Kaiser Permanente Medical Care Program
Community Rate Increases for 1985 to 1989 43
6 1 Types of Premium Rate Structures 149
6 2 Operating Budget for Staff Model and Group Model HMOs 156
6 3 Development of Medical Service Capitation Cost
(Based on Fee for Service Charge Method) 160
6 4 Determination of Total HMO Capitation Rate
(Including Medical Services Costs, Adjustments,
Administration, and Other Loadings) 163
6 5 Community Rating by Class: Example 1 180
6 6 Community Rating by Class: Example 2 183
6 7 Baseline Data for Community Rating by Class Using
Age/Sex Factors: Example 3 186
ix
x List of Tables
6 8 Derivation of Medical Service Cost for Ajax Box Company
Using Community Rating by Class: Example 3 188
6 9 Derivation of Premium Rate for Three Tier Contracts
Using Community Rating by Class: Example 3 189
7 1 Example of Adjusted Community Rating 202
List of Exhibits
3 1 HMO Cost Containment Methods 52
3 2 Summary of GAO Report on Physician Incentive Payments
by Prepaid Health Plans 64
6 1 Derivation of Community Rate Increase Factor 158
6 2 Flexible Forms of Community Rating: Two Tier
Rate Structure, Standard PMPM Revenue Requirement 166
6 3 Flexible Forms of Community Rating: Three Tier
Rate Structure, Standard PMPM Revenue Requirement 167
6 4 Flexible Forms of Community Rating: Recomposition of
Premiums to Match In Force Rates 171
6 5 Flexible Forms of Community Rating: The Effect
of Different Contract Mixes 172
6 6 Flexible Forms of Community Rating: The Effect
of Different Assumptions for Contract Mixes, Contract Sizes,
and In Force Rates 173
xi |
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| indexdate | 2024-07-20T08:43:17Z |
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| isbn | 0910701490 |
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| spelling | Wrightson, Charles William Verfasser aut HMO rate setting & financial strategy Charles William Wrightson Ann Arbor, Mich. Health Administration Press 1990 XXII, 354 S. graph. Darst. txt rdacontent n rdamedia nc rdacarrier Health Administration Press perspectives Health Maintenance Organizations economics United States Health maintenance organizations Rates United States Health maintenance organizations United States Finance Rate Setting and Review United States Krankenkasse (DE-588)4120613-7 gnd rswk-swf Gesundheitsvorsorge (DE-588)4136584-7 gnd rswk-swf Finanzierung (DE-588)4017182-6 gnd rswk-swf Health Maintenance Organization (DE-588)4202208-3 gnd rswk-swf USA USA (DE-588)4078704-7 gnd rswk-swf USA (DE-588)4078704-7 g Health Maintenance Organization (DE-588)4202208-3 s Finanzierung (DE-588)4017182-6 s DE-604 Krankenkasse (DE-588)4120613-7 s Gesundheitsvorsorge (DE-588)4136584-7 s HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=008444505&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Wrightson, Charles William HMO rate setting & financial strategy Health Maintenance Organizations economics United States Health maintenance organizations Rates United States Health maintenance organizations United States Finance Rate Setting and Review United States Krankenkasse (DE-588)4120613-7 gnd Gesundheitsvorsorge (DE-588)4136584-7 gnd Finanzierung (DE-588)4017182-6 gnd Health Maintenance Organization (DE-588)4202208-3 gnd |
| subject_GND | (DE-588)4120613-7 (DE-588)4136584-7 (DE-588)4017182-6 (DE-588)4202208-3 (DE-588)4078704-7 |
| title | HMO rate setting & financial strategy |
| title_auth | HMO rate setting & financial strategy |
| title_exact_search | HMO rate setting & financial strategy |
| title_full | HMO rate setting & financial strategy Charles William Wrightson |
| title_fullStr | HMO rate setting & financial strategy Charles William Wrightson |
| title_full_unstemmed | HMO rate setting & financial strategy Charles William Wrightson |
| title_short | HMO rate setting & financial strategy |
| title_sort | hmo rate setting financial strategy |
| topic | Health Maintenance Organizations economics United States Health maintenance organizations Rates United States Health maintenance organizations United States Finance Rate Setting and Review United States Krankenkasse (DE-588)4120613-7 gnd Gesundheitsvorsorge (DE-588)4136584-7 gnd Finanzierung (DE-588)4017182-6 gnd Health Maintenance Organization (DE-588)4202208-3 gnd |
| topic_facet | Health Maintenance Organizations economics United States Health maintenance organizations Rates United States Health maintenance organizations United States Finance Rate Setting and Review United States Krankenkasse Gesundheitsvorsorge Finanzierung Health Maintenance Organization USA |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=008444505&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
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