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The managed health care handbook:

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Format:	Buch
Sprache:	English
Veröffentlicht:	Gaithersburg, Md. Aspen Publ. 2001
Ausgabe:	4. ed.
Schlagworte:	Soins intégrés de santé Managed Care Programs > organization & administration > United States Managed care plans (Medical care) > United States > Management > Handbooks, manuals, etc Managed Care USA
Online-Zugang:	Inhaltsverzeichnis
Beschreibung:	XXXI, 1408 S. graph. Darst.
ISBN:	0834217260

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MARC


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Datensatz im Suchindex

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adam_text	Table of Contents About the Editor xxiv Contributors xxv Preface xxix Acknowledgments xxxi PART I—INTRODUCTION TO MANAGED CARE 1 CHAPTER 1—AN OVERVIEW OF MANAGED CARE 3 Peter D. Fox I Introduction 3 Managed Care: The Early Years (Pre 1970) 4 The Adolescent Years: 1970 1985 5 Managed Care Comes of Age: 1985 to the Present 9 Future Issues Facing Managed Care 13 Conclusion 15 CHAPTER 2—MANAGED CARE S REGULATORY EVOLUTION: DRIVING CHANGE IN THE NEW CENTURY 17 Frederick B. Abbey Forces Driving Federal Health Policy 17 Major Areas of Policy Development 21 Outlook 25 CHAPTER 3—TYPES OF MANAGED CARE ORGANIZATIONS 28 Eric R. Wagner Types of MCOs 30 HMO Models 33 Conclusion 41 vi The Managed Health Care Handbook CHAPTER 4—INTEGRATED HEALTH CARE DELIVERY SYSTEMS 42 Peter R. Kongstvedt, David W. Plocher, and Jean C. Stanford Introduction 42 Highly Integrated Delivery Systems 43 Market Characteristics 44 Types of IDSs 45 IPAs 45 PPMCs 47 Consolidated Medical Groups 50 PHOs 52 MSOs 56 Foundations 57 Staff Model 58 Physician Ownership Model 59 PSOs 60 Virtual Integration 62 Global Capitation 62 Acquisition of Physician Practices 64 Legal Pitfalls for IDSs 66 Critical Success Factors for IDSs 68 Conclusion 71 CHAPTER 5—ELEMENTS OF THE MANAGEMENT CONTROL AND GOVERNANCE STRUCTURE 73 Peter R. Kongstvedt Board of Directors 73 Key Management Positions 76 Committees 78 Management Control Structure 79 Conclusion 80 CHAPTER 6—EXAMINING COMMON ASSERTIONS ABOUT MANAGED CARE 81 Richard I. Smith, Daniel Thornton, and Terry Sollom Introduction 81 Managed Care Myths 82 Conclusion 88 PART II—THE HEALTH CARE DELIVERY SYSTEM 91 CHAPTER 7—PRIMARY CARE IN MANAGED HEALTH CARE PLANS 93 Peter R. Kongstvedt Introduction and Definitions 93 Recruiting 94 Nonphysician or Midlevel Practitioners 95 Types of Contracting Situations 97 Credentialing 100 The National Practitioner Data Bank 101 Healthcare Integrity and Protection Data Bank 103 Compensation 105 Orientation 105 Table of Contents vii Network Maintenance 105 Internet Based Activities 106 Removing Physicians from the Network 107 Conclusion 108 CHAPTER 8—COMPENSATION OF PRIMARY CARE PHYSICIANS IN MANAGED HEALTH CARE 110 Peter R. Kongstvedt Introduction 110 Basic Models of Reimbursement 111 Capitation 113 Withholds and Risk/Bonus Arrangements 118 Capitation Pools for Referral and Institutional Services 118 Full Professional Risk Capitation 124 Reasons To Capitate 125 Problems with Capitation Systems 126 Effect of Benefits Design on Reimbursement 127 Fee for Service 129 A Special Requirement for Reimbursement When Coinsurance Is in Place 131 Out of Network Fees 132 Discounts, Negotiated Fee Schedules, Fee Maximums, or Fee Allowances 132 Relative Value Scales 133 Global Fees 134 Problems with FFS in Managed Health Care Plans 137 Legislation and Regulation Applicable to Physician Incentive Programs 138 Civil Liability in Physician Compensation Programs 143 Conclusion 144 CHAPTER 9—PHYSICIAN COMPENSATION IN MEDICAL GROUPS AND HEALTH SYSTEMS 147 James A. Rodeghero Background 147 Traditional Concepts in Pay Plan Design 148 Pay Plan Design Issues 150 General Design Alternatives 153 Measurement Issues 156 The Role of Benefits in Total Compensation 157 Compensating Medical Directors and Administrative Physicians 158 Compensating Hospital Based Practitioners 159 Compensation in Faculty Practice Plans under Managed Care 159 Examples 161 Designing Performance Measures 162 Conclusion 163 CHAPTER 10—NONUTILIZATION BASED INCENTIVE COMPENSATION FOR PHYSICIANS 166 Peter R. Kongstvedt Introduction 166 Problems with Evaluation Systems 167 Categories for Evaluation of Physician Performance 168 Measuring the Categories and Producing a Result 172 Conclusion 174 viii The Managed Health Care Handbook CHAPTER 11—CONTRACTING AND REIMBURSEMENT OF SPECIALTY PHYSICIANS 175 Peter R. Kongstvedt 1 Introduction 175 How Many Specialty Care Physicians? 175 Primary versus Specialty Care Designation 176 Credentialing 177 Types of Reimbursement Arrangements 178 Organizational Models for Capitating Specialty Services 184 Common Problems with Specialty Capitation 186 Other Forms of Specialty Physician Reimbursement 187 Risk and Reward 189 Conclusion 189 CHAPTER 12—NEGOTIATING AND CONTRACTING WITH HOSPITALS AND INSTITUTIONS 191 Peter R. Kongstvedt Introduction 191 Hospital Network Development 191 Types of Reimbursement Arrangements 196 Outpatient Procedures 204 Conclusion 205 CHAPTER 13—ACADEMIC HEALTH CENTERS AND MANAGED CARE 206 Jennifer H. Lofland and David B. Nash Dimensions of the Problem 207 Strategies for Success 213 A New Role for MCOs 223 Conclusion 225 CHAPTER 14—HEALTH CENTERS AND MANAGED HEALTHCARE 228 Pamela J. Byrnes, Judith Shea, and Richard J. Jacobsen Introduction 228 Community Health Centers 230 Public Policy and Support 231 Entry into Managed Care ¦ 233 Operational and Strategic Responses to Managed Care 234 Formation of CHC Sponsored Health Plans 237 The Impact of Managed Care and Challenges for the Future 240 Conclusion 243 CHAPTER 15—COMPLEMENTARY AND ALTERNATIVE MEDICINE INTEGRATION: TRENDS, STRUCTURES, AND CHALLENGES 245 John Weeks Introduction 245 Orientation: Stakeholder Activity 245 Models and Challenges: Network Delivered Services 251 Table of Contents ix Challenges and Models: Hospitals and Health Systems 258 Conclusion: Exploratory Integration for Moving CAM Out of Quarantine 260 PART III—MEDICAL MANAGEMENT 265 CHAPTER 16—CARE MANAGEMENT AND CLINICAL INTEGRATION COMPONENTS 267 David W. Plocher, Wendy L. Wilson, Jacqueline A. Lutz, and Ann Huston The Context for Advanced Care Management 267 Defining Advanced Care Management 268 Integrating the Components of Care Management 269 The Role of Physicians in Care Management 272 Building an Advanced Care Management System: A Typical Process 273 Defining the Future State of Care Management 278 Conclusion 280 Appendix 16 A—Description of the Components of the Advanced Care Management System 281 CHAPTER 17—PRIMARY PREVENTION IN MANAGED HEALTH CARE 284 Leifl. Solberg Introduction 284 : Why Should an MCO Do Prevention? 285 Typology of HP/DP Activities 285 ; A Framework for Action 286 Taking Advantage of the Clinical Setting 287 ¦ Health Data Systems 291 j Population Based (Member) Programs 291 i Community Outreach Programs 291 Public Policy Initiatives 292 Conclusion 292 i CHAPTER 18—MANAGING BASIC MEDICAL SURGICAL UTILIZATION 294 Peter R. Kongstvedt Introduction 294 Return on Investment in Management of Medical Costs 294 Demand Management 295 Measurements of Utilization 298 Variations in Utilization 301 The Role of Electronic Commerce 305 Authorization or Denial of Payment for Services 305 Managing Utilization of Specialty Services 306 The Role of the Primary Care Physician in Specialty Services Management 307 Single Visit Authorizations Only 309 Specialty Physicians As Primary Physicians 310 f Prohibition of Secondary Referrals and Authorizations 311 j Review of Reasons for Referral 311 j Institutional Utilization Management 313 Common Methods for Managing Utilization 314 Alternatives to Acute Care Hospitalization 324 Case Management 326 Conclusion 327 x The Managed Health Care Handbook CHAPTER 19—CLINICAL SERVICES REQUIRING AUTHORIZATION 331 Peter R. Kongstvedt Definition of Services Requiring Authorization 331 Definition of Who Can Authorize Services 332 Claims Payment 334 Categories of Authorization 335 Staffing 337 Common Data Elements 338 Methods of Data Capture and Authorization Issuance 339 Authorization System Reports 341 Open Access HMOs 341 Specialty Physician Based Authorization Systems 342 Non Physician Based Authorization Systems 342 Conclusion 343 CHAPTER 20—ANCILLARY DIAGNOSTIC AND THERAPEUTIC SERVICES 344 Peter R. Kongstvedt Introduction 344 Ancillary Services 344 Physician Owned Ancillary Services 345 Data Capture 346 Financial Incentives 346 Feedback 346 Control Points 346 Contracting and Reimbursement for Ancillary Services 347 Conclusion 349 CHAPTER 21—THE EMERGENCY DEPARTMENT AND MANAGED CARE . 351 Casey Jason and Meera Kanhouwa Overview 351 Challenges Shared by Managed Care and Emergency Medicine 352 Creating Efficiencies and Improving Productivity 355 Technology Impact 363 Opportunities with Managed Care 366 CHAPTER 22—CASE MANAGEMENT AND MANAGED CARE 371 Catherine M. Mullahy The Case Manager s Role 371 Patient Profile: Not Every Case Needs a Case Manager 372 On Site versus Telephone Based Case Management 374 Case Managers in Managed Care 375 Case Management Work Format and Process 375 Utilization Review: Preadmission and Concurrent Review and Case Management 384 Preadmission and Concurrent Review Case Management Reports 388 Red Flags: Indicators for Case Management 393 Timing Case Management Intervention 393 Beyond the Case Management Basics 397 A Long Term Solution to a Long Term Problem 400 Table of Contents xi CHAPTER 23—FUNDAMENTALS AND CORE COMPETENCIES OF DISEASE MANAGEMENT 402 David W. Plocher Definition and Clarification 402 Barriers and Drivers for Disease Management 405 Business Plan 405 Survey of Disease Management Programs 406 Important Linkages 408 Support from Electronic Commerce 409 Conclusion 411 CHAPTER 24—PRESCRIPTION DRUG BENEFITS IN MANAGED CARE 413 Robert P. Navarro Financial Basis for Pharmacy Benefit Management 413 Pharmacy Program Cost Components 415 Principles of Pharmacy Benefit Management 417 Managing the Supply and Demand 418 Pharmacy Information Systems and Health Informatics 418 Pharmacy Benefit Management Companies (PBMs) 423 Pharmacy Benefit Management Program Components 426 Physician Provider Network 428 Pharmacy Provider Network 429 Pharmacy Provider Audits 432 Drug Formulary Management 433 Pharmaceutical Manufacturer Discount and Rebate Contracts 438 Prescription Patient Copayments 439 ! Role of Pharmacy Programs in Disease Management and Quality Improvement i Programs 444 ¦¦ Quality Improvement in Pharmacy Benefit Management 444 Measuring Pharmacy Benefit Management Program Performance 446 Future Changes in Pharmacy Benefit Management 447 \| Conclusion 447 CHAPTER 25—MANAGED BEHAVIORAL HEALTH CARE AND CHEMICAL DEPENDENCY SERVICES 451 Donald F. Anderson, Jeffrey L. Berlant, Katherine O. Sternbach, Danna Mauch, H.G. Whittington, William R. Maloney, and Terri Goens Introduction 451 Historical Perspective 452 i Key Treatment Principles 456 Benefit Plan Design 461 Utilization Management 463 Channeling Mechanisms 465 Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives 467 I Quality Assurance 469 \| BH Information Systems 473 1 Public/Private Systems Integration 476 Emerging Issues 477 Conclusion 478 xii The Managed Health Care Handbook CHAPTER 26—HOME HEALTH CARE 480 Peggy H. Rodebush, Laura L. Waltrip, and G. David Baker Introduction 480 What Is Home Care? 481 History of Home Care 481 Indicators and Predictors of Home Care Demand 482 Home Care Services and Disciplines 486 Home Care Providers 486 Regulations Guiding Home Care 488 Financing Home Care Services 490 Recent Legislation and Regulatory Issues Affecting Home Care 492 Measuring Quality in Home Care Services 493 Examples of Advanced Clinical Practices in Home Care 494 CHAPTER 27—SUBACUTE CARE WITHIN THE MANAGED CARE SYSTEM 496 Kathleen M. Griffin Categories 496 Subacute Patients 496 Subacute Providers 497 Subacute Care Sites in the Future 499 Subacute Care within a Continuum of Care 499 Payment for Subacute Care 500 Selecting a Quality Subacute Provider 501 Conclusion 504 Appendix 27 A—NSCA and Joint Commission Definitions of Subacute Care 505 Appendix 27 B—Categories of Subacute Care 506 CHAPTER 28—HOSPICE AND END OF LIFE CARE 508 Anne C. Dye, Peggy H. Rodebush, and Gen Hempel Medical Management and End of Life Care 508 The Basics of Hospice Care 510 Financing and Reimbursement 511 Size of the U.S. Hospice Industry 512 Major Policy Issues 513 Service Models 515 Hospice Cost and Staffing 517 Specialty Programs 517 Future Integration and Affiliation Strategies 519 CHAPTER 29—CLINICAL PATHWAYS: LINKING OUTCOMES FOR PATIENTS, CLINICIANS, PAYERS, AND EMPLOYERS 521 Richard J. Coffey and Sarah S. LeRoy Introduction 521 Background and Terminology 522 Scopes and Uses 522 Environment 524 Development 525 Application 528 Table of Contents xiii Alternative Formats and Sample Uses 529 Results 533 Conclusion 538 CHAPTER 30—QUALITY MANAGEMENT IN MANAGED CARE 539 Pamela B. Siren Introduction 539 Traditional Quality Assurance 539 Components of a Quality Management Program 543 A Process Model for a Modern Quality Management Program 544 Conclusion 554 CHAPTER 31—MEASURING AND MANAGING OF CLINICAL OUTCOMES 556 Michael Pine Domains of Clinical Outcomes Measurement 556 Goals of Clinical Outcomes Measurement 556 Measuring Comparative Risk Adjusted Clinical Outcomes 558 Using Data on Risk Adjusted Costs To Craft Measures of Clinical Performance 567 Using Adverse Outcome Rates To Reduce Costs 570 Using Control Charts To Get a Dynamic View of Performance 572 i Relating Clinical Outcomes to Processes of Care 572 Monitoring Clinical Outcomes of Ambulatory Care 575 \| Conclusion 578 1 CHAPTER 32—USING DATA AND PROVIDER PROFILING IN MEDICAL J MANAGEMENT 579 Peter R. Kongstvedt, Norbert I. Gold field, and David W. Plocher Introduction 579 Use of Data and Information in Medical Management 580 Patient Data Confidentiality 583 Data Elements and the Application of Reports 586 General Types of Reports 590 Provider Profiling 595 Desired Characteristics of Provider Profiles 597 The Need To Adjust for Severity of Illness 600 Selection of a Profiling Vendor 610 The Future of Data Use 614 Conclusion 615 CHAPTER 33—PHYSICIAN BEHAVIOR CHANGE IN MANAGED V HEALTH CARE 618 Peter R. Kongstvedt Introduction 618 General Aspects of Physician Practice Behavior 618 General Approaches to Changing Behavior 626 Programmatic Approaches to Changing Physician Behavior 628 Addressing Noncompliance by Individual Physicians 630 Conclusion 633 xiv The Managed Health Care Handbook CHAPTER 34—MEMBER BEHAVIOR CHANGE 637 Nancy W. Spangler Introduction 637 They Know Better, So Why Don t They Just Stop? 637 Models for Affecting Patient Behaviors 641 Tools for Enhancing Change 646 From Theory into Practice: Humana s CHIP Program 649 Conclusion 651 PART IV—OPERATIONAL MARKETING AND MANAGEMENT 655 CHAPTER 35—INFORMATION SYSTEMS IN MANAGED HEALTH CARE PLANS 657 James S. Slubowski Introduction 657 Core Managed Care Information System 658 Electronic Data Interchange 662 Privacy and Confidentiality under HIPAA 663 Value Added Services—The Next Generation 666 HEDIS 670 Information Services Department 673 Conclusion 674 CHAPTER 36—INFORMATION SYSTEMS AND ELECTRONIC COMMERCE FOR PROVIDER SYSTEMS IN MANAGED HEALTH CARE 676 Robert G. Reese and Rick Majzun Introduction: Major Issues Facing Health Care Provider Organizations in the Year 2000 676 Health Care Is a Business in an Information Economy 676 Health Care Provider Organizations Are Building the Information Infrastructure for a New Era in Health Care 677 Pressures on Both the Cost and Revenue Sides of the Equation Are Increasing 677 Information Technology Should Support Business Strategy and Market Need 677 Interconnectivity 678 Data Repositories or Warehouses: The Backbone of the Organization s Clinical and Financial Systems 679 Enterprise Wide Information Systems 680 Use of Information Technology in Managing Care 680 Computerized Medical Records 681 Clinical Decision Support Systems 682 Knowledge Management Systems 683 Data Privacy and Security 684 Electronic Commerce 684 Capital Budgeting for Information Technology 687 Organizational Structure of Information Technology Departments 689 Client Relationships 689 Outsourcing the Information Technology Function 691 Conclusion: Information Technology Will Play a Key Role in Improving the Health Care Provider Organization s Ability To Manage Care 692 Table of Contents xv CHAPTER 37—ELECTRONIC COMMERCE IN MANAGED HEALTH CARE 694 Britton L. Pirn and Sean D. Kenny E Commerce in Health Care 694 E Commerce Technologies 696 E Commerce Functionality 701 External Impact 703 Internal E Commerce Opportunities 705 Challenges 707 Critical Success Factors 708 Conclusion 709 CHAPTER 38—CLAIMS AND BENEFITS ADMINISTRATION 710 Robin L. McElfatrick and Robert S. Eichler Introduction 710 Claims: Positioning, Purpose, and Opportunities 711 Organizational Structure and Staffing 713 Claims Operations Management 718 Productivity 729 Turn Around Time 731 Staff Training and Development 732 Quality 735 Policy and Procedure 737 Coordination with Other Departments/Functions 739 Systems Support 739 Claims Business Functions 743 Other Issues 751 Conclusion 754 CHAPTER 39—OTHER PARTY LIABILITY AND COORDINATION OF BENEFITS 755 Barry S. Scheur, Robin L. McElfatrick, and Robert S. Eichler Definitions 756 Contractual Support/Requirements 758 Legal Issues Based on Case Law 760 Organizational Placement (with Dedicated Staff) 761 COB: Basic Procedure Defined 761 Subrogation: Basic Procedure Defined 763 Accounting for OPL 763 OPL Policy Issues 766 OPL in a Capitated Environment 766 Outsourcing OPL 768 Conclusion 769 CHAPTER 40—MEMBER SERVICES AND CONSUMER AFFAIRS 771 Peter R. Kongstvedt Provision of General Information 772 Conclusion 797 xvi The Managed Health Care Handbook CHAPTER 41—SALES AND MARKETING IN MANAGED HEALTH CARE PLANS: THE PROCESS OF DISTRIBUTION 798 Gail Marcus and John C. Thomson What Managed Care Organizations Deliver 798 Challenges Facing MCOs 800 An Overview of the Managed Care Market 804 Key Decision Makers and Influencers in the Managed Care Distribution Process 804 The Managed Care Sales Process 809 How the Managed Care Team Delivers 812 The Management of Sales and Marketing Professionals 815 Conclusion 816 CHAPTER 42—THE EMPLOYER S VIEW OF MANAGED HEALTH CARE: SHOW ME THE VALUE 817 MichaelJ. Taylor Recent Managed Care Trends Affecting Employers 817 How These Trends Impact Employers Both Large and Small 818 The Large Group Employer: 5,000 Lives Plus 818 The Moderate Group Employer: 500 5,000 Lives 819 The Medium Group Employer: 50 500 Lives 819 The Small Group Employer: 0 50 Lives 820 How Employers Purchase Value (1988 1998) 820 Looking for Value: 2000 and Beyond 822 Future Trends 824 Conclusion 825 CHAPTER 43—THE IMPACT OF CONSUMERISM ON MANAGED HEALTH CARE 828 Jacqueline A. Lutz and Hindy J. Shaman Why Is Consumerism a Significant Trend? 828 Who Is the New Health Care Consumer? 835 What Are the Implications of Consumerism? 836 How Can Organizations Develop a Consumer Strategy? 845 What Consumerism Means for the Managed Care Industry 846 Conclusion 846 CHAPTER 44—ACCREDITATION AND PERFORMANCE MEASUREMENT PROGRAMS FOR MANAGED CARE ORGANIZATIONS 849 Margaret E. O Kane Introduction 849 Oversight by Type of Organization 850 National Committee for Quality Assurance 851 The Utilization Review Accreditation Commission 861 Joint Commission on Accreditation of Healthcare Organizations 865 Conclusion 869 CHAPTER 45—RISK MANAGEMENT IN MANAGED CARE 871 Barbara J. Youngberg Introduction 871 Changes in the Health Care Organization Related to Managed Care 873 Operational Risks under Managed Care 875 Table of Contents xvii Managing Corporate Negligence 876 Clinical Decision Making 879 Utilization Management Issues 879 Emerging Case Law 879 Reducing Utilization Management Exposure 880 Externally Imposed Practice Guidelines or Standards of Care 881 Multi Site Challenges 881 The Convergence of Financial and Risk Management 882 Using the Risk Management Process To Control the Risks of Managed Care 884 Conclusion 884 CHAPTER 46—COMMON OPERATIONAL PROBLEMS IN MANAGED HEALTH CARE PLANS 886 Peter R. Kongstvedt Introduction and Background 886 Common versus Unique Problems or Events 887 Common Problems in Managed Care Organizations 888 Conclusion 903 PART V—FINANCE AND UNDERWRITING 905 CHAPTER 47—OPERATIONAL FINANCE AND BUDGETING 907 Dale F. Harding Background 907 Financial Statement Components 908 Balance Sheeet 915 Regulatory Reporting Considerations 917 Budgeting and Financial Forecasting 919 Conclusion 921 CHAPTER 48—TAX ISSUES RELATING TO HEALTH RISK BEARING ENTITIES 922 Phillip G. Royalty and Terry A. Jacobs Taxable Health Risk Bearing Entities 922 Tax Exempt Health Risk Bearing Entities 927 Appendix 48 A—Internal Revenue Service Manual Exempt ORganizations Handbook— Chapter 27: Health Maintenance Organizations 935 CHAPTER 49—UNDERWRITING AND RATING FUNCTIONS COMMON TO MOST MARKETS 945 Stephen M. Cigich and Michael G. Sturm Underwriting 945 Rating 947 Conclusion 951 CHAPTER 50—UNDERWRITING AND RATING FUNCTIONS BY MARKET 952 Michael G. Sturm Individual Nongovernment Market 952 Commercial Group Market 954 Medicare Supplement 967 Medicare Risk 968 xviii The Managed Health Care Handbook MedicaidRisk 969 Conclusion 970 CHAPTER 51—ACTUARIAL SERVICES IN AN INTEGRATED DELIVERY SYSTEM 971 Stephen M. Cigich Summary of Actuarial Services 971 Identifying and Realizing Opportunities 972 Creating Incentive Structures 974 Measuring Results 975 Conclusion 975 CHAPTER 52—OPERATIONAL UNDERWRITING IN MANAGED CARE ORGANIZATIONS 977 Gregory J. Lippe Historical Overview 977 Sales and Underwriting Collaboration 979 Management Information System 979 Regulation 980 Major Risk Factors 981 Underwriting As an Internal Control 982 Employer Group Underwriting 983 Key Employer Group Data 984 Market Factors and Trends 985 Community Rating Methodologies 986 Underwriting Principles 994 Administrative Service Only Underwriting 997 Effective Underwriting: Lessons Learned 997 Conclusion 999 CHAPTER 53—PROVIDER EXCESS LOSS COVERAGE 1000 Scott A. Walker Introduction 1000 Capitation—The Need for Protection 1001 PEL under Provider Risk Contracting 1003 Types of PEL Coverage 1004 Specific Excess Rate Development 1004 Experience Specific PEL Rating 1016 Aggregate Excess Rate Development 1023 PEL Policy Coverage Form 1025 Coverage Availability 1032 Conclusion 1032 Appendix 53 A—Sample PEL Policy Language 1034 PART VI—SPECIAL MARKET SEGMENTS 1041 CHAPTER 54—THE FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM AND MANAGED CARE 1043 Christine C. Rinn The Application Process 1044 Premium Contribution and Benefit Design 1044 Table of Contents xix Patients Bill of Rights and Responsibilities 1045 Premium Rating under the FEHBP 1045 0PM Audits and Appeals 1051 FEHBP and False Claims Liability 1054 OPM s Policy on Error Reporting 1055 Miscellaneous Contracting Issues 1055 Quality Assurance 1057 Conclusion 1057 CHAPTER 55—MEDICARE AND MANAGED CARE 1060 Carlos Zarabozo and Jean D. LeMasurier Introduction 1060 Organization of the Chapter 1061 Who Is Eligible for a Medicare Risk Contract? 1061 The Exception in State Licensure: Provider Sponsored Organizations 1062 Other New Options 1063 Muddying the Waters: Plans versus Organizations 1065 Federal Preemption 1072 What the Contract Requires (Finally!) 1073 Limitations on Physician Incentive Plans 1075 Consumer Protections 1076 Provider Protections and Rights: Conscience Protection 1077 Information Dissemination 1078 Enrollment 1078 Marketing Rules 1081 Interactions with Your Government 1081 The Contracting Process 1082 Web Resources and Other Contacts 1083 Future Direction of the Program 1083 CHAPTER 56—MEDICARE + CHOICE: THE HEALTH PLAN S VIEW 1086 Craig S. Schub and Nick Franklin Introduction 1086 Today s Elderly 1086 The Demographic Imperative: Aging Population and Unpredictable Health Care Costs 1088 Public Policy Initiatives: From 1965 to the Balanced Budget Act 1088 Evolving Challenges and Opportunities of Medicare + Choice (Risk) Contractors 1092 Changing Dynamics of the Delivery System 1096 Future Trends 1103 CHAPTER 57—MEDICAID MANAGED CARE 1105 Robert E. Hurley and Stephen A. Somers Introduction 1105 Medicaid—Origins and Evolution 11°6 Medicaid Managed Care—Background and Models 1107 Operational Features 1108 Successes of Medicaid Managed Care 1H3 Shortfalls of Medicaid Managed Care 1116 The Challenging Contemporary Context 1119 Longer Term Questions and Concerns 112 Conclusion 1122 xxii The Managed Health Care Handbook Delegated Board Authority 1245 Advisory Committees 1245 Conflict of Interest Policy 1246 Tax Exemption and Charitable Benefit 1247 Physician Compensation 1248 Practice Acquisitions/Valuation 1249 Medicare/Medicaid Provider Numbers 1250 Antitrust Law 1250 Independent Contractor Status 1251 Covenants Not To Compete 1255 Conclusion 1255 CHAPTER 66—ERISA AND MANAGED CARE 1257 Jacqueline M. Saue and Gregg H. Dooge Documentation, Reporting, and Disclosure Requirements 1257 Plan Design Considerations 1259 Amendment of Plans 1262 Fiduciary Duties 1263 Challenges to Benefit Denials 1264 ERISA s Civil Enforcement Scheme and Remedies 1267 ERISA Preemption 1267 Conclusion 1280 CHAPTER 67—THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 1285 Charles N. Kahn III, Dean A. Rosen, Marianne Miller, and Kathleen H. Fyjfe Introduction 1285 Overview 1286 Provisions: Portability and Access 1287 New Access Initiatives 1293 Amendments to HIPAA Portability and Access Provisions 1294 Provisions: Administrative Simplification 1295 HIPAA Administration and Enforcement 1299 An Early Report on the Effects of HIPAA Portability and Access Provisions 1300 Conclusion 1304 CHAPTER 68—HEALTH PLAN CORPORATE COMPLIANCE PROGRAMS 1306 Mike Treash Corporate Compliance on Paper 1306 Corporate Compliance in Operation 1307 Structure 1308 Leadership 1309 Education and Development 1311 Measures and Incentives 1311 Staffing 1312 Communication 1313 Conclusion 1320 Table of Contents xxiii CHAPTER 69—STATE REGULATION OF MANAGED CARE 1322 Richard I. Smith and Kristin Stewart Introduction 1322 State Oversight: The Regulatory Process 1323 State Regulation of Other Products 1330 Managed Care Legislation 1334 Regulation by Market Segment 1341 The State Experience—Conclusion 1343 EPILOGUE—MANAGED HEALTH CARE AT THE MILLENNIUM 1346 Peter R. Kongstvedt Introduction—The Rollercoaster That Never Stops 1346 Using the Magic Eight Ball: The Answer Is Hazy—Try Again Later 1347 They Were Right All Along—Managed Health Care Is in Chaos 1347 Reversing Entropy with a Little Help from Professor Heisenberg—Predicting, Leading, and Acting in a Chaotic Managed Health Care Environment 1349 Handicapping the Field—The Stratification of Predictability 1350 Driving the Nitroglycerine Truck on a Foggy Night—Leadership, Strategy, and Action in the Chaotic World 1353 Door Number One, Two, or Three—Choosing Strategic Options 1355 Conclusion—Shake the Magic Eight Ball and Try Again 1356 GLOSSARY OF TERMS AND ACRONYMS 1357 INDEX 1378
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spelling	The managed health care handbook ed. by Peter R. Kongstvedt 4. ed. Gaithersburg, Md. Aspen Publ. 2001 XXXI, 1408 S. graph. Darst. txt rdacontent n rdamedia nc rdacarrier Soins intégrés de santé Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Handbooks, manuals, etc Managed Care (DE-588)4461436-6 gnd rswk-swf USA USA (DE-588)4078704-7 gnd rswk-swf USA (DE-588)4078704-7 g Managed Care (DE-588)4461436-6 s DE-604 Kongstvedt, Peter R. Sonstige (DE-588)140444904 oth HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009188967&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis
spellingShingle	The managed health care handbook Soins intégrés de santé Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Handbooks, manuals, etc Managed Care (DE-588)4461436-6 gnd
subject_GND	(DE-588)4461436-6 (DE-588)4078704-7
title	The managed health care handbook
title_auth	The managed health care handbook
title_exact_search	The managed health care handbook
title_full	The managed health care handbook ed. by Peter R. Kongstvedt
title_fullStr	The managed health care handbook ed. by Peter R. Kongstvedt
title_full_unstemmed	The managed health care handbook ed. by Peter R. Kongstvedt
title_short	The managed health care handbook
title_sort	the managed health care handbook
topic	Soins intégrés de santé Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Handbooks, manuals, etc Managed Care (DE-588)4461436-6 gnd
topic_facet	Soins intégrés de santé Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Handbooks, manuals, etc Managed Care USA
url	http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009188967&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA
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MARC

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