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The managed health care handbook:

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Format:	Buch
Sprache:	English
Veröffentlicht:	Gaithersburg, Md. Aspen Publ. 1996
Ausgabe:	3. ed.
Schlagworte:	Managed Care Programs > organization & administration > United States Managed care plans (Medical care) > United States > Management Managed Care USA
Online-Zugang:	Inhaltsverzeichnis
Beschreibung:	XXXI, 1045 S. graph. Darst.
ISBN:	0834207338

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Datensatz im Suchindex

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adam_text	Titel: The managed health care handbook Autor: Kongstvedt, Peter R Jahr: 1996 Table of Contents CONTRIBUTORS.......................................................................................................................xxv PREFACE..................................................................................................................................xxix ACKNOWLEDGMENTS.........................................................................................................xxxi PART 1-INTRODUCTION TO MANAGED CARE................................................................1 CHAPTER 1-AN OVERVIEW OF MANAGED CARE..........................................................3 Peter D. Fox Managed Care: The Early Years (Before 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 AND HEALTH CARE REFORM: EVOLUTION OR REVOLUTION?........................................................................................................................16 Frederick B. Abbey Federal Health Policy Drivers....................................................................................................16 Major Areas of Policy Development..........................................................................................18 Conclusion..................................................................................................................................29 CHAPTER 3-TYPES OF MANAGED CARE ORGANIZATIONS.....................................33 EricR. Wagner Types of Managed Care Organizations and Common Acronyms..............................................34 HMO Models..............................................................................................................................40 Conclusion..................................................................................................................................44 vi The Managed Health Care Handbook CHAPTER 4-INTEGRATED HEALTH CARE DELIVERY SYSTEMS...........................46 Peter R. Kongstvedt and David W. Plocher Independent Practice Associations.............................................................................................47 Physician Practice Management Organizations..........................................................................48 Group Practice without Walls.....................................................................................................50 Consolidated Medical Group......................................................................................................51 PHOs...........................................................................................................................................53 MSOs..........................................................................................................................................56 Foundation Model.......................................................................................................................57 Staff Model.................................................................................................................................59 Physician Ownership Model.......................................................................................................60 Virtual Integration......................................................................................................................60 Global Capitation........................................................................................................................61 Providing the Insurance Function...............................................................................................61 Legal Pitfalls...............................................................................................................................62 Conclusion..................................................................................................................................64 CHAPTER 5-ACQUISITIONS, JOINT VENTURES, AND PARTNERSHIPS BETWEEN PROVIDERS AND MANAGED CARE ORGANIZATIONS..............................................66 Peter R. Kongstvedt and David W. Plocher The Grass Must Be Greener!......................................................................................................66 General Trends............................................................................................................................67 Acquisition of Providers by MCOs............................................................................................68 De Novo Start-Up of Practices...................................................................................................71 Providers Becoming Licensed HMOs........................................................................................71 Joint Ventures between Providers and Health Plans..................................................................72 Conclusion..................................................................................................................................77 CHAPTER 6-ELEMENTS OF THE MANAGEMENT CONTROL AND GOVERNANCE STRUCTURE............................................................................................................................78 Peter R. Kongstvedt Board of Directors......................................................................................................................78 Key Management Positions........................................................................................................81 Committees.................................................................................................................................82 Management Control Structure...................................................................................................83 Conclusion..................................................................................................................................84 Table of Contents vii PART II-THE HEALTH CARE DELIVERY SYSTEM........................................................85 CHAPTER 7-PRIMARY CARE IN CLOSED PANEL PLANS...........................................87 Peter R. Kongstvedt Needs Assessment......................................................................................................................87 Nonphysician Providers..............................................................................................................90 Recruiting...................................................................................................................................90 Compensation.............................................................................................................................96 Credentialing...............................................................................................................................98 Orientation..................................................................................................................................98 Productivity.................................................................................................................................99 Retention of Quality Physicians...............................................................................................100 Conclusion................................................................................................................................102 CHAPTER 8-PRIMARY CARE IN OPEN PANEL PLANS...............................................104 Peter R. Kongstvedt Definitions................................................................................................................................104 Network Development..............................................................................................................104 Types of Contracting Situations...............................................................................................108 Credentialing.............................................................................................................................111 Medical Record Review...........................................................................................................114 Compensation...........................................................................................................................114 Orientation................................................................................................................................114 Network Management..............................................................................................................114 Conclusion................................................................................................................................118 CHAPTER 9-COMPENSATION OF PRIMARY CARE PHYSICIANS IN OPEN PANEL PLANS......................................................................................................120 Peter R. Kongstvedt Basic Models of Reimbursement..............................................................................................120 Capitation..................................................................................................................................121 The Federal Government s Physician Incentive Rule..............................................................124 Withholds and Risk/Bonus Arrangements................................................................................129 Capitation Pools for Referral and Institutional Services..........................................................130 Full-Risk Capitation..................................................................................................................134 Reasons to Capitate...................................................................................................................135 Problems with Capitation Systems...........................................................................................135 Effect of Benefits Design on Reimbursement..........................................................................136 viii The Managed Health Care Handbook FFS .........................................................................................................................................139 Problems with FFS in Managed Health Care Plans..................................................................143 Conclusion................................................................................................................................144 CHAPTER 10-PHYSICIAN COMPENSATION IN GROUPS AND INTEGRATED DELIVERY SYSTEMS..........................................................................................................147 James A. Rodeghero Background...............................................................................................................................147 Traditional Concepts in Pay Plan Design.................................................................................148 Pay Plan Design Issues.............................................................................................................149 General Design Alternatives.....................................................................................................152 Measurement Issues..................................................................................................................155 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................................................160 Cases and Examples.................................................................................................................160 Designing Performance Measures............................................................................................162 Conclusion................................................................................................................................164 CHAPTER 11-NON-UTILIZATION-BASED INCENTIVE COMPENSATION FOR PHYSICIANS.................................................................................................................166 Peter R. Kongstvedt Closed Panels Compared with Open Panels.............................................................................166 The Value of Formal Performance Evaluations.......................................................................167 Problems with Evaluation Systems..........................................................................................168 Categories for Evaluation of Physician Performance...............................................................169 Measuring the Categories and Producing a Result...................................................................172 Conclusion................................................................................................................................175 CHAPTER 12-CONTRACTING AND REIMBURSEMENT OF SPECIALTY PHYSICIANS..........................................................................................................................176 Peter R. Kongstvedt HowManySCPs?.....................................................................................................................177 Primary versus Specialty Care Designation.............................................................................178 Closed Panels: In-House and Outside Contracts......................................................................179 Credentialing.............................................................................................................................179 Types of Reimbursement Arrangements..................................................................................179 Common Problems with Specialty Capitation..........................................................................185 Other Forms of Specialty Physician Reimbursement...............................................................186 Risk/Bonus Arrangements........................................................................................................187 Table of Contents ix Non-Utilization-Based Incentive Compensation.....................................................................189 Prohibition of Subauthorizations..............................................................................................189 Conclusion................................................................................................................................189 CHAPTER 13-SPECIALTY NETWORKS FROM THE SPECIALIST S VIEW............191 Allan Fine Assessing Market Conditions...................................................................................................192 Developing Specialty Networks...............................................................................................194 Medical Staff Assessment.........................................................................................................196 Organizational Form.................................................................................................................196 Package Pricing........................................................................................................................196 Antitrust Considerations...........................................................................................................198 Moving from Rhetoric to Action..............................................................................................198 Implementation Requirements..................................................................................................200 Parting Advice for Specialists..................................................................................................200 Conclusion................................................................................................................................201 CHAPTER 14-NEGOTIATING AND CONTRACTING WITH HOSPITALS AND INSTITUTIONS......................................................................................................................202 Peter R. Kongstvedt Reasons To Contract.................................................................................................................202 Hospital Network Development...............................................................................................202 Types of Reimbursement Arrangements..................................................................................207 Conclusion................................................................................................................................214 CHAPTER 15-ACADEMIC HEALTH CENTERS AND MANAGED CARE..................215 Richard L. Solit and David B. Nash Dimensions of the Problem......................................................................................................216 Strategies for Success...............................................................................................................221 A New Role for MCOs.............................................................................................................229 Conclusion................................................................................................................................231 CHAPTER 16-MANAGED CARE AND COMMUNITY HEALTH CENTERS..............234 C. David Spencer Brief History.............................................................................................................................234 Types of Contracts Involving Managed Care and CHCs.........................................................236 Goals and Attributes of CHCs As Contractors.........................................................................238 Goals and Attributes of HMOs As Contractors........................................................................240 Steps That CHCs Must Take...................................................................................................241 Steps That HMOs Should Take................................................................................................243 Conclusion................................................................................................................................244 x The Managed Health Care Handbook PART III-MEDICAL MANAGEMENT................................................................................247 CHAPTER 17-MANAGING BASIC MEDICAL-SURGICAL UTILIZATION...............249 Peter R. Kongstvedt Administrative Cost versus Medical Loss Ratio......................................................................249 Demand Management...............................................................................................................249 Specialty Physician Utilization Management...........................................................................252 Institutional UM........................................................................................................................257 Conclusion................................................................................................................................272 CHAPTER 18-CASE MANAGEMENT AND MANAGED CARE.....................................274 Catherine M. Mullahy The Case Manager s Role.........................................................................................................274 Case Managers in Managed Care.............................................................................................277 The Case Management Work Format and Process...................................................................278 Utilization Review: Preadmission Review, Concurrent Review, and Case Management.......287 Preadmission and Concurrent Review Case Management Reports..........................................288 RedFlags: Indicators for Case Management............................................................................290 Timing Case Management Intervention...................................................................................291 Beyond the Case Management Basics......................................................................................294 Beyond Reform.........................................................................................................................299 CHAPTER 19-CRITICAL PATHS: LINKING OUTCOMES FOR PATIENTS, CLINICIANS, AND PAYERS...............................................................................................301 Richard J. Coffey, Janet S. Richards, Susan A. Wintermeyer-Pingel, and Sarah S. LeRoy Background and Terminology..................................................................................................301 Scope and Uses of Critical Paths..............................................................................................302 Environment for Critical Paths.................................................................................................303 Approach to Developing Critical Paths....................................................................................304 Use of Critical Paths.................................................................................................................307 Alternative Formats and Sample Uses......................................................................................309 Results.......................................................................................................................................314 Conclusion and Recommendations...........................................................................................316 CHAPTER 20-DISEASE MANAGEMENT..........................................................................318 David W. Plocher Definition..................................................................................................................................318 Rationale and Requirements for Successful Demonstrations...................................................318 Table of Contents xi Carve-Outs................................................................................................................................320 Conventional Case Management and Disease Management....................................................320 Selection of Diseases................................................................................................................320 Experience from Early Demonstrations....................................................................................322 Caveats from the Market..........................................................................................................324 Getting Your Pilot Program Started.........................................................................................324 The Future.................................................................................................................................326 CHAPTER 21-MANAGING UTILIZATION OF ANCILLARY AND EMERGENCY SERVICES...............................................................................................................................330 Peter R. Kongstvedt Ancillary Services.....................................................................................................................330 Emergency Department............................................................................................................336 Conclusion................................................................................................................................339 CHAPTER 22-MANAGED BEHAVIORAL HEALTH CARE SERVICES......................341 Donald F. Anderson, Jeffrey L. Berlant, Danna Mauch, and William R. Maloney Key Treatment Principles.........................................................................................................342 Benefit Plan Design..................................................................................................................347 Risk Assessment and Capitation...............................................................................................350 Utilization Management...........................................................................................................351 Channeling Mechanisms...........................................................................................................353 Provider Networks....................................................................................................................354 Quality Assurance.....................................................................................................................357 Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives......359 Information Systems.................................................................................................................362 Public-Private Systems Integration...........................................................................................363 Emerging Issues........................................................................................................................364 Conclusion................................................................................................................................365 CHAPTER 23-PHARMACEUTICAL SERVICES IN MANAGED CARE.......................367 Henry F. Blissenbach and Peter M. Penna Cost of Drugs............................................................................................................................368 The Pharmacy Benefit..............................................................................................................368 Certificate of Coverage.............................................................................................................369 Managed Health Care and the Pharmacy Benefit.....................................................................370 Management of Quality............................................................................................................381 Qualitative DUR.......................................................................................................................384 Measurement of Success...........................................................................................................385 Pharmacy Benefit Management: The Next Phase....................................................................386 Conclusion................................................................................................................................387 xii The Managed Health Care Handbook CHAPTER 24-SUBACUTE CARE AND MANAGED CARE---------------------------------388 Kathleen M. Griffin Subacute Care Defined.............................................................................................................388 Subacute Care Categories.........................................................................................................388 Subacute Patients......................................................................................................................388 Subacute Providers...................................................................................................................389 Subacute Care within a Continuum of Care.............................................................................391 Payment for Subacute Care......................................................................................................393 Selecting a Quality Subacute Provider.....................................................................................394 Conclusion................................................................................................................................397 Appendix 24-A-NSCA and Joint Commission Definitions of Subacute Care......................398 Appendix 24-B-Categories of Subacute Care........................................................................400 CHAPTER 25-QUALITY MANAGEMENT IN MANAGED CARE.................................402 Pamela B. Siren and Glenn L. Laffel Traditional Quality Assurance..................................................................................................402 Components of a Quality Management Program: Building on Tradition................................405 A Process Model for a Modern Quality Management Program...............................................406 Setting the Improvement Agenda.............................................................................................422 Conclusion................................................................................................................................422 CHAPTER 26-CHANGING PROVIDER BEHAVIOR IN MANAGED CARE PLANS....................................................................................................427 Peter R. Kongstvedt Inherent Difficulties in Modifying Physician Behavior...........................................................427 General Approaches to Changing Behavior.............................................................................431 Programmatic Approaches to Changing Physician Behavior...................................................432 Changing the Behavior of Individual Physicians.....................................................................434 Conclusion................................................................................................................................436 CHAPTER 27-USING DATA IN MEDICAL MANAGEMENT____________________440 Peter R. Kongstvedt General Requirements for Using Data to Manage the Health Care Delivery System..............440 Focus.......................................................................................................................................443 Hospital Utilization Reports.....................................................................................................444 Outpatient Utilization...............................................................................................................445 Provider Profiling.....................................................................................................................447 Conclusion.......................................................................................................... ....451 Table of Contents xiii PART IV-OPERATIONAL MANAGEMENT AND MARKETING..................................453 CHAPTER 28-INFORMATION SYSTEMS OPERATIONS AND ORGANIZATION STRUCTURES........................................................................................................................455 Robert Reese General Organization Structure and Reporting Relationships..................................................456 Annual Operating Goals with Quarterly Updates for Refinements..........................................456 Cost Management.....................................................................................................................456 Client Relationships..................................................................................................................457 Intellectual Property..................................................................................................................458 Outsourcing versus Ownership.................................................................................................458 Hardware Considerations..........................................................................................................459 Interconnectivity.......................................................................................................................460 EFT/ERA..................................................................................................................................463 Data Repositories......................................................................................................................465 The National Committee for Quality Assurance and the Health Plan Employer Data and Information Set Reporting....................................................................................................466 Conclusion................................................................................................................................466 CHAPTER 29-AUTHORIZATION SYSTEMS....................................................................469 Peter R. Kongstvedt Definition of Services Requiring Authorization.......................................................................469 Definition of Who Can Authorize Services..............................................................................470 Claims Payment........................................................................................................................471 Categories of Authorization......................................................................................................472 Staffing.....................................................................................................................................474 Common Data Elements...........................................................................................................475 Methods of Data Capture and Authorization Issuance.............................................................476 Authorization System Reports..................................................................................................477 Conclusion................................................................................................................................478 CHAPTER 30-MEMBER SERVICES AND CONSUMER ÄFF AIRS...............................479 Peter R. Kongstvedt Training and Staffing................................................................................................................480 Accessing Member Services.....................................................................................................480 Performance Standards.............................................................................................................481 Service and Help.......................................................................................................................482 Member Complaints and Grievances........................................................................................483 Formal Grievance Procedure....................................................................................................485 Data Collection and Analysis...................................................................................................487 xiv The Managed Health Care Handbook Proactive Approaches to Member Services..............................................................................488 Conclusion................................................................................................................................490 CHAPTER 31-CLAIMS AND BENEFITS ADMINISTRATION.......................................491 Robert S. Eichler and Robin L. McElfatrick Claims: Positioning, Purpose, and Opportunities.....................................................................491 Organizational Structure and Staffing......................................................................................494 Claims Operations Management...............................................................................................497 Productivity...............................................................................................................................508 TAT .........................................................................................................................................510 Staff Training and Development..............................................................................................512 Quality......................................................................................................................................514 Policy and Procedure................................................................................................................517 Coordination with Other Departments/Functions.....................................................................519 Systems Support.......................................................................................................................519 Claims Business Functions.......................................................................................................523 Conclusion................................................................................................................................530 CHAPTER 32-OTHER PARTY LIABILITY AND COORDINATION OF BENEFITS.........................................................................................................................532 Barry S. Scheur, Robin L. McElfatrick, and Robert S. Eichler Definitions................................................................................................................................532 Contractual Support/Requirements...........................................................................................534 Organizational Placement (with Dedicated Staff)....................................................................536 COB: Basic Procedure Defined................................................................................................537 Subrogation: Basic Procedure Defined.....................................................................................538 Accounting for OPL.................................................................................................................539 OPL Policy Issues.....................................................................................................................541 OPL in a Capitated Environment..............................................................................................542 Conclusion................................................................................................................................543 CHAPTER 33-OPTIMIZING HEALTH PLAN OPERATIONS........................................545 Ron M. Davis, James A. Williams, and Dana E. Frank What Is Reengineering?............................................................................................................545 Why Should MCOs Reengineer?..............................................................................................546 What Does a Reengineered MCO Process Look Like?............................................................549 Hallmarks of Reengineering.....................................................................................................551 Reengineering Step by Step......................................................................................................551 Critical Success Factors............................................................................................................551 Measuring Success....................................................................................................................556 The Future of MCO Operations................................................................................................556 Table of Contents xv CHAPTER 34-ASSESSING THE MARKET FOR MANAGED CARE............................558 Eric R. Wagner What Are We Planning To Seil?..............................................................................................559 What or Who Is the Market?....................................................................................................559 Review of Market Demographics and Conditions....................................................................559 Profile of Competition..............................................................................................................563 Understanding the Regulatory Environment............................................................................564 Analysis of Employers and Their Needs..................................................................................565 Conclusion................................................................................................................................566 CHAPTER 35-MARKETING MANAGED HEALTH CARE PLANS..............................567 John P. Anton Market Research.......................................................................................................................567 Product and Marketing Diversification....................................................................................569 Moving Ahead..........................................................................................................................573 Prospecting...............................................................................................................................573 Marketing Communications and Sales Promotion...................................................................575 Your Marketing Team..............................................................................................................577 It Is Never Over........................................................................................................................579 Conclusion................................................................................................................................579 CHAPTER 36-THE EMPLOYER S VIEW OF MANAGED HEALTH CARE: FROM A PASSIVE TO AN AGGRESSIVE ROLE...........................................................580 Anthony M. Kotin and Thomas J. Kuhlman Health Maintenance Organization: The Early Years..............................................................580 Managed Indemnity Plans........................................................................................................581 Employers Confront the Delivery System................................................................................581 Point-of-Service Managed Care Emerges................................................................................585 How Do Employers Choose MCOs?........................................................................................586 Employer Activism in Managed Care......................................................................................587 HEDIS.......................................................................................................................................591 The Future of POS....................................................................................................................591 Conclusion................................................................................................................................592 CHAPTER 37-EXTERNAL ACCREDITATION OF MANAGED CARE PLANS..........593 Margaret E. O Kane Types of Managed Care............................................................................................................594 Quality Assurance and Improvement Systems in MCOs.........................................................595 xvi The Managed Health Care Handbook Development of Accreditation Programs for Managed Care...................................................598 Administrative Issues Related to MCOs...................................................................................598 Accreditation of UR Organizations..........................................................................................599 Preferred Provider Accreditation..............................................................................................602 Accreditation of HMOs or Prepaid Managed Care Systems....................................................603 Conclusion................................................................................................................................607 CHAPTER 38-RISK MANAGEMENT IN MANAGED CARE-------------------------------608 Barbara J. Youngberg Changes in the Health Care Organization Related to Managed Care.......................................610 Operational Risks under Managed Care...................................................................................611 Managing Corporate Negligence..............................................................................................612 Clinical Risks............................................................................................................................613 Multisite Challenges.................................................................................................................617 The Convergence of Financial and Risk Management.............................................................618 Risk Financing..........................................................................................................................619 Utilizing the Risk Management Process To Control the Risks of Managed Care....................619 Conclusion................................................................................................................................620 CHAPTER 39-COMMON OPERATIONAL PROBLEMS IN MANAGED HEALTH CARE PLANS..........................................................................................................................622 Peter R. Kongstvedt Undercapitalization of New Plans............................................................................................622 Predatory Pricing or Low-Balling............................................................................................623 Overpricing...............................................................................................................................624 Unrealistic Projections..............................................................................................................625 Uncontrolled Growth................................................................................................................626 Improper IBNR Calculations and Accrual Methods................................................................627 Failure To Reconcile Accounts Receivable and Membership..................................................628 Overextended Management......................................................................................................628 Failure To Use Underwriting....................................................................................................628 Failure To Understand Sales and Marketing............................................................................629 Failure of Management To Understand Reports......................................................................629 Failure To Track Medical Costs and Utilization Correctly......................................................630 Systems Inability To Manage the Business..............................................................................630 Failure To Educate and Reeducate Providers...........................................................................631 Failure To Deal with Difficult or Noncompliant Providers......................................................631 Conclusion................................................................................................................................632 PART V-FINANCE AND UNDERWRITING.......................................................................633 CHAPTER 40-OPERATIONAL FINANCE AND BUDGETING......................................635 Dale F. Harding Background................................................................................................. 535 Financial Statement Components......................................................................................636 Table of Contents xvii Regulatory Reporting Considerations.......................................................................................644 Budgeting and Financial Forecasting.......................................................................................646 Conclusion................................................................................................................................647 CHAPTER 41-TAXATION OF MANAGED HEALTH CARE PLANS............................648 Terry A. Jacobs and Phillip G. Royalty Health Maintenance Organizations...........................................................................................648 Additional Types of Managed Care Organizations..................................................................655 Participation of Tax Exempt Hospitals in Taxable MCOs.......................................................657 Conclusion................................................................................................................................657 CHAPTER 42-ACTUARIAL SERVICES IN AN INTEGRATED DELIVERY SYSTEM.............................................................................................................659 Stephen M. Cigich Identifying Opportunities..........................................................................................................660 Creating Incentive Structures...................................................................................................664 Measuring Results....................................................................................................................665 Conclusion................................................................................................................................665 CHAPTER 43-RATING AND UNDERWRITING...............................................................667 Stephen M. Cigich Rating versus Underwriting......................................................................................................668 Rate Structure Development.....................................................................................................668 Underwriting.............................................................................................................................675 Conclusion................................................................................................................................677 CHAPTER 44--OPERATIONAL UNDERWRITING IN MANAGED CARE ORGANIZATIONS________________________________________...............................679 Gregory J. Lippe Historical Overview..................................................................................................................679 Sales and Underwriting Collaboration......................................................................................680 Management Information System.............................................................................................680 Major Risk Factors...................................................................................................................681 Underwriting as an Internal Control.........................................................................................683 Employer Group Underwriting.................................................................................................683 Key Employer Group Data.......................................................................................................685 Market Factors and Trends.......................................................................................................686 Community Rating Methodologies...........................................................................................686 Underwriting Principles............................................................................................................694 xviii The Managed Health Care Handbook Effective Underwriting: Lessons Learned................................................................................697 Conclusion................................................................................................................................699 PART VI-SPECIAL MARKET SEGMENTS.......................................................................701 CHAPTER 45-THE FEDERAL EMPLOYEES HEALTH BENEFIT PROGRAM AND MANAGED CARE..................................................................................................................703 Joel L. Michaels and Christine C. Rinn The Application Process...........................................................................................................704 Premium Contribution and Benefit Design..............................................................................704 Premium Rating under the FEHBP...........................................................................................705 OPM Audits and Appeals.........................................................................................................708 FEHBP and False Claims Liability...........................................................................................711 Miscellaneous Contracting Issues.............................................................................................712 Conclusion................................................................................................................................713 CHAPTER 46-MEDICARE AND MANAGED CARE........................................................715 Carlos Zarabozo and Jean D. LeMasurier TGIF (The Government Is Frightening) Unless You Know Your Acronyms..........................715 Understanding the Adjusted Average Per Capita Cost.............................................................716 The Adjusted Community Rate/APR Comparison...................................................................717 What If You Make a Mistake in Computing the ACR/APR?..................................................718 A Little Bit of History...............................................................................................................719 The Requirements To Obtain a TEFRA Contract....................................................................722 Flexibility in Contracting..........................................................................................................724 Which Office Does What, Where To Write, and Whom To Call.............................................725 The Steps of the Contracting Process.......................................................................................726 Beneficiary Rights and Responsibilities...................................................................................727 What Is Different about Having a Medicare Member?............................................................727 Whatever Happened to Big Brother?........................................................................................729 Alternatives to Risk Contracting for the Risk Averse..............................................................730 Medicare s Dual Option Strategy Shifts to Medicare Choices.................................................730 Medicare Managed Care (The HMO Model)-1985-1995.....................................................731 Conclusion................................................................................................................................737 CHAPTER 47-MEDICARE RISK PLANS: THE HEALTH PLAN S VIEW...................741 Roger S. Taylor and Craig Schub The Active Elderly........................................................................................ 741 Health Care Options for Seniors.......................................................................................742 The Demographic Imperative...........................................................................................742 Becoming a Medicare Risk Contractor..................................................... 745 Table of Contents xix Preparing the Delivery System.................................................................................................749 Working with Special Populations...........................................................................................753 The Government As a Payer and a Partner..........................................................»....................757 Future Trends............................................................................................................................759 CHAPTER 48-MEDICAID MANAGED CARE...................................................................761 Robert E. Hurley, Leonard Kirschner, and Thomas W. Bone Background and History...........................................................................................................761 Medicaid and its Beneficiaries..................................................................................................765 Models and Approaches to Managed Care...............................................................................767 Impacts of Managed Care.........................................................................................................769 Operational Issues for the Medicaid Product Line...................................................................770 Future Trends............................................................................................................................775 Conclusion................................................................................................................................777 CHAPTER 49-CHAMPUS AND THE DEPARTMENT OF DEFENSE MANAGED CARE PROGRAMS.........................................................................................779 John F. Boyer and Larry Sobel Legal Authority and Responsibilities.......................................................................................780 Medical Benefits Program........................................................................................................780 Program Funds..........................................................................................................................780 CHAMPUS Benefit Coverage..................................................................................................781 CHAMPUT Managed Care Demonstrations............................................................................781 The TRICARE Program...........................................................................................................784 Comparison with Medicare.......................................................................................................786 Conclusion................................................................................................................................787 CHAPTER 50-HEALTH MAINTENANCE ORGANIZATIONS IN RURAL MARKETS..........................................................................................................788 Tracey Thompson Turner, Norman C. Payson, and Richard B. Salmon Historie, Demographic, and Geographie Barriers....................................................................789 Competition, Physician Supply, and Hospital Capacity...........................................................790 Regulatory Factors....................................................................................................................791 Conquering the Barriers to Rural HMO Development.............................................................791 Selecting the Right HMO Model for Rural Markets................................................................792 Developing Rural Provider Networks......................................................................................792 Integrated Health Care Delivery Systems.................................................................................795 Marketing Strategies for Rural HMOs.....................................................................................796 Balancing the Economic Equation............................................................................................797 MaineCare: A Case Study of the Uninsured Market................................................................799 Conclusion................................................................................................................................799 xx The Managed Health Care Handbook CHAPTER 51-MANAGED CARE DENTAL BENEFITS...................................................802 Fred L. Horowitz The Dental Delivery System.....................................................................................................804 Recruiting.................................................................................................................................804 Credentialing.............................................................................................................................804 Compensation...........................................................................................................................805 Utilization Review....................................................................................................................805 Specialty Care...........................................................................................................................806 Accreditation.............................................................................................................................806 Conclusion................................................................................................................................806 CHAPTER 52-WORKERS COMPENSATION: TOWARD COMPREHENSIVE MEDICAL EVENT MANAGEMENT.................................................................................808 Gregory L. Johnson and Edward H. Lipson The Language of Change..........................................................................................................808 Workers Compensation: The Origin ofthe Social Contract...................................................809 Initial Efforts at Cost Containment...........................................................................................810 Key Success Factors for HMOs in Workers Compensation...................................................811 The Employer Perspective: Changing the Corporate Culture..................................................813 The Next Step for Employers: Comprehensive Medical Events Management........................813 Conclusion................................................................................................................................814 PART VII-REGULATORY AND LEGAL ISSUES.............................................................817 CHAPTER 53-STATE REGULATION OF MANAGED CARE........................................819 Garry Carneal State Oversight: The Regulatory Process.................................................................................820 Anti-Managed Care Legislation...............................................................................................828 Insurance Reform Initiatives.....................................................................................................831 Regulation by Market Segments...............................................................................................832 The State Experience................................................................................................................833 CHAPTER 54-FEDERAL QUALIFICATION: A FOUNDATION FOR THE FUTURE................................................................................................................835 Christine C. Boesz Federal Qualification................................................................................ ...835 Medicare Contracting............................................................................. g36 The Application: Overview.................................................................. 836 The Federal Review: What To Expect........................................................ .... ... .. . 846 After Qualification..................................................................... 847 Conclusion........................................................................ 847 Table of Contents xxi CHAPTER 55-LEGAL ISSUES IN PROVIDER CONTRACTING...................................849 Mark S. Joffe General Issues in Contracting...................................................................................................850 Contract Structure.....................................................................................................................851 Common Clauses, Provisions, and Key Factors.......................................................................852 Conclusion................................................................................................................................863 Appendix 55-A-Sample Physician Agreement......................................................................864 Appendix 55-B-Sample Hospital Agreement........................................................................876 CHAPTER 56-LEGAL ISSUES IN INTEGRATED DELIVERY SYSTEMS...................887 Jerry R. Peters Definitions................................................................................................................................887 IDS Models...............................................................................................................................888 Governance...............................................................................................................................889 Committees...............................................................................................................................892 Delegated Board Authority.......................................................................................................893 Advisory Committees...............................................................................................................894 Conflict of Interest Policy.........................................................................................................894 Tax Exemption and Charitable Benefit....................................................................................895 Physician Compensation...........................................................................................................897 Practice Acquisitions/Valuation...............................................................................................898 Medicare/Medicaid Provider Numbers.....................................................................................898 Antitrust Law............................................................................................................................899 Independent Contractor Status..................................................................................................900 Covenants Not To Compete......................................................................................................904 Conclusion................................................................................................................................904 CHAPTER 57-ANTITRUST IMPLICATIONS OF PROVIDER EXCLUSION..............906 William G. Kopit and Alexandre B. Bouton The Importance of Market Power.............................................................................................906 The Relevant Market................................................................................................................908 Exclusive Dealing Arrangements.............................................................................................908 The Importance of Efficiencies................................................................................................910 Antitrust Standing.....................................................................................................................910 Group Boycotts: Exclusion of Providers..................................................................................912 State AWP Legislation.............................................................................................................918 Conclusion................................................................................................................................923 CHAPTER 58-MEDICAL MANAGEMENT AND LEGAL OBLIGATIONS TOMEMBERS........................................................................................................................930 James L. Touse Obligations To Conduct Medical Management Activities.......................................................930 Contractual Actions Related to Medical Management Activities............................................932 xxii The Managed Health Care Handbook Negligence Actions Related to Medical Management Activities.............................................935 Recommendations.....................................................................................................................939 Conclusion................................................................................................................................942 CHAPTER 59-ERISA AND MANAGED CARE..................................................................944 Jacqueline M. Saue and Gregg H. Dooge Documentation, Reporting and Disclosure Requirements........................................................944 Plan Design Considerations......................................................................................................946 Amendment of Plans.................................................................................................................949 Fiduciary Duties........................................................................................................................950 Challenges to Benefit Denials..................................................................................................951 ERISA s Civil Enforcement Scheme and Remedies................................................................952 ERISA Preemption...................................................................................................................953 Administrative Services Only Contracts..................................................................................959 AWPLaws................................................................................................................................960 Capitated Administrative Services Only Contracts..................................................................962 Conclusion................................................................................................................................963 CHAPTER 60-EFFECTIVE UTILIZATION OF LEGAL SERVICES______________967 James L Touse The Role of Legal Counsel.......................................................................................................967 Determining the Likely Demand for Legal Services................................................................968 Assessing Available Resources................................................................................................969 Budgeting for the Cost of Providing Services to Clients..........................................................970 Managing the Provision of Services to Clients.........................................................................971 Conclusion................................................................................................................................975 AFTERWORD-WHAT MIGHT THE FUTURE HOLD?_________________________976 Frederick B. Abbey, Garry Carneal, Peter D. Fox, Robert E. Hurley, Peter R. Kongstvedt, Jerry R. Peters, Jacqueline M. Saue, Craig Schub, Roger Taylor, and Carlos Zarabozo The Federal Sector....................................................................................................................976 SafeHarbors................................................................................ 981 erisa........................................................iZZZZZZ!ZZIZZZ!ZZZ!Z982 State Regulatory Issues.................................................................................... 982 Legal Issues Affecting Integrated Delivery Systems................................................................984 The Provider World......................................................................... 984 The Payor World............................................ZZZZZZZZ!!Z!!Z T!!!T. ! .» .985 Medical Management................................................................ 985 Conclusion................................................................................. 985 Table of Contents xxiii GLOSSARY OF TERMS AND ACRONYMS.........................................................................987 INDEX .......................................................................................................................................1005 ABOUT THE EDITOR.............................................................................................................1045
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spellingShingle	The managed health care handbook Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management 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 Peter R. Kongstvedt [ed.]
title_fullStr	The managed health care handbook Peter R. Kongstvedt [ed.]
title_full_unstemmed	The managed health care handbook Peter R. Kongstvedt [ed.]
title_short	The managed health care handbook
title_sort	the managed health care handbook
topic	Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Managed Care (DE-588)4461436-6 gnd
topic_facet	Managed Care Programs organization & administration United States Managed care plans (Medical care) United States Management Managed Care USA
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