Essentials of Managed Health Care / Edition 5

by Peter R. Kongstvedt

Overview

This is the most comprehensive and widely-used textbook on managed care. The Fifth Edition of this authoritative text provides practical knowledge and advice to help you master the complexities of managed care today. With learning objectives for each chapter, a glossary of terms and common acronyms, study questions, tables and charts, and the expert guidance of Peter R. Kongstvedt, Essentials of Managed Health Care is a perfect introduction to the key concepts of managed care. This revision includes updates to all chapters, as well as new sections on the most relevant topics in managed care today such as: pay for performance, consumer-directed healthcare plans, payor/provider collaboration, and electronic enablement of clinical activities supported by health plans. The chapter on Medicare has been completely revised to reflect the recent Medicare Prescription Drug Act.

Product Details

ISBN-13:	9780763739836
Publisher:	Jones & Barlett Learning
Publication date:	03/28/2007
Edition description:	5E
Pages:	841
Product dimensions:	7.04(w) x 10.05(h) x 1.67(d)

About the Author

Kongstvedt, Peter R., MD, FACP (Ernst & Young LLP)

Table of Contents

Contents: INTRODUCTION TO MANAGED HEALTH CARE * AN OVERVIEW OF MANAGED CARE* Study Objectivies* Introduction* Managed Care: The Early Years (Pre-1970)* The Adolescent Years: 1970-1985* Managed Care Comes of Age: 1985 to the Present* Future Issues Facing Managed Care* Conclusion* Study Questions* CHAPTER 2--TYPES OF MANAGED CARE ORGANIZATIONS* Study Objectives* Types of MCOs* HMO Models* Conclusion* Sudy questions* CHAPTER 3--INTEGRATED HEALTH CARE DELIVERY SYSETMS* Study Objectives* Introduction* Highly Integrated Delivery Systems* Market Characteristics* Types of ISDs* IPAs* PPMCs* Consolidated Medical Groups* PHOs* MSOs* Foundations* Staff Model* Pysician Ownership Model* PSOs* Virtual Integration* Global Capitation* Acquisition of Physician Practices* Legal Pitfalls for IDSs* Critical Success Factors for IDSs* Conclusion* Study Questions* CHAPTER 4--ELEMENTS OF THE MANAGEMENT CONTROL AND GOVERNANACE STRUCTURE* Study Objectives* Board of Directors* Key Management Positions* Committees* Management Control Structure* Conclusion* Study Questions* CHAPTER 5--EXAMINING COMMON ASSERTIONS ABOUT MANAGED CARE* Study Objectives* Introduction* Managed Care Myths* Conclusion* Study Questions* PART 2--THE HEALTH CARE DELIVERY SYSTEM* CHAPTER 6--PRIMARY CARE IN MANAGED HEALH CARE PLANS* Study Objectives* Introduction and Definitions* Recruiting* Nonphysician or Midlevel Practioners* Types of Contracting Situations* Credentialing* The National Practioner Data Bank* Healthcare Integrity and Production Data Bank* Compensation* Network Maintenance* Internet-Based Activities* Removing Phsicians from the Network* Conclusion* Study Questions* CHAPTER 7--COMPENSATION OF PRIMARY CAREPHYSICIANS IN MANAGED HEALTH CARE* Study Objectives* Introduction* Basic Models of Reimbursment* Capitation* Witholds and Risk/Bonus Arrangements* Capitation Pools for Referral and Institutional Services* Full Professional Risk Capitation* Reasons to Capitate* Problems with the Capitation Systems* Effect of Benefits Design on reimbursment* Fee for Service* A Special Requirement for Reimbursment When Coinsurance Is in Place* Out-of-Network Fees* Discounts, Negoitated Fee Scheduals, Fee Maximums, or Fee Allowances* Relative Value Scales* Global Fees* Problems with FFS in Managed Health Care Plans* Legislation and Regulation Applicable to Physician Incentive Programs* Civil Liability in Physician Compensation Programs* Conclusion* Study Questions* CHAPTER 8--CONTRACTING AND REIMBURSMENT OF SPECIALTY PHYSICANS* Study Objectives* Introduction* How Many Specialty Care Physicians? * Primary versus Specialty Care Designation* Credentialing* types of Reimbursment Arrangements* Organizational Models for Capitating Speciatly Services* Common Problems with Speciatly Capitation* Other Forms of Speciatly Physician Reimbursment* Risk and Reward* Conclusion* Study Questions* CHAPTER 9--NEGOTIATING AND CONTRACTING WITH HOSPITALS, INSTITUTIONS, AND ANCILLARY SERVICES* Study Objectives* Introduction* Hospital network Development* Types of reimbursment Arrangements* Outpatient procedures* Ancillary Services* Conclusion* Study Questions* PART 3--MEDICAL MANAGEMENT* CHAPTER 10--CARE MANAGEMENT AND CLINICAL INTEGRATION COMPONENTS* Study Objectives* The Context for Advanced Care Management* Defining Advanced Care Management* Integrating the Components of Care Management* The Role of Physicians in Care Management* Building an Advanced Care Management System: A Typical Process* Defining the Future State of Care Management* Conclusion* Study Questions* Appendix 10--A--Description of the Components of the Advanced Care Management System* CHAPTER 11--MANAGING BASIC MEDICAL-SURGICAL UTILIZATION* Study Objectivies* Introduction* Return on Investment in Management of Medical Costs* Demand Management* Measurements of Utilization* Variations in Utilization* The Role of Electronic Commerce* Authorization or Denial of Payment for Services* Managing Utilization of Specialty Services* The Role of the Primary Care Physicians in Specialty Services Management* Single Visit Authorizations Only* Specialty Physicians As Primary Physicians* Prohibition of Secondary Referrals and Authorazitions* Review of Reasons for Refferal* Institutional Utilization Management* Common Methods for Managing Utilization* Alternatives to Acute Care Hospitalization* Case Management* Conclusion* Study Questions* CHAPTER 12--CLINICAL SERVICES REQUIRING AUTHORIZATION* Study Objectives* Definintion of Services Requiring Authorization* Definition Who Can Authorize Services* Claims Payment* Categories of Authorization* Staffing* Common Data Elements* Methods of Data Capture and Authorization Issuance* Authorization System Reports* Open Access HMOs* Specialty-Physicians Based Authorization Systems* Non-Physician-Based Authorization Systems* Conclusion* Study Questions* CHAPTER 13--CASE MANAGEMENT AND MANAGED CARE* Study Objectives* The Case Manager’ s Role* Patient Profile: Not Every Case Needs a Case Manager* On-Site versus Telephone-Based Authorization Case Management* Case Managers in Managed Care* Case Management Work Format and Process* Utilization Review: Preadmission and Concurrent Review and Case Management* Preadmission and Concurrent Review Case Management Reports* Red Flags: Indicators for Case Management* Timing Case Management Intervention* Beyond the Case Management Basics* A Long-Term Solution to a Long-Term Problem* Study Questions* CHAPTER 14--FUNDAMENTALS AND CORE COMPETENCIES OF DISEASE MANAGEMENT* Study Objectives* Definition and Clarification* Barriers and Drivers for Disease Management Programs* Important linkages* Support from Electronic Commerce* Conclusion* Study Questions* CHAPTER 15--PRESCRIPTION DRUG BENEFITS IN MANAGED CARE* study Objectives* Financial Basis for Pharmacy Benefit Management* Pharmacy Program Cost Components* Principles of Pharmacey Benefit Management* Managing the Supply and Demand* Pharmacy Information Systems and Health Informatics* Pharmacy Benefit Management Companies (PBMs)* Pharmacy Benefit Management Program Components* Physician Provider Network* Pharmacy Provider Network* Pharmacy Provider Audits* Drug Formulary Management* Pharmaceutical Manufacturer Discount and Rebate Contracts* Prescription Patient Copayments Role of Pharmacy Programs in Disease Management and Quality Improvement Programs* Quality Improvements in Pharmacy Benefit Management*Measuring Pharmacy Benefit Management Program Preformance* Future Changes in Pharmacy Benefit Management* Conclusion* Study Questions* CHAPTER 16--MANAGED BEHAVIORAL HEALTH CARE AND CHEMICAL DEPENDENCY SERVICES* Study Objectives* Introduction* Historical Perspective* Key Treatment Principles* Benefit Plan Design* Utilization Management* Channeling Mechanisms* Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives* Quality Assurance* BH Information Systems* Public/Private Systems Integration* Emerging Issues* Conclusion* Study Questions* CHAPTER 17--QUALITY MANAGEMENT IN MANAGED CARE* Study Objectives* Introduction* Traditional Quality Assurance* Components of a Quality Management Program* A Process Model for a Modern Quality Management Program* Conclusion* Study Questions* CHAPTER 18--USING DATA AND PROVIDER PROFILING IN MEDICAL MANAGEMENT* Study Objectives* Introduction* Use of Data and Information in Medical Management* Patient data Confidentialty* Data Elements and the Application of Reports* Provider Profiling* Desired Characteristics of Provider Profiles* Selection of a Profiling Vendor* The Future of Data Use* Conclusion* Study Questions* CHAPTER 19--PHYSICANS BEHAVIOR CHANGE IN MANAGED HEALTH CARE* Study Objectives* Introduction* General Aspects of Physician Practice Behavior* General Approaches to Changing Behavior* Addressing Nonvompliance by Individual Physicians* Conclusion* Study Questions* PART 4--OPERATIONAL MARKETING AND MANAGEMENT* CHAPTER 20--INFORMATION SYSTEMS IN MANAGED HEALTH CARE PLANS* Study Objectives* Introduction* Core Managed Care Information System* Electronic Data Interchange* Privacy and confidentiality under HIPAA* Value-Added Services--The Next Generation* HEDIS* Information Services Department* Conclusion* Study Questions* CHAPTER 21--CLAIMS AND BENEFITS ADMINSTRATION* Study Objectives* Introduction* Claims: Positioning, Purpose, and Opportunities* Organizational Structure and Staffing* Claims Operations Management* Productivity* Turn Around Time* Staff Training and Development* Quality* Police and Procedure* Coordination with Other Departments/Functions* Systems Support* Claims Business Functions* Other Issues* Conclusion* Study Questions* CHAPTER 22--MEMBER SERVICES AND CONSUMER AFFAIRS* Study Objectives* Provision of General Information* Conclusion* Study Questions* CHAPTER 23--SALES AND MARKETING IN MANAGED HEALTH CARE PLANS: THE PROCESS OF DISTRIBUTION* Study Objectives* What Managed Care Organizations Deliver* Challenges Facing MCOs* An Overview of the Managed Care Market* Key Decision Makers and Influencers in the Managed Care Distribution Process* The Managed Care Sales Process* How the Managed Care Team Delivers* The Management of Sales and marketing Professioals* Conclusion* Study Questions* CHAPTER 24--THE EMPLOYER’ S VIEW OF MANAGED HEALTH CARE: SHOW ME THE VALUE* Study Objectives* Recent Managed Care Trends Affecting Employers* How These Trends Impact Employers Both Large and Small* The Large Group Employer: 5,000 Lives Plus* The Modrate Group Employer: 500--5,000 Lives* The Medium Group Employer: 50--500 Lives* The Small Group Employer: 0--50* How Employers Purchase Value (1988--1998)* Looking for Value : 2000 and Beyond* Future Trends* Conclusion* Study Quedtions* CHAPTER 26--ACCREDITATION AND PREFORMANCE MEASUREMENT PROGRAMS FOR MANAGED CARE ORGANIZATIONS* Study Objectives* Introduction* Oversight by Type of Organization* National Committee for Quality Assurance* The Utilization Review Accreditation Commission* Joint Commision on Accredation of Healt

Editorial Reviews

5 Stars! from Doody

This book provides a detailed description of the history and current trends in healthcare policy as they affect the development of managed healthcare in the United States. In addition, the operational, financial, legal, and regulatory issues affecting managed care systems and organizations are addressed. Potential sources of problems and specific solutions that could be used to abate the problems and enhance the functions and outcomes of managed healthcare are emphasized. This book is appropriately designed as a text for postgraduate study. It would be useful for students of healthcare administration, organizational design, and finance. However, it would also be of benefit to healthcare professionals who are likely to be employed by or working with managed healthcare organizations or systems. This second edition makes extensive use of current experience, data, and resources. The tables and exhibits are reflective of the latest information available on national and selected state/regional levels. The references and suggested additional readings are of recent vintage and enhance the expert resources available to the reader. The design is an educational one, with learning objectives heading each chapter, followed by study questions and references at the end of the chapter. This format assists the reader to focus on the essential content contained in each chapter. In addition, the glossary provided assists the reader with technical terms and the myriad of acronyms used throughout the text. This book is well designed and developed in an organized and logical manner. It is well worth consideration as a text for graduate study. Moreover, it would serve as an excellent basic referencetext for healthcare professionals working in today's changing healthcare environment.

Margaret M. Murphy

This is the latest edition of the editor's popular text, a companion to his now classic The Managed Health Care Handbook, 4th edition (Aspen Publishers, Inc. 2000). In this book he reviews key concepts of the evolving managed care system in America. The book is organized into six parts, and the editor offers a broad, if not deep, discussion of most relevant issues in managed care. The editor offers this work to provide the reader with a solid understanding of the fundamental concepts, purposes, organization, and function of managed healthcare. The book is geared toward physicians and others exploring the world of managed care and managers in any healthcare sector. It is appropriate for graduate students in healthcare administration. The content ranges far and wide in the managed care field. In Part I the basics of the managed care system are included, both facts and myths. In Part II contributors explore the organization and financing of healthcare delivery and in Part III they explain the various tactics used to manage the access to, cost of, and quality of healthcare. In Part IV details of the marketing and management for a managed care organization are presented. Part V is an illumination of recent trends in managing the care of Medicaid and Medicare patients. Finally, in Part VI contributors explore the current legal and regulatory environment of healthcare. In each chapter the reader is guided with study objectives, study questions, and an up-to-date bibliography. Chapters are cross-referenced to each other and to the parent text. There are black-and-white illustrations, useful tables and graphs, and a glossary of terms and acronyms. The editor describes theU.S. healthcare system as a "complexly adapting system." The information in this text is needed to reach beyond the notion of managed care as a "simplistic monolith," or as the final answer for our current dilemmas. This is a comprehensive primer on the subject of managed care. As with the other books in this series, in this new edition the editor once again strives to keep up with the fluid nature of managed care. His works have become the standard by which similar books will be measured.

Daniel K. Bixler

Provides practical knowledge and advice on the complexities of managed care. Part I overviews the history of managed health care and describes basic types of managed care plans and integrated health care delivery systems. Part II reviews basic provider sectors and how managed care works within them, and Part III addresses how managed care actually manages health care. Part IV looks at nonmedical operations of a health plan, and Part V covers Medicare and Medicaid. Part VI offers a brief overview of legal and regulatory topics. Learning features include chapter objectives, a glossary, and study questions. This is a companion to the parent text, . The editor is a partner in an international accounting and consulting firm. Annotation c. Book News, Inc., Portland, OR (booknews.com)

Booknews

Reviewer: Daniel K. Bixler, MD, MMM, FAAP (Creighton University Medical Center)
Description: This is the latest edition of the editor's popular text, a companion to his now classic The Managed Health Care Handbook, 4th edition (Aspen Publishers, Inc. 2000). In this book he reviews key concepts of the evolving managed care system in America. The book is organized into six parts, and the editor offers a broad, if not deep, discussion of most relevant issues in managed care.
Purpose: The editor offers this work to provide the reader with a solid understanding of the fundamental concepts, purposes, organization, and function of managed healthcare.
Audience: The book is geared toward physicians and others exploring the world of managed care and managers in any healthcare sector. It is appropriate for graduate students in healthcare administration.
Features: The content ranges far and wide in the managed care field. In Part I the basics of the managed care system are included, both facts and myths. In Part II contributors explore the organization and financing of healthcare delivery and in Part III they explain the various tactics used to manage the access to, cost of, and quality of healthcare. In Part IV details of the marketing and management for a managed care organization are presented. Part V is an illumination of recent trends in managing the care of Medicaid and Medicare patients. Finally, in Part VI contributors explore the current legal and regulatory environment of healthcare. In each chapter the reader is guided with study objectives, study questions, and an up-to-date bibliography. Chapters are cross-referenced to each other and to the parent text. There are black-and-white illustrations, useful tables and graphs, and a glossary of terms and acronyms.
Assessment: The editor describes the U.S. healthcare system as a "complexly adapting system." The information in this text is needed to reach beyond the notion of managed care as a "simplistic monolith," or as the final answer for our current dilemmas. This is a comprehensive primer on the subject of managed care. As with the other books in this series, in this new edition the editor once again strives to keep up with the fluid nature of managed care. His works have become the standard by which similar books will be measured.

Doody's Review Service