The Managed Health Care Handbook

Front Cover
Peter Reid Kongstvedt
Jones & Bartlett Learning, 2001 - Medical - 1408 pages
2 Reviews
This thoroughly revised and updated book provides a strategic and operational resource for use in planning and decision-making. The Handbook enables readers to fine-tune operation strategies by providing updates on critical managed care issues, insights to the complex managed care environment, and methods to gain and maintain cost-efficient, high quality health services. With 30 new chapters, it includes advice from managers in the field on how to succeed in every aspect of managed care including: quality management, claims and benefits administration, and managing patient demand. The Handbook is considered to be the standard resource for the managed care industry.
  

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Contents

Ibid 17 K N Lohr et al Chronic Disease in a General Adult
13
CHAPTER 3TYPES OF MANAGED CARE ORGANIZATIONS
28
CHAPTER 4INTEGRATED HEALTH CARE DELIVERY SYSTEMS
42
CHAPTER 5ELEMENTS OF THE MANAGEMENT CONTROL
73
Management Control Structure
79
PART IITHE HEALTH CARE DELIVERY SYSTEM
91
CHAPTER 8COMPENSATION OF PRIMARY CARE PHYSICIANS
110
Withholds and RiskBonus Arrangements
118
Conclusion
633
CHAPTER 34MEMBER BEHAVIOR CHANGE
637
PART IVOPERATIONAL MARKETING AND MANAGEMENT
655
CHAPTER 36INFORMATION SYSTEMS AND ELECTRONIC COMMERCE
676
Clinical Decision Support Systems
682
Organizational Structure of Information Technology Departments
689
CHAPTER 37ELECTRONIC COMMERCE IN MANAGED HEALTH CARE
694
CHAPTER 38CLAIMS AND BENEFITS ADMINISTRATION
710

Full Professional Risk Capitation
124
A Special Requirement for Reimbursement When Coinsurance Is in Place
131
Health Care Financing Administration HCFA
133
Problems with FFS in Managed Health Care Plans
137
Civil Liability in Physician Compensation Programs
143
Pay Plan Design Issues
150
Measurement Issues
156
Designing Performance Measures
162
Categories for Evaluation of Physician Performance
168
Conclusion
174
CHAPTER 11CONTRACTING AND REIMBURSEMENT
175
Organizational Models for Capitating Specialty Services
184
CHAPTER 12NEGOTIATING AND CONTRACTING WITH
191
Outpatient Procedures
204
Industry Report Academic Medical Centers and Managed Care Uneasy
227
Community Health Centers
230
Formation of CHCSponsored Health Plans
237
Conclusion
243
Network Delivered Services
251
PART IIIMEDICAL MANAGEMENT
265
The Role of Physicians in Care Management
272
Defining the Future State of Care Management
278
CHAPTER 17PRIMARY PREVENTION IN MANAGED HEALTH CARE
284
CHAPTER 18MANAGING BASIC MEDICALSURGICAL UTILIZATION
294
CHAPTER 19CLINICAL SERVICES REQUIRING AUTHORIZATION
331
CHAPTER 20ANCILLARY DIAGNOSTIC AND THERAPEUTIC SERVICES
344
CHAPTER 21THE EMERGENCY DEPARTMENT AND MANAGED CARE
351
CHAPTER 22CASE MANAGEMENT AND MANAGED CARE
371
CHAPTER 23FUNDAMENTALS AND CORE COMPETENCIES
402
Important Linkages
408
CHAPTER 25MANAGED BEHAVIORAL HEALTH CARE
451
Benefit Plan Design
461
Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives
467
BH Information Systems
473
CHAPTER 26HOME HEALTH CARE
480
CHAPTER 27SUBACUTE CARE WITHIN THE MANAGED
496
Conclusion
504
LINKING OUTCOMES
521
Application
528
CHAPTER 30QUALITY MANAGEMENT IN MANAGED CARE
539
CHAPTER 31MEASURING AND MANAGING OF CLINICAL OUTCOMES
556
CHAPTER 32USING DATA AND PROVIDER PROFILING IN MEDICAL
579
Data Elements and the Application of Reports
586
Provider Profiling
595
Selection of a Profiling Vendor
610
CHAPTER 33PHYSICIAN BEHAVIOR CHANGE IN MANAGED
618
General Approaches to Changing Behavior
626
CHAPTER 39OTHER PARTY LIABILITY AND COORDINATION
755
Organizational Placement with Dedicated Staff
761
Outsourcing OPL
768
CHAPTER 41SALES AND MARKETING IN MANAGED
798
An Overview of the Managed Care Market
804
How the Managed Care Team Delivers
812
How These Trends Impact Employers Both Large and Small
818
Future Trends
824
CHAPTER 44ACCREDITATION AND PERFORMANCE MEASUREMENT
849
The Utilization Review Accreditation Commission
861
Conclusion
869
CHAPTER 46COMMON OPERATIONAL PROBLEMS IN MANAGED
886
Du Davis K Collins K S and Morris C 1991 Managed Care
896
Conclusion
903
CHAPTER 48TAX ISSUES RELATING TO HEALTH RISKBEARING ENTITIES
922
Health Maintenance Organizations
935
CHAPTER 49UNDERWRITING AND RATING FUNCTIONS
945
Conclusion
951
CHAPTER 51ACTUARIAL SERVICES IN AN INTEGRATED DELIVERY SYSTEM
971
CHAPTER 52OPERATIONAL UNDERWRITING IN MANAGED CARE
977
Employer Group Underwriting
983
Underwriting Principles
994
CHAPTER 53PROVIDER EXCESS LOSS COVERAGE
1000
PART VISPECIAL MARKET SEGMENTS
1041
CHAPTER 55MEDICARE AND MANAGED CARE
1060
THE HEALTH PLANS VIEW
1086
CHAPTER 57MEDICAID MANAGED CARE
1105
CHAPTER 58CHAMPUS AND THE DEPARTMENT OF DEFENSE
1124
The TRICARE Program
1130
CHAPTER 60MANAGED CARE DENTAL BENEFITS
1146
PART VIIREGULATORY AND LEGAL ISSUES
1163
ATTACKING
1203
Physician Unions
1211
Conclusion
1219
Negligence Actions Related to Medical Management Activities
1229
Recommendations
1235
CHAPTER 65LEGAL ISSUES IN INTEGRATED DELIVERY SYSTEMS
1241
CHAPTER 66ERISA AND MANAGED CARE
1257
CHAPTER 67THE HEALTH INSURANCE PORTABILITY
1285
New Access Initiatives
1293
HIPAA Administration and Enforcement
1299
CHAPTER 68HEALTH PLAN CORPORATE COMPLIANCE PROGRAMS
1306
CHAPTER 69STATE REGULATION OF MANAGED CARE
1322
EPILOGUEMANAGED HEALTH CARE AT THE MILLENNIUM
1346
GLOSSARY OF TERMS AND ACRONYMS
1357
INDEX
1378
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