Essentials of Managed Health Care, Volume 1

Front Cover
Peter Reid Kongstvedt
Jones & Bartlett Learning, Jan 1, 2001 - Managed care plans (Medical care) - 883 pages
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Contents

CHAPTER 2TYPES OF MANAGED CARE ORGANIZATIONS
17
CHAPTER 3INTEGRATED HEALTH CARE DELIVERY SYSTEMS
31
CHAPTER 4ELEMENTS OF THE MANAGEMENT CONTROL
63
Management Control Structure
70
Conclusion
79
CHAPTER 6PRIMARY CARE IN MANAGED HEALTH CARE PLANS
85
CHAPTER 7COMPENSATION OF PRIMARY CARE PHYSICIANS
103
Withholds and RiskBonus Arrangements
110
Desired Characteristics of Provider Profiles
397
Selection of a Profiling Vendor
409
Conclusion
416
General Approaches to Changing Behavior
427
Conclusion
434
CHAPTER 20INFORMATION SYSTEMS IN MANAGED HEALTH CARE PLANS
441
CHAPTER 21CLAIMS AND BENEFITS ADMINISTRATION
461
CHAPTER 22MEMBER SERVICES AND CONSUMER AFFAIRS
507

Full Professional Risk Capitation
117
Fee for Service
123
Problems with FFS in Managed Health Care Plans
130
Civil Liability in Physician Compensation Programs
136
How Many Specialty Care Physicians?
142
Organizational Models for Capitating Specialty Services
150
Study Questions
156
CHAPTER 9NEGOTIATING AND CONTRACTING WITH
157
Outpatient Procedures
170
PART IIIMEDICAL MANAGEMENT
177
The Role of Physicians in Care Management
185
Conclusion
192
CHAPTER 12CLINICAL SERVICES REQUIRING AUTHORIZATION
235
CHAPTER 13CASE MANAGEMENT AND MANAGED CARE
249
CHAPTER 14FUNDAMENTALS AND CORE COMPETENCIES
281
Important Linkages
287
CHAPTER 15PRESCRIPTION DRUG BENEFITS IN MANAGED CARE
293
CHAPTER 16MANAGED BEHAVIORAL HEALTH CARE
332
Benefit Plan Design
342
Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives
348
BH Information Systems
354
CHAPTER 17QUALITY MANAGEMENT IN MANAGED CARE
361
CHAPTER 18USING DATA AND PROVIDER PROFILING IN MEDICAL
379
Data Elements and the Application of Reports
385
General Types of Reports
391
CHAPTER 23SALES AND MARKETING IN MANAGED
535
An Overview of the Managed Care Market
541
How the Managed Care Team Delivers
549
CHAPTER 24THE EMPLOYERS VIEW OF MANAGED
555
CHAPTER 25THE IMPACT OF CONSUMERISM ON MANAGED HEALTH CARE
566
CHAPTER 26ACCREDITATION AND PERFORMANCE MEASUREMENT
587
The Utilization Review Accreditation Commission
600
Conclusion
608
Conclusion
626
CHAPTER 29UNDERWRITING AND RATING FUNCTIONS
643
Conclusion
653
CHAPTER 31MEDICAID MANAGED CARE
684
PART VIREGULATORY AND LEGAL ISSUES
703
CHAPTER 33LEGAL LIABILITY RELATED TO MEDICAL
743
Negligence Actions Related to Medical Management Activities
751
Recommendations
758
CHAPTER 34THE HEALTH INSURANCE PORTABILITY
764
New Access Initiatives
772
HIPAA Administration and Enforcement
778
Study Questions
784
Outlook
820
GLOSSARY OF TERMS AND ACRONYMS
833
INDEX
855
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