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Managed Health Care [“MHC”]: A Stakeholder’s
Perspective
OVERVIEW OF MANAGED CARE
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
TYPES OF MANAGED CARE
ORGANIZATIONS
Types of MCOs
HMO Models
INTEGRATED HEALTH CARE
DELIVERY SYSTEMS
Highly Integrated Delivery Systems
Market Characteristics
Types of IDSs
IPAs
PPMCs
Consolidated Medical Groups
PHOs
MSOs
Foundations
Staff Model
Physician Ownership Model
PSOs
Virtual Integration
Global Capitation
Acquisition of Physician Practices
Legal Pitfalls for IDSs
Critical Success Factors for IDSs
ELEMENTS OF THE MANAGEMENT
CONTROL
AND GOVERNANCE STRUCTURE
Board of Directors
Key Management Positions
Committees
Management Control Structure
Conclusion
Study Questions
EXAMINING COMMON ASSERTIONS
ABOUT MANAGED CARE
Managed Care Myths
PRIMARY CARE IN MANAGED
HEALTH CARE PLANS
Introduction and
Definitions
Recruiting
Nonphysician or Midlevel Practitioners
Types of Contracting Situations
Credentialing
The National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
Compensation
Orientation
Network Maintenance
Internet-Based Activities
Removing Physicians from the Network
COMPENSATION OF PRIMARY CARE
PHYSICIANS
IN MANAGED HEALTH CARE
Basic Models of Reimbursement
Capitation
Withholds and
Risk/Bonus Arrangements
Capitation Pools for
Referral and Institutional Services
Full Professional Risk
Capitation
Reasons To Capitate
Problems with
Capitation Systems
Effect of Benefits
Design on Reimbursement
Fee for Service
A Special Requirement
for Reimbursement When Coinsurance Is in Place
Out-of-Network Fees
Discounts, Negotiated
Fee Schedules, 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
CONTRACTING AND REIMBURSEMENT
OF SPECIALTY PHYSICIANS
How
Many Specialty Care Physicians?
Primary versus
Specialty Care Designation
Credentialing
Types of Reimbursement
Arrangements
Organizational Models
for Capitating Specialty Services
Common Problems with
Specialty Capitation
Other Forms of
Specialty Physician Reimbursement
Risk and Reward
NEGOTIATING AND CONTRACTING
WITH HOSPITALS, INSTITUTIONS, AND ANCILLARY SERVICES
Hospital Network Development
Types of Reimbursement
Arrangements
Outpatient Procedures
Ancillary Services
Conclusion
Study Questions
CARE MANAGEMENT AND CLINICAL
INTEGRATION COMPONENTS
The Context for
Advanced
Defining Advanced
Integrating the
Components
The Role of Physicians
Building an Advanced
Care Management System: A Typical Process
Defining the Future
State of Care Management
MANAGING BASIC
MEDICAL-SURGICAL UTILIZATION
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 Physician in Specialty Services
Management
Single Visit
Authorizations Only
Specialty Physicians
As Primary Physicians
Prohibition of
Secondary Referrals and Authorizations
Review of Reasons for
Referral
Institutional
Utilization Management
Common Methods for
Managing Utilization
Alternatives to Acute
Care Hospitalization
Case Management
CLINICAL SERVICES REQUIRING
AUTHORIZATION
Definition of Services
Requiring Authorization
Definition of 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-Physician
Based Authorization Systems
Non-Physician-Based
Authorization Systems
CASE MANAGEMENT AND MANAGED
CARE
The Case Manager's
Role
Patient Profile: Not
Every Case Needs a Case Manager
On-Site versus
Telephone-Based 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
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