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Tables of Contents for The Managed Health Care Handbook
Chapter/Section Title
Page #
Page Count
About the Editor
xxiv
Contributors
xxv
Preface
xxix
Acknowledgments
xxxi
PART I---INTRODUCTION TO MANAGED CARE
1
90
An Overview of Managed Care
3
14
Peter D. Fox
Introduction
3
1
Managed Care: The Early Years (Pre-1970)
4
1
The Adolescent Years: 1970-1985
5
4
Managed Care Comes of Age: 1985 to the Present
9
4
Future Issues Facing Managed Care
13
2
Conclusion
15
2
Managed Care's Regulatory Evolution: Driving Change in the New Century
17
11
Frederick B. Abbey
Forces Driving Federal Health Policy
17
4
Major Areas of Policy Development
21
4
Outlook
25
3
Types of Managed Care Organizations
28
14
Eric R. Wagner
Types of MCOs
30
3
HMO Models
33
8
Conclusion
41
1
Integrated Health Care Delivery Systems
42
31
Peter R. Kongstvedt
David W. Plocher
Jean C. Stanford
Introduction
42
1
Highly Integrated Delivery Systems
43
1
Market Characteristics
44
1
Types of IDSs
45
1
IPAs
45
2
PPMCs
47
3
Consolidated Medical Groups
50
2
PHOs
52
4
MSOs
56
1
Foundations
57
1
Staff Model
58
1
Physican Ownership Model
59
1
PSOs
60
2
Virtual Integration
62
1
Global Capitation
62
2
Acquisition of Physician Practices
64
2
Legal Pitfalls for IDSs
66
2
Critical Success Factors for IDSs
68
3
Conclusion
71
2
Elements of the Management Control and Governance Structure
73
8
Peter R. Kongstvedt
Board of Directors
73
3
Key Management Positions
76
2
Committees
78
1
Management Control Structure
79
1
Conclusion
80
1
Examining Common Assertions about Managed Care
81
10
Richard I. Smith
Daniel Thornton
Terry Sollom
Introduction
81
1
Managed Care Myths
82
6
Conclusion
88
3
PART II---THE HEALTH CARE DELIVERY SYSTEM
91
174
Primary Care in Managed Health Care Plans
93
17
Peter R. Kongstvedt
Introduction and Definitions
93
1
Recruiting
94
1
Nonphysician or Midlevel Practitioners
95
2
Types of Contracting Situations
97
3
Credentialing
100
1
The National Practitioner Data Bank
101
2
Healthcare Integrity and Protection Data Bank
103
2
Compensation
105
1
Orientation
105
1
Network Maintenance
105
1
Internet-Based Activities
106
1
Removing Physicians from the Network
107
1
Conclusion
108
2
Compensation of Primary Care Physicians in Managed Health Care
110
37
Peter R. Kongstvedt
Introduction
110
1
Basic Models of Reimbursement
111
2
Capitation
113
5
Withholds and Risk/Bonus Arrangements
118
1
Capitation Pools for Referral and Institutional Services
118
6
Full Professional Risk Capitation
124
1
Reasons to Capitate
125
1
Problems with Capitation Systems
126
1
Effect of Benefits Design on Reimbursement
127
2
Fee for Service
129
2
A Special Requirement for Reimbursement When Coinsurance Is in Place
131
1
Out-of-Network Fees
132
1
Discounts, Negotiated Fee Schedules, Fee Maximums, or Fee Allowances
132
1
Relative Value Scales
133
1
Global Fees
134
3
Problems with FFS in Managed Health Care Plans
137
1
Legislation and Regulation Applicable to Physician Incentive Programs
138
5
Civil Liability in Physician Compensation Programs
143
1
Conclusion
144
3
Physician Compensation in Medical Groups and Health Systems
147
19
James A. Rodeghero
Background
147
1
Traditional Concepts in Pay Plan Design
148
2
Pay Plan Design Issues
150
3
General Design Alternatives
153
3
Measurement Issues
156
1
The Role of Benefits in Total Compensation
157
1
Compensating Medical Directors and Administrative Physicians
158
1
Compensating Hospital-Based Practitioners
159
1
Compensation in Faculty Practice Plans under Managed Care
159
2
Examples
161
1
Designing Performance Measures
162
1
Conclusion
163
3
Nonutilization-Based Incentive Compensation for Physicians
166
9
Peter R. Kongstvedt
Introduction
166
1
Problems with Evaluation Systems
167
1
Categories for Evaluation of Physician Performance
168
4
Measuring the Categories and Producing a Result
172
2
Conclusion
174
1
Contracting and Reimbursement of Specialty Physicians
175
16
Peter R. Kongstvedt
Introduction
175
1
How Many Specialty Care Physicians?
175
1
Primary versus Specialty Care Designation
176
1
Credentialing
177
1
Types of Reimbursement Arrangements
178
6
Organizational Models for Capitating Specialty Services
184
2
Common Problems with Specialty Capitation
186
1
Other Forms of Specialty Physician Reimbursement
187
2
Risk and Reward
189
1
Conclusion
189
2
Negotiating and Contracting with Hospitals and Institutions
191
15
Peter R. Kongstvedt
Introduction
191
1
Hospital Network Development
191
5
Types of Reimbursement Arrangements
196
8
Outpatient Procedures
204
1
Conclusion
205
1
Academic Health Centers and Managed Care
206
22
Jennifer H. Lofland
David B. Nash
Dimensions of the Problem
207
6
Strategies for Success
213
10
A New Role for MCOs
223
2
Conclusion
225
3
Health Centers and Managed Health Care
228
17
Pamela J. Byrnes
Judith Shea
Richard J. Jacobsen
Introduction
228
2
Community Health Centers
230
1
Public Policy and Support
231
2
Entry into Managed Care
233
1
Operational and Strategic Responses to Managed Care
234
3
Formation of CHC-Sponsored Health Plans
237
3
The Impact of Managed Care and Challenges for the Future
240
3
Conclusion
243
2
Complementary and Alternative Medicine Integration: Trends, Structures, and Challenges
245
20
John Weeks
Introduction
245
1
Orientation: Stakeholder Activity
245
6
Models and Challenges: Network Delivered Services
251
7
Challenges and Models: Hospitals and Health Systems
258
2
Conclusion: Exploratory Integration for Moving CAM Out of Quarantine
260
5
PART III---MEDICAL MANAGEMENT
265
390
Care Management and Clinical Integration Components
267
17
David W. Plocher
Wendy L. Wilson
Jacqueline A. Lutz
Ann Huston
The Context for Advanced Care Management
267
1
Defining Advanced Care Management
268
1
Integrating the Components of Care Management
269
3
The Role of Physicians in Care Management
272
1
Building an Advanced Care Management System: A Typical Process
273
5
Defining the Future State of Care Management
278
2
Conclusion
280
1
Description of the Components of the Advanced Care Management System
281
3
Primary Prevention in Managed Health Care
284
10
Leif I. Solberg
Introduction
284
1
Why Should an MCO Do Prevention?
285
1
Typology of HP/DP Activities
285
1
A Framework for Action
286
1
Taking Advantage of the Clinical Setting
287
4
Health Data Systems
291
1
Population-Based (Member) Programs
291
1
Community Outreach Programs
291
1
Public Policy Initiatives
292
1
Conclusion
292
2
Managing Basic Medical-Surgical Utilization
294
37
Peter R. Kongstvedt
Introduction
294
1
Return on Investment in Management of Medical Costs
294
1
Demand Management
295
3
Measurements of Utilization
298
3
Variations in Utilization
301
4
The Role of Electronic Commerce
305
1
Authorization or Denial of Payment for Services
305
1
Managing Utilization of Specialty Services
306
1
The Role of the Primary Care Physician in Specialty Services Management
307
2
Single Visit Authorizations Only
309
1
Specialty Physicians As Primary Physicians
310
1
Prohibition of Secondary Referrals and Authorizations
311
1
Review of Reasons for Referral
311
2
Institutional Utilization Management
313
1
Common Methods for Managing Utilization
314
10
Alternatives to Acute Care Hospitalization
324
2
Case Management
326
1
Conclusion
327
4
Clinical Services Requiring Authorization
331
13
Peter R. Kongstvedt
Definition of Services Requiring Authorization
331
1
Definition of Who Can Authorize Services
332
2
Claims Payment
334
1
Categories of Authorization
335
2
Staffing
337
1
Common Data Elements
338
1
Methods of Data Capture and Authorization Issuance
339
2
Authorization System Reports
341
1
Open Access HMOs
341
1
Specialty-Physician Based Authorization Systems
342
1
Non-Physician-Based Authorization Systems
342
1
Conclusion
343
1
Ancillary Diagnostic and Therapeutic Services
344
7
Peter R. Kongstvedt
Introduction
344
1
Ancillary Services
344
1
Physician-Owned Ancillary Services
345
1
Data Capture
346
1
Financial Incentives
346
1
Feedback
346
1
Control Points
346
1
Contracting and Reimbursement for Ancillary Services
347
2
Conclusion
349
2
The Emergency Department and Managed Care
351
20
Casey Jason
Meera Kanhouwa
Overview
351
1
Challenges Shared by Managed Care and Emergency Medicine
352
3
Creating Efficiencies and Improving Productivity
355
8
Technology Impact
363
3
Opportunities with Managed Care
366
5
Case Management and Managed Care
371
31
Catherine M. Mullahy
The Case Manager's Role
371
1
Patient Profile: Not Every Case Needs a Case Manager
372
2
On-Site versus Telephone-Based Case Management
374
1
Case Managers in Managed Care
375
1
Case Management Work Format and Process
375
9
Utilization Review: Preadmission and Concurrent Review and Case Management
384
4
Preadmission and Concurrent Review Case Management Reports
388
5
Red Flags: Indicators for Case Management
393
1
Timing Case Management Intervention
393
4
Beyond the Case Management Basics
397
3
A Long-Term Solution to a Long-Term Problem
400
2
Fundamentals and Core Competencies of Disease Management
402
11
David W. Plocher
Definition and Clarification
402
3
Barriers and Drivers for Disease Management
405
1
Business Plan
405
1
Survey of Disease Management Programs
406
2
Important Linkages
408
1
Support from Electronic Commerce
409
2
Conclusion
411
2
Prescription Drug Benefits in Managed Care
413
38
Robert P. Navarro
Financial Basis for Pharmacy Benefit Management
413
2
Pharmacy Program Cost Components
415
2
Principles of Pharmacy Benefit Management
417
1
Managing the Supply and Demand
418
1
Pharmacy Information Systems and Health Informatics
418
5
Pharmacy Benefit Management Companies (PBMs)
423
3
Pharmacy Benefit Management Program Components
426
2
Physician Provider Network
428
1
Pharmacy Provider Network
429
3
Pharmacy Provider Audits
432
1
Drug Formulary Management
433
5
Pharmaceutical Manufacturer Discount and Rebate Contracts
438
1
Prescription Patient Copayments
439
5
Role of Pharmacy Programs in Disease Management and Quality Improvement Programs
444
1
Quality Improvement in Pharmacy Benefit Management
444
2
Measuring Pharmacy Benefit Management Program Performance
446
1
Future Changes in Pharmacy Benefit Management
447
1
Conclusion
447
4
Managed Behavioral Health Care and Chemical Dependency Services
451
29
Donald F. Anderson
Jeffrey L. Berlant
Katherine O. Sternbach
Danna Mauch
H.G. Whittington
William R. Maloney
Terri Goens
Introduction
451
1
Historical Perspective
452
4
Key Treatment Principles
456
5
Benefit Plan Design
461
2
Utilization Management
463
2
Channeling Mechanisms
465
2
Provider Structures for Integrated Delivery Systems To Meet Managed Care Objectives
467
2
Quality Assurance
469
4
BH Information Systems
473
3
Public/Private Systems Integration
476
1
Emerging Issues
477
1
Conclusion
478
2
Home Health Care
480
16
Peggy H. Rodebush
Laura L. Waltrip
G. David Baker
Introduction
480
1
What Is Home Care?
481
1
History of Home Care
481
1
Indicators and Predictors of Home Care Demand
482
4
Home Care Services and Disciplines
486
1
Home Care Providers
486
2
Regulations Guiding Home Care
488
2
Financing Home Care Services
490
2
Recent Legislation and Regulatory Issues Affecting Home Care
492
1
Measuring Quality in Home Care Services
493
1
Examples of Advanced Clinical Practices in Home Care
494
2
Subacute Care Within the Managed Care System
496
12
Kathleen M. Griffin
Categories
496
1
Subacute Patients
496
1
Subacute Providers
497
2
Subacute Care Sites in the Future
499
1
Subacute Care within a Continuum of Care
499
1
Payment for Subacute Care
500
1
Selecting a Quality Subacute Provider
501
3
Conclusion
504
1
NSCA and Joint Commission Definitions of Subacute Care
505
1
Categories of Subacute Care
506
2
Hospice and End-of-Life Care
508
13
Anne C. Dye
Peggy H. Rodebush
Geri Hempel
Medical Management and End-of-Life Care
508
2
The Basics of Hospice Care
510
1
Financing and Reimbursement
511
1
Size of the U.S. Hospice Industry
512
1
Major Policy Issues
513
2
Service Models
515
2
Hospice Cost and Staffing
517
1
Specialty Programs
517
2
Future Integration and Affiliation Strategies
519
2
Clinical Pathways: Linking Outcomes for Patients, Clinicians, Payers, and Employers
521
18
Richard J. Coffey
Sarah S. LeRoy
Introduction
521
1
Background and Terminology
522
1
Scopes and Uses
522
2
Environment
524
1
Development
525
3
Application
528
1
Alternative Formats and Sample Uses
529
4
Results
533
5
Conclusion
538
1
Quality Management in Managed Care
539
17
Pamela B. Siren
Introduction
539
1
Traditional Quality Assurance
539
4
Components of a Quality Management Program
543
1
A Process Model for a Modern Quality Management Program
544
10
Conclusion
554
2
Measuring and Managing of Clinical Outcomes
556
23
Michael Pine
Domains of Clinical Outcomes Measurement
556
1
Goals of Clinical Outcomes Measurement
556
2
Measuring Comparative Risk-Adjusted Clinical Outcomes
558
9
Using Data on Risk-Adjusted Costs To Craft Measures of Clinical Performance
567
3
Using Adverse Outcome Rates To Reduce Costs
570
2
Using Control Charts To Get a Dynamic View of Performance
572
1
Relating Clinical Outcomes to Processes of Care
572
3
Monitoring Clinical Outcomes of Ambulatory Care
575
3
Conclusion
578
1
Using Data and Provider Profiling in Medical Management
579
39
Peter R. Kongstvedt
Norbert I. Goldfield
David W. Plocher
Introduction
579
1
Use of Data and Information in Medical Management
580
3
Patient Data Confidentiality
583
3
Data Elements and the Application of Reports
586
4
General Types of Reports
590
5
Provider Profiling
595
2
Desired Characteristics of Provider Profiles
597
3
The Need To Adjust for Severity of Illness
600
10
Selection of a Profiling Vendor
610
4
The Future of Data Use
614
1
Conclusion
615
3
Physician Behavior Change in Managed Health Care
618
19
Peter R. Kongstvedt
Introduction
618
1
General Aspects of Physician Practice Behavior
618
8
General Approaches to Changing Behavior
626
2
Programmatic Approaches to Changing Physician Behavior
628
2
Addressing Noncompliance by Individual Physicians
630
3
Conclusion
633
4
Member Behavior Change
637
18
Nancy W. Spangler
Introduction
637
1
They Know Better, So Why Don't They Just Stop?
637
4
Models for Affecting Patient Behaviors
641
5
Tools for Enhancing Change
646
3
From Theory into Practice: Human's CHIP Program
649
2
Conclusion
651
4
PART IV---OPERATIONAL MARKETING AND MANAGEMENT
655
250
Information Systems in Managed Health Care Plans
657
19
James S. Slubowski
Introduction
657
1
Core Managed Care Information System
658
4
Electronic Data Interchange
662
1
Privacy and Confidentiality under HIPAA
663
3
Value-Added Services-The Next Generation
666
4
HEDIS
670
3
Inforamtion Services Department
673
1
Conclusion
674
2
Information Systems and Electronic Commerce for Provider Systems in Managed Health Care
676
18
Robert G. Reese
Rick Majzun
Introduction: Mjor Issues Facing Health Care Provider Organizations in the Year 2000
676
1
Health Care Is a Business in an Information Economy
676
1
Health Care Provider Organizations Are Building the Information Infrastructure for a New Era in Health Care
677
1
Pressures on Both the Cost and Revenue Sides of the Equation Are Increasing
677
1
Information Technology Should Support Business Strategy and Market Need
677
1
Interconnectivity
678
1
Data Respositories or Warehouses: The Backbone of the Organization's Clinical and Financial Systems
679
1
Enterprise-Wide Information Systems
680
1
Use of Information Technology in Managing Care
680
1
Computerized Medical Records
681
1
Clinical Decision Support Systems
682
1
Knowledge Management Systems
683
1
Data Privacy and Security
684
1
Electronic Commerce
684
3
Capital Budgeting for Information Technology
687
2
Organizational Structure of Information Technology Departments
689
1
Client Relationships
689
2
Outsourcing the Information Technology Function
691
1
Conclusion: Information Technology Will Play a Key Role in Improving the Health Care Provider Organization's Ability To Manage Care
692
2
Electronic Commerce In Managed Health Care
694
16
Britton L. Pim
Sean D. Kenny
E-Commerce in Health Care
694
2
E-Commerce Technologies
696
5
E-Commerce Functionality
701
2
External Impact
703
2
Internal E-Commerce Opportunities
705
2
Challenges
707
1
Critical Success Factors
708
1
Conclusion
709
1
Claims and Benefits Administration
710
45
Robin L. McElfatrick
Robert S. Eichler
Introduction
710
1
Claims: Positioning, Purpose, and Opportunities
711
2
Organizational Structure and Staffing
713
5
Claims Operations Management
718
11
Productivity
729
2
Turn Around Time
731
1
Staff Training and Development
732
3
Quality
735
2
Policy and Procedure
737
2
Coordination with Other Departments/Functions
739
1
Systems Support
739
4
Claims Business Functions
743
8
Other Issues
751
3
Conclusion
754
1
Other Party Liability and Coordination of Benefits
755
16
Barry S. Scheur
Robin L. McElfatrick
Robert S. Eichler
Definitions
756
2
Contractual Support/Requirements
758
2
Legal Issues Based on Case Law
760
1
Organizational Placement (with Dedicated Staff)
761
1
COB: Basic Procedure Defined
761
2
Subrogation: Basic Procedure Defined
763
1
Accounting for OPL
763
3
OPL Policy Issues
766
1
OPL in a Capitated Environment
766
2
Outsourcing OPL
768
1
Conclusion
769
2
Member Services and Consumer Affairs
771
27
Peter R. Kongstvedt
Provision of General Information
772
25
Conclusion
797
1
Sales and Marketing in Managed Health Care Plans: The Process of Distribution
798
19
Gail Marcus
John C. Thomson
What Managed Care Organizations Deliver
798
2
Challenges Facing MCOs
800
4
An Overview of the Managed Care Market
804
1
Key Decision Makers and Influencers in the Managed Care Distribution Process
804
5
The Managed Care Sales Process
809
3
How the Managed Care Team Delivers
812
3
The Management of Sales and Marketing Professionals
815
1
Conclusion
816
1
The Employer's View of Managed Health Care: Show me the Value
817
11
Michael J. Taylor
Recent Managed Care Trends Affecting Employers
817
1
How These Trends Impact Employers Both Large and Small
818
1
The Large Group Employer: 5,000 Lives Plus
818
1
The Moderate Group Employer: 500-5,000 Lives
819
1
The Medium Grou Employer: 50-500 Lives
819
1
The Small Group Employer: 0-50 Lives
820
1
How Employers Purchase Value (1988-1998)
820
2
Looking for Value: 2000 and Beyond
822
2
Future Trends
824
1
Conclusion
825
3
The Impact of Consumerism on Managed Health Care
828
21
Jacqueline A. Lutz
Hindy J. Shaman
Why Is Consumerism a Significant Trend?
828
7
Who Is the New Health Care Consumer?
835
1
What Are the Implications of Consumerism?
836
9
How Can Organizations Develop a Consumer Strategy?
845
1
What Consumerism Means for the Managed Care Industry
846
1
Conclusion
846
3
Accreditation and Performance Measurement Programs for Managed Care Organizations
849
22
Margaret E. O'Kane
Introduction
849
1
Oversight by Type of Organization
850
1
National Committee for Quality Assurance
851
10
The Utilization Review Accreditation Commission
861
4
Joint Commission on Accreditation of Healthcare Organizations
865
4
Conclusion
869
2
Risk Management in Managed Care
871
15
Barbara J. Youngberg
Introduction
871
2
Changes in the Health Care Organization Related to Managed Care
873
2
Operational Risks under Managed Care
875
1
Managing Corporate Negligence
876
3
Clinical Decision Making
879
1
Utilization Management Issues
879
1
Emerging Case Law
879
1
Reducing Utilization Management Exposure
880
1
Externally Imposed Practice Guidelines or Standards of Care
881
1
Multi-Site Challenges
881
1
The Convergence of Financial and Risk Management
882
2
Using the Risk Management Process To Control the Risks of Managed Care
884
1
Conclusion
884
2
Common Operational Problems in Managed Health Care Plans
886
19
Peter R. Kongstvedt
Introduction and Background
886
1
Common versus Unique Problems or Events
887
1
Common Problems in Managed Care Organizations
888
15
Conclusion
903
2
PART V---FINANCE AND UNDERWRITING
905
136
Operational Finance and Budgeting
907
15
Dale F. Harding
Background
907
1
Financial Statement Components
908
7
Balance Sheet
915
2
Regulatory Reporting Considerations
917
2
Budgeting and Financial Forecasting
919
2
Conclusion
921
1
Tax Issues Relating to Health Risk-Bearing Entities
922
23
Phillip G. Royalty
Terry A. Jacobs
Taxable Health Risk-Bearing Entities
922
5
Tax Exempt Health Risk-Bearing Entities
927
18
Internal Revenue Service Manual Exempt ORganizations Handbook---Chapter 27: Health Maintenance Organizations
935
10
Underwriting and Rating Functions Common to Most Markets
945
7
Stephen M. Cigich
Michael G. Sturm
Underwriting
945
2
Rating
947
4
Conclusion
951
1
Underwriting and Rating Functions by Market
952
19
Michel G. Sturm
Individual Nongovernment Market
952
2
Commercial Group Market
954
13
Medicare Supplement
967
1
Medicare Risk
968
1
Medicaid Risk
969
1
Conclusion
970
1
Actuarial Services in an Integrated Delivery System
971
6
Stephen M. Cigich
Summary of Actuarial Services
971
1
Identifying and Realizing Opportunities
972
2
Creating Incentive Structures
974
1
Measuring Results
975
1
Conclusion
975
2
Operational Underwriting in Managed Care Organizations
977
23
Gregory J. Lippe
Historical Overview
977
2
Sales and Underwriting Collaboration
979
1
Management Information System
979
1
Regulation
980
1
Major Risk Factors
981
1
Underwriting As an Internal Control
982
1
Employer Group Underwriting
983
1
Key Employer Group Data
984
1
Market Factors and Trends
985
1
Community Rating Methodologies
986
8
Underwriting Principles
994
3
Administrative Service Only Underwriting
997
1
Effective Underwriting: Lessons Learned
997
2
Conclusion
999
1
Provider Excess Loss Coverage
1000
41
Scott A. Walker
Introduction
1000
1
Capitation-The Need for Protection
1001
2
PEL under Provider Risk Contracting
1003
1
Types of PEL Coverage
1004
1
Specific Excess Rate Development
1004
12
Experience-Specific PEL Rating
1016
7
Aggregate Excess Rate Development
1023
2
PEL Policy Coverage Form
1025
7
Coverage Availability
1032
1
Conclusion
1032
2
Sample PEL Policy Language
1034
7
PART VI---SPECIAL MARKET SEGMENTS
1041
122
The Federal Employees Health Benefits Program and Managed Care
1043
17
Christine C. Rinn
The Application Process
1044
1
Premium Contribution and Benefit Design
1044
1
Patients' Bill of Rights and Responsibilities
1045
1
Premium Rating under the FEHBP
1045
6
OPM Audits and Appeals
1051
3
FEHBP and False Claims Liability
1054
1
OPM's Policy on Error Reporting
1055
1
Miscellaneous Contracting Issues
1055
2
Quality Assurance
1057
1
Conclusion
1057
3
Medicare and Managed Care
1060
26
Carlos Zarabozo
Jean D. LeMasurier
Introduction
1060
1
Organization of the Chapter
1061
1
Who Is Eligible for a Medicare Risk Contract?
1061
1
The Exception in State Licensure: Provider-Sponsored Organizations
1062
1
Other New Options
1063
2
Muddying the Waters: Plans versus Organizations
1065
7
Federal Preemption
1072
1
What the Contract Requires (Finally!)
1073
2
Limitations on Physician Incentive Plans
1075
1
Consumer Protections
1076
1
Provider Protections and Rights: Conscience Protection
1077
1
Information Dissemination
1078
1
Enrollment
1078
3
Marketing Rules
1081
1
Interactions with Your Government
1081
1
The Contracting Process
1082
1
Web Resources and Other Contacts
1083
1
Future Direction of the Program
1083
3
Medicare + Choice: The Health Plan's View
1086
19
Craig S. Schub
Nick Franklin
Introduction
1086
1
Today's Elderly
1086
2
The Demographic Imperative: Aging Population and Unpredictable Health Care Costs
1088
1
Public Policy Initiatives: From 1965 to the Balanced Budget Act
1088
4
Evolving Challenges and Opportunities of Medicare + Choice (Risk) Contractors
1092
4
Changing Dynamics of the Delivery System
1096
7
Future Trends
1103
2
Medicaid Managed Care
1105
19
Robert E. Hurley
Stephen A. Somers
Introduction
1105
1
Medicaid-Origins and Evolution
1106
1
Medicaid Managed Care-Background and Models
1107
1
Operational Features
1108
5
Successes of Medicaid Managed Care
1113
3
Shortfalls of Medicaid Managed Care
1116
3
The Challenging Contemporary Context
1119
1
Longer Term Questions and Concerns
1120
2
Conclusion
1122
2
Champus and the Department of Defense Managed Care Programs
1124
9
Steve Lillie
Larry Sobel
Legal Authority and Responsibilities
1125
1
The Military Medical Benefits Program
1125
1
Eligibility for TRICARE
1126
1
TRICARE Options
1126
1
TRICARE Benefits
1126
1
TRICARE Cost Sharing
1127
1
TRICARE Beneficiary Assistance
1127
1
Origins of TRICARE--Managed Care Demonstrations
1127
3
The TRICARE Program
1130
1
Managed Care Support Contracts
1131
1
Comparing TRICARE and Medicare Managed Care
1131
1
Conclusion: Next Steps for the TRICARE Program
1132
1
Managed Care Organizations in Rural Areas
1133
13
Keith J. Mueller
Status of Managed Care in Rural Areas
1134
1
Appreciating the Rural Context for Managed Care
1135
2
Reasons To Expect Managed Care Development in Rural Areas
1137
1
Building Successful Managed Care in Rural Areas
1137
5
The Future
1142
2
Conclusion
1144
2
Managed Care Dental Benefits
1146
8
Fred L. Horowitz
Bruce H. Safran
Wayne A. Paul
Evelyn F. Ireland
Dental HMOs
1146
1
Dental PPOs
1147
2
Referral Plans
1149
1
The Dental Delivery System
1149
1
Recruiting
1150
1
Credentialing
1150
1
Compensation
1150
1
Utilization Review
1151
1
Quality Improvement
1151
1
Specialty Care
1152
1
Accreditation
1152
1
Conclusion
1152
2
Workers' Compensation Managed Care: The Search for Integration
1154
9
Alex L. Swedlow
Gregory L. Johnson
Introduction
1154
1
Workers' Compensation: The Origin of the Social Contract
1154
1
Early Controls on Medical Costs
1155
2
Key Success Factors
1157
1
Twenty-Four Hour Coverage: A Solution in Search of Customers
1157
1
Addressing Worker Expectations
1158
1
Developing Protocols for Case Management
1159
1
The Employer Perspective: Changing the Corporate Culture
1159
1
The Next Step: Comprehensive Medical Events Management
1159
1
Conclusion
1160
3
PART VII---REGULATORY AND LEGAL ISSUES
1163
183
Legal Issues in Provider Contracting
1165
38
Mark S. Joffe
General Issues in Contracting
1166
1
Contract Structure
1167
1
Common Clauses, Provisions, and Key Factors
1168
13
Conclusion
1181
1
Sample Physician Agreement
1182
12
Sample Hospital Agreement
1194
9
Antirust Remedies for Managed Care: Attacking Barriers to Free Markets
1203
18
William G. Kopit
Robert Hudock
Introduction
1203
1
Enforcement of the Antitrust and Unfair Competition Laws
1203
1
The Antitrust Laws
1204
3
Provider Networks
1207
4
Physician Unions
1211
2
Virtual Mergers
1213
1
Exclusive Dealing Arrangements by Competitors
1214
1
Most Favored Nation Clauses
1214
1
Section 2 of the Sherman Act
1215
4
Conclusion
1219
2
Legal Liability Related to Medical Management Activities
1221
20
James L. Touse
Obligations to Conduct Medical Management Activities
1222
1
Common Law Medical Management Liability Actions
1223
1
Contract Actions Related to Medical Management Activities
1224
5
Negligence Actions Related to Medical Management Activities
1229
6
Recommendations
1235
4
Conclusion
1239
2
Legal Issues in Integrated Delivery Systems
1241
16
Jerry R. Peters
Definitions
1241
1
IDS Models
1242
1
Provider-Sponsored Organizations
1243
1
Governance
1244
1
Committees
1244
1
Delegated Board Authority
1245
1
Advisory Committees
1245
1
Conflict of Interest Policy
1246
1
Tax Exemption and Charitable Benefit
1247
1
Physician Compensation
1248
1
Practice Acquisitions/Valuation
1249
1
Medicare/Medicaid Provider Numbers
1250
1
Antitrust Law
1250
1
Independent Contractor Status
1251
4
Convenants Not To Compete
1255
1
Conclusion
1255
2
Erisa and Managed Care
1257
28
Jacqueline M. Saue
Gregg H. Dooge
Documentation, Reporting, and Disclosure Requirements
1257
2
Plan Design Considerations
1259
3
Amendment of Plans
1262
1
Fiduciary Duties
1263
1
Challenges to Benefit Denials
1264
3
ERISA's Civil Enforcement Scheme and Remedies
1267
1
ERISA Preemption
1267
13
Conclusion
1280
5
The Health Insurance Portability and Accountability Act of 1996
1285
21
Charles N. Kahn III
Dean A. Rosen
Marianne Miller
Kathleen H. Fyffe
Introduction
1285
1
Overview
1286
1
Provisions: Portability and Access
1287
6
New Access Initiatives
1293
1
Amendments to HIPAA Portability and Access Provisions
1294
1
Provisions: Administrative Simplification
1295
4
HIPAA Administration and Enforcement
1299
1
An Early Report on the Effects of HIPAA Portability and Access Provisions
1300
4
Conclusion
1304
2
Health Plan Corporate Compliance Programs
1306
16
Mike Treash
Corporate Compliance on Paper
1306
1
Corporate Compliance in Operation
1307
1
Structure
1308
1
Leadership
1309
2
Education and Development
1311
1
Measures and Incentives
1311
1
Staffing
1312
1
Communication
1313
7
Conclusion
1320
2
State Regulation of Managed Care
1322
24
Richard I. Smith
Kristin Stewart
Introduction
1322
1
State Oversight: The Regulatory Process
1323
7
State Regulation of Other Products
1330
4
Managed Care Legislation
1334
7
Regulation by Market Segment
1341
2
The State Experience-Conclusion
1343
3
EPILOGUE---MANAGED HEALTH CARE AT THE MILLENNIUM
1346
11
Peter R. Kongstvedt
Introduction--The Rollercoaster That Never Stops
1346
1
Using the Magic Eight Ball: The Answer Is Hazy--Try Again Later
1347
1
They Were Right All Along-Managed Health Care Is in Chaos
1347
2
Reversing Entropy with a Little Help from Professor Heisenberg--Predicting, Leading, and Acting in a Chaotic Managed Health Care Environment
1349
1
Handicapping the Field--The Stratification of Predictability
1350
3
Driving the Nitroglycerine Truck on a Foggy Night--Leadership, Strategy, and Action in the Chaotic World
1353
2
Door Number One, Two, or Three--Choosing Strategic Options
1355
1
Conclusion--Shake the Magic Eight Ball and Try Again
1356
1
Glossary of Terms and Acronyms
1357
21
Index
1378