A Guide to Managed Care Medicine

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ISBN: 9780834217652 | 0834217651
Cover: Paperback
Copyright: 4/1/2000

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A Guide to Managed Care Medicine is based on the content of a thirty-two contact hour program attended by over twelve hundred physicians. This practical resource provides practitioners with the information they need to better understand the implications of managed care on their patients and on their medical practices. The book includes detailed learning objectives, case studies, review questions, detailed notes, suggested readings, and a bibliography.

Contributors

Preface

Paving a Pathway to Managed Care Medicine

(24)

Learning Objectives

(1)

What Defines Managed Care?

(1)

What Do Managed Care Plans Generally Include?

(1)

Two Kinds of Managed Care for the New Millenium

(1)

How Did Managed Care Evolve?

(2)

Why Have Health Care Costs Increased?

(2)

What Types of Managed Care Exist Today?

(4)

What Is Public Sector Managed Care?

(3)

What Are the Five Stages of Managed Care?

(1)

What Market Implications Does Managed Care Bring Physicians?

(1)

What Ethical Dilemmas Does Managed Health Care Cause Physicians?

(2)

Case Studies

(6)

Removing the Mystery Surrounding Health Economics

(20)

Learning Objectives

(1)

Why the Increasing Interest in Health Economics?

(2)

What Is the Relationship between Health Economic Analysis and Managed Care?

(1)

What Are Common Quantitative Tools for Health Economic Analysis?

(7)

What Are Some Limitations of Health Economic Analysis?

(1)

How Does Health Economic Analysis Relate to Outcomes Management?

(1)

What 10 Steps Constitute Health Economic Analysis?

(2)

What Is Meant by Quality of Life?

(1)

How Is Quality of Life Measured?

(1)

How Do Managed Care Plans Use Quality-of-Life Information?

(1)

How Can Health Economic Analysis Contribute to Cost-Effective Medical Care?

(1)

What Are the Challenges and Opportunities of Health Economic Analysis?

(1)

Case Studies

(2)

Creating New Knowledge Using Information Technology

(12)

Learning Objectives

(1)

What Is Medical Informatics?

(1)

Why Is Medical Informatics Important in Managed Care?

(3)

Why Should Physicians Develop Computerized Patient Records?

(2)

Are There Managed Care Roles for Telemedicine, Intranets, and the Internet?

(2)

What Are Some Ethical Concerns in Informatics?

(1)

Case Studies

(3)

Managing the Managed Care Contract

(22)

Learning Objectives

(1)

How Can Physicians Select Attractive Managed Care Partners?

(1)

What Questions Should Physicians Ask Managed Care Organizations Before Signing Their Contracts?

(2)

What Terms Exist in a Typical Contract?

(1)

What Terms Exist in a Typical Managed Care Contract?

(12)

Can A Physician Negotiate a Managed Care Contract?

(1)

Who Should Carefully Review a Managed Care Contract?

(1)

Are There Questions To Ask Before Signing a Managed Care Contract?

(4)

What Tactics Lead to the ``Bottom Line'' during Managed Care Contract Negotiations?

(1)

Case Studies

(2)

Medicaid and Medicare as Managed Care Purchasers

(10)

Learning Objectives

(1)

Where Did Medicaid Come From?

(1)

What Makes These Plans Similar and Not So Similar After 35 Years?

(2)

What Is Managed Medicare?

(2)

What Benefits Are Included in a Managed Medicare Plan?

(1)

What Should Providers Remember about Accepting Managed Medicare?

(1)

How Does HCFA Measure the Quality of Care Given by Its Contracted Providers?

(1)

What Is Medicare + Choice?

(1)

What Lessons Have Managed Medicare Providers Learned?

(1)

Case Study

(2)

What Changes in Medical Practices Can One Expect under Managed Care

(16)

Learning Objectives

(1)

What Can a Physician Do To Accept and Manage Risk?

(2)

How Should Physicians Deal with Capitated Compensation?

(1)

What Changes in Practice Management Can Be Expected under Managed Care?

(2)

How Do Primary Care Physicians Function as Case Managers?

(1)

What About Using Physician Extenders?

(1)

What About Preventive Services under Managed Care?

(1)

What Can Be Expected with Regard to Patient Satisfaction Surveys?

(2)

What Can a Medical Practice Really Do To Influence Health of a Managed Care Member?

(4)

Case Studies

102

(3)

How Are Physician Providers Monitored and Managed?

105

(10)

Learning Objectives

105

(1)

How Does Managed Care Perceive Standardization of Medical Care?

105

(1)

What Is Profiling?

106

(1)

How Do HEDIS and NCQA Help with Profiling?

107

(1)

How Do Managed Care Organizations Conduct Provider Profiling?

108

(1)

Why Are Prescribing Patterns Profiled?

109

(1)

How Is Profiling Applied at the Provider Level?

110

(3)

Case Study

113

(2)

Why Disease State Management and Demand Management Are Growing Industries

115

(10)

What Is Disease State Management?

115

(1)

What Are the Principles and Candidates behind Disease State Managment Programs?

116

(1)

Why Are Pharmaceutical Companies Active in Disease State Management?

117

(1)

What Are Demand Management Programs?

118

(1)

How Is Demand by Managed Care Members Managed?

118

(3)

How Are Demands for Referrals and Specialists Managed?

121

(1)

How Is Demand for Institutional Services Managed?

121

(2)

Case Study

123

(2)

Twelve Practica Steps To Build Practice Success with Managed Care

125

(18)

Learning Objectives

125

(1)

Twelve Steps To Increase Productivity, Decrease Practice Variation and Build Success with Managed Care

126

(14)

Practice Success: A Conclusion

140

(1)

Case Studies

140

(3)

Managing the Risk in Managed Care

143

(16)

Learning Objectives

143

(1)

The Stakeholders

143

(1)

What Is Risk?

144

(2)

Managed Care Risk: A Message to Physicians

146

(1)

How Is Managed Care Risk Regulated?

146

(2)

Self-Insured Employer Groups and Growing Federal Oversight

148

(3)

Professional Licensure

151

(1)

How Do Insurers Manage the Risk of Various Employer Groups?

151

(1)

The Large Employer Group

152

(1)

The Medium Employer Group

153

(1)

The Small Employer Group

154

(1)

How Does the Risk Management of These Various Employer Groups Affect the Provider?

155

(1)

Case Studies

155

(4)

Managing Information Needs of Patients and Populations in Managed Care Plans

159

(28)

Learning Objectives

159

(1)

How Do Consumers Deal with Variation in Health Care?

160

(1)

How Do Employers Select Health Plans?

161

(1)

Population Health-The New Paradigm of Medicine

162

(1)

What Trends Are Creating This New Health Care Paradigm?

163

(1)

The Need for Information-Rich Systems

164

(1)

Managed Care Today

164

(1)

How Has the Managed Care Paradigm Shifted Care?

165

(1)

What Problems Resulted from the Paradigm Shift?

166

(1)

Why Did Medicine and Public Health Converge?

166

(1)

Why Must Medicine and Public Health Collaborate Once Again?

166

(1)

The Shift from Public Health to Population Health

167

(1)

Clinical Practice Guidelines

168

(1)

What Is the Physician's Role in Guideline Development?

169

(1)

Disease Management

170

(2)

Preventive Care

172

(1)

National Initiatives Addressing Health Care Quality: NCQA, JCAHO, FACCT

173

(11)

Case Study: A Quality Improvement Activity

184

(3)

Managing Medical Practice Compensation under Managed Care

187

(34)

Learning Objectives

187

(1)

Why Is Physician Compensation So Challenging?

187

(1)

What Methods Are Used to Reimburse Physicians under Managed Care?

188

(9)

Case Studies

197

(3)

Antitrust Considerations in Contracting

200

(4)

Stop-Loss Insurance

204

(2)

What Can Physicians Expect Next?

206

(1)

Case Studies

206

(6)

A Medical Practice Analysis: From the ACMCM ``Tool Box''

212

(9)

Careers as a Medical Leader

221

(10)

Learning Objectives

221

(1)

What Is a Medical Leader?

221

(1)

What Does a Medical Leader Do for a Managed Care Organization?

222

(1)

What Is a Prescription for Becoming a Medical Leader in Managed Care?

223

(1)

Leadership vs. Management

224

(1)

What Rewards Can One Expect as a Medical Leader in Managed Care?

225

(1)

Case Study

226

(1)

Medical Director Job Description

226

(5)

Prescriptions for Practitioners Living with Managed Care

231

(8)

Tips for Efficient Scheduling

236

(3)

Glossary

239

(20)

Common Acronyms

259

(4)

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A Guide to Managed Care Medicine

Summary

Table of Contents

Supplemental Materials