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E-raamat: Healthcare Management: Managed Care Organisations and Instruments

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This book offers a systematic overview of the organisational forms and management instruments implemented in managed care. Advocates consider managed care to be a logical and necessary developmental step in modern healthcare systems.

This textbook on Healthcare Management provides a systematic and comprehensive overview of the organisational forms and management instruments implemented in managed care.

Within the international discussion on the structure of healthcare systems, managed care is an increasingly important topic. Over more than twenty years managed care approaches have fundamentally influenced healthcare systems in terms of patient orientation, efficiency, and quality. Experts assume that up to 20% of healthcare expenses can be saved by applying high-quality managed care approaches. By using suitable organisational forms and management principles, not only can costs be reduced, but the quality of medical service provision can be augmented. Managed care is therefore much more than a cost-cutting strategy. 

Advocates consider managed care to be a logical and necessary developmental step in modern healthcare systems. An increase in quality and at the same time a reduction of costs is not seen as contradictory but rather as consistent. Therefore, managed care is a response to changed challenges in the provision of healthcare.?

Part I Basic Ideas of Managed Care
1 Definitions and Concepts
3(14)
1.1 Supporting and Inhibiting Factors of Managed Care
3(3)
1.2 Definitions of Managed Care
6(3)
1.3 Which Instruments and Organisational Forms Belong to Managed Care9
9(2)
1.4 What Changes for Those Involved in the Managed Care Context?
11(2)
Literature
13(4)
2 Main Characteristics of the American Healthcare System
17(10)
2.1 Funding Healthcare
17(5)
2.1.1 Government and Compulsory Contribution Schemes
18(2)
2.1.2 Private Healthcare Coverage Plans
20(2)
2.2 Delivering Healthcare Services
22(1)
2.3 Receiving Healthcare Services
23(1)
Literature
24(3)
3 Theoretical Concepts for the Assessment of Managed Care
27(18)
3.1 Transaction Cost Theory
27(2)
3.1.1 Fundamental Ideas
27(1)
3.1.2 Transaction Costs
28(1)
3.2 Reasons for Market Failure: Williamson's Organisational Failure Framework of 1975
29(4)
3.2.1 Market, Hierarchy or Cooperations
31(1)
3.2.2 The Suitability of Transaction Cost Theory in Healthcare
32(1)
3.3 Principal-Agent Theory
33(2)
3.4 Information Asymmetries and Behavioural Uncertainties
35(5)
3.4.1 Coordination Patterns
37(3)
3.4.2 Principal-Agent Theory for the Analysis of Steering Elements in Healthcare
40(1)
Literature
40(5)
Part II Managed Care Organisations and Products
4 Preliminary Remarks
45(4)
Literature
48(1)
5 Insurance-Based Managed Care Organisations and Products
49(18)
5.1 Staff, Group, IPA and Network Model HMOs
49(11)
5.1.1 Basic Idea
49(2)
5.1.2 Staff Model HMOs
51(2)
5.1.3 Group Model HMOs
53(5)
5.1.4 IPA Model HMOs
58(1)
5.1.5 Network Model HMOs
58(2)
5.2 Consumer-Driven Health Plans (CDHPs) and Health Savings Accounts
60(4)
5.2.1 Guidelines and Health Policy Goals
60(1)
5.2.2 Forms and Prevalence
61(2)
5.2.3 Assessment
63(1)
Literature
64(3)
6 Provider-Based Managed Care Organisations and Products
67(20)
6.1 Independent Practice Associations (WA)
67(1)
6.2 Preferred Provider Organisations (PPO)
68(1)
6.3 Networks
69(3)
6.4 Integrated Delivery Systems (IDS)
72(8)
6.5 Accountable Care Organisations (ACO)
80(1)
6.6 Patient-Centred Medical Homes (PCMH)
81(2)
Literature
83(4)
7 Institutions in the Managed Care Environment
87(10)
7.1 Management Service Organisations (MSO)
87(2)
7.2 Physician Practice Management Companies (PPMC)
89(1)
7.3 Pharmacy Benefit Management (PBM)
90(4)
7.3.1 Elements of Pharmacy Benefit Management (PBM)
91(3)
7.3.2 Assessment
94(1)
Literature
94(3)
8 Conclusion
97(6)
Literature
99(4)
Part III Managed Care Instruments
9 Contract Design
103(16)
9.1 Selective Contracting
103(5)
9.1.1 Introductory Remarks
103(1)
9.1.2 Selective Contracts with Physicians
104(2)
9.1.3 Selective Contracts with Hospitals
106(1)
9.1.4 Assessment of Selective Contracting
107(1)
9.2 Structuring the Insurance Contracts
108(8)
9.2.1 Basic Concepts
108(1)
9.2.2 Options for Managing Pre-contract Risks
108(1)
9.2.3 Options for Managing Post-contract Risks
109(6)
9.2.4 Assessment
115(1)
Literature
116(3)
10 Compensation Systems
119(30)
10.1 Foundation
119(3)
10.2 Forms of Compensation
122(11)
10.2.1 Salary
123(1)
10.2.2 Factor Cost Reimbursement
123(1)
10.2.3 Fee-for-Service
124(1)
10.2.4 Daily Rates (Per Diem)
125(1)
10.2.5 Case Rates and Diagnosis Related Groups (DRGs)
126(2)
10.2.6 Bundled Payments
128(3)
10.2.7 Capitation
131(2)
10.3 Pay-for-Performance (P4P) and Public Reporting
133(9)
10.3.1 Pay-for-Performance
133(2)
10.3.2 Design of the Model
135(4)
10.3.3 Public Reporting
139(1)
10.3.4 Basic Principle
139(2)
10.3.5 Negative Incentives
141(1)
10.4 Conclusion
142(1)
Literature
143(6)
11 Quality Management
149(46)
11.1 Guidelines and Clinical Pathways
149(7)
11.1.1 Basic Concepts
149(2)
11.1.2 Forms and Objectives of Guidelines
151(1)
11.1.3 Areas of Application for Guidelines
152(1)
11.1.4 Assessment
153(3)
11.2 Disease Management and Chronic Care
156(10)
11.2.1 Introductory Remarks
156(1)
11.2.2 Elements of Disease Management
157(1)
11.2.3 Stages of Disease Management
158(3)
11.2.4 Chronic Care Model
161(3)
11.2.5 Critical Assessment of Disease Management and Chronic Care Management
164(2)
11.3 Case Management
166(6)
11.3.1 Introduction
166(2)
11.3.2 Range of Tasks of the Case Manager
168(2)
11.3.3 Case Management Procedure
170(1)
11.3.4 Evaluating Case Management
171(1)
11.4 Patient Coaching
172(5)
11.4.1 Specifications of Patient Coaching
173(3)
11.4.2 Assessment
176(1)
11.5 Principles of Managed Care
177(10)
11.5.1 Preliminary Remarks
177(1)
11.5.2 Quality Planning ("Plan")
178(5)
11.5.3 Quality Implementation ("Do")
183(1)
11.5.4 Quality Inspection ("Check")
183(3)
11.5.5 Implementation of Quality Improvement Measures ("Act")
186(1)
11.5.6 Assessment
186(1)
Literature
187(8)
12 Cost Management
195(18)
12.1 Gatekeeping
195(4)
12.1.1 Basic Idea
195(1)
12.1.2 Forms of Gatekeeping
196(1)
12.1.3 Significance and Mechanisms
197(1)
12.1.4 Assessment
198(1)
12.2 Formularies
199(4)
12.2.1 Fundamental Concepts and Effective Mechanisms
199(2)
12.2.2 Goals of Implementing Formularies
201(1)
12.2.3 Assessment
202(1)
12.3 Utilisation Review and Management
203(6)
12.3.1 Basic Concepts
204(1)
12.3.2 Forms of Utilisation Review and Utilisation Management
205(2)
12.3.3 Importance and Effective Mechanisms
207(1)
12.3.4 Assessment
208(1)
Literature
209(4)
13 Evaluation Procedure
213(28)
13.1 Overview
213(1)
13.2 Health Economic Evaluation
214(7)
13.2.1 Cost Analysis
215(1)
13.2.2 Cost-Effectiveness Analysis
216(1)
13.2.3 Cost-Utility Analysis
217(2)
13.2.4 Cost-Benefit Analysis
219(1)
13.2.5 Sensitivity Analysis
220(1)
13.3 Preference Measurement
221(7)
13.3.1 Patient Benefits and Preferences
221(1)
13.3.2 Measurement of Preferences
222(1)
13.3.3 The Foundational Methods: The Conjoint Analysis (CA)
223(1)
13.3.4 The Discrete Choice Experiment
223(4)
13.3.5 Assessment
227(1)
13.4 Evidence-Based Medicine (EBM)
228(3)
13.4.1 Systematic Acquisition of Information
229(1)
13.4.2 Analysis of the Evidence
230(1)
13.4.3 Application of Evidence Found in Individual Cases
230(1)
13.5 Health Services Research
231(2)
13.6 Health Technology Assessment (HTA)
233(2)
Literature
235(6)
Part IV Evaluation of Managed Care
14 Preliminary Remarks
241(4)
Literature
242(3)
15 Cost Effects of Managed Care
245(2)
Literature
246(1)
16 Quality Effects of Managed Care
247(4)
Literature
249(2)
17 Access Effects of Managed Care
251(2)
Literature
252(1)
18 Acceptance of Managed Care
253(4)
18.1 Acceptance from the Insured and Patients
253(1)
18.2 Acceptance from Physicians
254(1)
Literature
254(3)
19 Conclusion
257(2)
Literature
258(1)
Index 259
Dr. Volker Eric Amelung is Professor for International Healthcare System Research at the Medical University of Hannover. Professor Amelung is also the president of the German Managed Care Association (BMC), Berlin. BMC, a leading independent healthcare association, elaborates innovative concepts in healthcare management and healthcare policy. Volker Eric Amelung is a member of several national and international healthcare associations and internationally affiliated with healthcare management professionals. His research focuses on healthcare policy, managed care and healthcare systems. He is a prolific author on issues of managed care, healthcare policy, new technologies, and integrated delivery systems.
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