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Managed Health Care in the New Millennium: Innovative Financial Modeling for the 21st Century [Kõva köide]

(President, EthiCare Breakthrough Solutions/EthiCare Revenue Cycle Management Inc., Las Vegas, Nevada, USA)
  • Formaat: Hardback, 306 pages, kõrgus x laius: 229x152 mm, kaal: 589 g, 49 Tables, black and white; 3 Illustrations, black and white
  • Ilmumisaeg: 05-Dec-2011
  • Kirjastus: Productivity Press
  • ISBN-10: 143984030X
  • ISBN-13: 9781439840306
  • Formaat: Hardback, 306 pages, kõrgus x laius: 229x152 mm, kaal: 589 g, 49 Tables, black and white; 3 Illustrations, black and white
  • Ilmumisaeg: 05-Dec-2011
  • Kirjastus: Productivity Press
  • ISBN-10: 143984030X
  • ISBN-13: 9781439840306
David Samuels, a leading authority on financial models in healthcare, draws on his multidisciplinary background in all aspects of managed care to provide an expansive yet detailed perspective of this complex field. Grounded in evidence-based modeling, the books multidisciplinary focus puts the spotlight on core concepts from the standpoints of health plans, hospitals, physician practice, and their respective integrated network models.

Youll learn what happened when a countrys national health care plan is developed with problematic underwriting, why hospitals will always be victimized at their payers bargaining table, and even how to improve the current primary care shortage at both 50% less provider costs as well as with triple their members compliance in wellness care. The book gives you the critical tools to stay ahead of the learning curve, engage patients to take responsibility for their own and their familys health status, and improve your differentiation in a RAPIDLY changing marketplace.

Arvustused

Managed Health Care in the New Millennium is elegant in both the simplicity of its premise, as well as the detail in which David Samuels lays out a prescription for navigating the uncharted, murky waters of Health Cares future. His rational, plausible take on the complex problems, and possible solutions, while not offered as a panacea for an industry in turmoil, is fresh and bold. For once, consumers are not ignored as hapless victims, or un-savvy consumers. Instead, they are given practical tools and a voice, which may just be the future path to simultaneously cut costs and improve the quality of the care they so well deserve. Well done David!Andre B. Van Niekerk, PhD, Dean, School of Business, Woodbury University, President, (LBR) Luxury Branding Research, Los Angeles

Managed Care in the New Millennium is more than a very readable future history of managed healthcare. Its a call to action for those who must make decisions on how healthcare services should be delivered and how the financing on managed care should be carefully structured towards common medical and financial goals. Managed Care in the New Millennium should be required reading for everyone needing to understand how managed healthcare worked in the past, is now "working" in the present and how managed care will evolve in the future. Mr. Samuels presents valuable information for medical and hospital administrators, healthcare insurance companies, legislators, human resource managers, consultants, and individual patients that is long overdue.Lawrence R. Lievense, FHFMA, FACMPE, Healthcare FINANCIAL Experts, Inc.,

David Samuels book comes to the market just in time for health plans, physicians and hospitals to consider new options in a post reform environment. An expert in reimbursement and the mathematical fundamentals of prospective payment for over three decades, David has updated his original book, Capitation, in line with the refocused needs of providers and payers to collaborate over value instead of fighting one another over manipulated fees schedules and volume. In short order we get a 15-year update on where managed care went wrong in its reimbursement and how the use of performance data and more thoughtful application of care management techniques can build accountability into a mutual framework of payment and service for purchasers and providers. The author then goes one step further into offering innovation upon a theme to expand the thinking and capabilities of providers and purchasers to share savings and put in place key performance indicators using predictable formulas. Davids work can help many healthcare executives do a better job of understanding and planning for the future. We recommend his publications to our clients and believe his innovation offers insight into what accountable care means and how the consumer will eventually benefit through a more rational and defined care system.William J De Marco MA, CMC, President and Chief Executive Officer, De Marco & Associates, Inc.

David Samuels offers great insight into the health care insurance markets and the enormous potential of capitation to contribute to the solutions our Nation so sorely needs. Capitation will inevitably impact the industry's evolution and I know of no more comprehensive and detailed a depiction of its strengths and opportunities than Managed Health Care in the New Millennium. Carl Heard, MD, MMM, Independent Locums Physician, Consultant for Medical Management

Preface xv
Acknowledgments xix
About the Author xxi
Chapter 1 An Updated Introduction to Managed Care and Capitation
1(24)
Introduction
1(4)
A Simple Definition---But Not So Simple History---Of Managed Care and Capitation
5(1)
Understanding Managed Care in the Private and Public Sectors: A Reality Check
6(4)
Understanding Capitation---And Not Just Financially
10(4)
Effects of Public Policies on Capitation and Capitated Relationships
14(2)
A Simplified Understanding of Managed Care Models
16(1)
Two Basic Demand Models of Managed Care: Illness-Based versus Wellness-Based
16(1)
Understanding Health Plans
17(8)
Chapter 2 Understanding Managed Care Industry Operations
25(62)
Introduction to the Insurance Industry
25(2)
Understanding ERISA Implications for HMOs and Employers
27(2)
Responsibility for Negligence under ERISA
27(1)
Administration of Practice Management
27(1)
Credentialing of Network Providers
28(1)
Actions of Employed Staff/Practitioners
28(1)
Contractual Liability Issues
28(1)
Unreasonable Benefit Determination
29(1)
Balance-Billing Violations of FQHMOs
29(1)
Introduction to Managed Care Underwriting
29(3)
Purchaser Selection
30(1)
Benefit Plan Design
30(1)
Claims History
30(1)
Role of MCO Reinsurance
31(1)
Aggregate Reinsurance
31(1)
Individual Reinsurance
31(1)
Introduction to Commercially Insured Populations
32(2)
The "50-50 Rule"
32(1)
Control of Commercial Risk Populations
33(1)
Understanding Rating Methodologies: Community versus Experience
34(6)
Community Ratings
34(1)
Basic Community Ratings
34(2)
Community Ratings by Class
36(2)
Experience Rating Methodologies
38(2)
Experience-Based Community Ratings
40(1)
Understanding and Predicting Medical Losses
40(2)
Introduction to Actuarial Mathematics
42(1)
Premium and Product Issues
43(1)
Payer Premium Revenues
43(1)
Payer Nonoperating Revenue Sources
43(1)
Employer Benefit Plan Design
44(3)
Cost-Sharing Impacts on Product Design
45(1)
Deductible Mechanisms
45(1)
Share-of-Cost Payments
45(1)
Out-of-Pocket Maximums
46(1)
Incentives and Disincentives
46(1)
Health Plan Enrollment
47(1)
Cost Data to Predict Losses
47(3)
Community Utilization and Service Intensities
48(1)
Impact of Utilization Management
48(1)
Effectiveness of Health Care Management
48(1)
Probability Matrix of Predicted Use
48(1)
Operational Loss Sources
48(1)
MCO Operational Elements to Minimize Losses
49(1)
Payer-Provider Risk Relationships
50(1)
Stop-Loss and PMPM Relationships
51(3)
Underwriting and Reinsurance Relationships
52(2)
Other Interrelationships
54(1)
Risk Banding and Provider Risk-Sharing Arrangements
55(2)
Payer-Provider Financial Relationships
57(2)
Cost Sharing
57(1)
Reinsurance Recoveries
58(1)
COB Relationships
58(1)
"Pursue-and-Pay" COB Method
59(1)
"Pay-and-Pursue" COB Method
59(1)
Capitation Adjustments Based on Percentage of Premium Revenue
59(5)
Claims Management and Processing
60(3)
Claims Adjudication
63(1)
Referral Management
64(6)
Provider Authorizations
64(3)
Prospective Authorizations
67(1)
Concurrent Authorizations
68(1)
Retrospective Authorizations
69(1)
Pended Authorizations
69(1)
Denied Authorizations
69(1)
Subordinate ("Sub-") Authorizations
70(1)
Payer Development of Provider Panels
70(1)
Outcomes Reporting
71(1)
Advanced Studies in Capitated Managed Care
72(9)
Per Member, per Month
73(3)
Full-Risk Capitation
76(1)
Global Capitation
77(1)
Gatekeeping and Primary Care Capitation
78(1)
Contact and Specialty Care Capitation
78(1)
Subcapitation Modeling
79(1)
Tertiary Capitation
80(1)
Nonindexed Capitation
81(1)
Understanding of "Operational" Capitation for the Health Care Industry
81(4)
Conclusion
85(2)
Chapter 3 Managed Care Provider and Practitioner Operations
87(26)
Introduction
87(1)
The Board of Directors
87(2)
Board Committees
89(1)
MCO Managers
89(3)
Chief Executive Officer
89(2)
Medical Director
91(1)
Network Director
91(1)
Chief Financial Officer
91(1)
Operations Director
91(1)
Marketing Director
91(1)
General Counsel/Compliance
92(1)
Payer Benefit Determination
92(1)
MCO Services
92(1)
MCO Economics
93(1)
Specialty HMOs
93(1)
Federal Qualification Eligibility by Office for Managed Care
93(4)
Application Process for FQHMO Qualification
95(1)
Site Visit Prior to FQHMO Qualification
96(1)
FQHMO Postqualification Process
96(1)
MCO Marketing and Product Development
97(3)
Market Segmentation Strategies
97(1)
Defining Desirable Market Segments
98(1)
Strategic Product-Positioning Drivers
99(1)
Distribution Channel Drivers of Effective Product Placement
99(1)
Revenue Drivers Based on Requests for Proposal and Requests for Information
100(1)
Request for Proposal
100(1)
Request for Information
100(1)
Payer and Practitioner/Provider Services
101(3)
Contracting
101(2)
Carve-Outs versus Carve-Ins
103(1)
Outsourcing
103(1)
Strategies to Manage Provider/Practitioner Costs
104(2)
Practitioner Profiling
104(1)
Episodes-of-Care Profiling
105(1)
Incentive Compensation Data
105(1)
Payer/Provider Budgeting and Financial/Resource Estimation
106(5)
MCO Budgeting
106(1)
Analyses of Administrative Costs
106(1)
Analyses of Capitated Medical Service Costs
106(1)
Analyses of Fee-for-Service Practitioner Costs
107(1)
Office Visit Frequency
108(1)
Nonnetwork and Referral Services Data
108(1)
Hospital Inpatient Utilization/Payment Data
108(2)
Comparative Market Data
110(1)
Conclusion
111(2)
Chapter 4 Managed Care Organization Quality Benchmarking
113(22)
Introduction
113(1)
Accreditation of HMOs under NCQA
114(7)
NCQA Accreditation Process
115(1)
Areas of NCQA Review
116(2)
Clinical Indicators Measured through MCO Accreditation
118(1)
Joint Commission Quality Indicators
118(1)
Health-Plan Employer Data and Information Set
118(3)
URAC Accreditation Procedures
121(3)
URAC Accreditation Process
121(1)
Areas of URAC Review
121(2)
Responsibility
123(1)
Information
123(1)
Procedures
123(1)
Appeals of Denied Authorizations
123(1)
Confidentiality
123(1)
Staff and Program Requirements
124(1)
Accessibility
124(1)
Accreditation of Preferred Provider Organizations
124(1)
AAPI Review Process
124(1)
Areas of AAPI Review
125(1)
Introduction to Six Sigma Quality Benchmarking Methodology
125(3)
Quality Improvement and Benchmarking Approach for Six Sigma
128(1)
Utilizing Six Sigma Benchmarking in MCO Operations
129(2)
Learning from Clinicians: Health Care Finance's Best Response to Six Sigma
131(1)
Conclusion
132(3)
Chapter 5 Managing the Managed Care Enrollee
135(28)
Introduction
135(2)
Managed Care Expectations of Enrollees
137(3)
Managed Care Enrollee Access and Accessibility Modeling
140(5)
Accessibility to Appropriate Specialty Care
142(1)
Provider/Practitioner Autonomy
143(1)
Access to Non-Allopaths and Allied Health Professionals
144(1)
Managed Care Choice
145(1)
Managed Care Quality at the Enrollee Level
146(5)
Managed Care Enrollee Impacts on Provider/Practitioner Costs
151(3)
Health Guidance Services for Managed Care Enrollees
154(1)
Community-Based Health Information
154(1)
Payer- or MCO-Provided Consumer Education
154(1)
Enrollee Health Guidance Internet Sites
154(1)
Enrollee Responsibility to Comply with Strategies for Treatment, Disease Adaptation, Health Status Improvement, and Healthiness Management
155(1)
Appropriateness of Provider Resource Utilization of Enrollees
156(1)
Methods of Transforming Behavior of Capitated Enrollees
157(3)
Lifestyle Improvement Contracts
158(1)
Incentivizing Enrollee Compliance
159(1)
Establishing Enrollee "Feedback Loops"
160(1)
Typical Member Rights and Responsibilities
160(2)
MCO Responsibilities for Improper Care
160(1)
MCO Contractual Responsibilities to Enrollees
161(1)
Conclusion
162(1)
Chapter 6 Enrollee-Based Financial and Mathematical Prediction Models
163(14)
Introduction
163(1)
Overview of Case Management/Utilization Management
163(2)
Use of Financial Data Derived from CM/UM
165(1)
Incurred-but-Not-Reported Case Management Data
165(7)
Indicators of Inappropriate IBNR Levels
166(1)
Inpatient Services
166(3)
Outpatient Services
169(1)
Practitioner Services
169(1)
Other Medical Services
170(1)
Ancillary Services
170(1)
Prescription Drugs
171(1)
Reinsurance Premiums
171(1)
Administrative Expenses
171(1)
Managed Care-Specific Financial Indicators
172(2)
Payer Indicators
173(1)
Practitioner Indicators
173(1)
Average Visits PMPY
173(1)
Referrals PMPY
173(1)
Authorization Compliance
174(1)
MCO Internal Control
174(1)
Controlling Claims by Linking to Authorizations
174(1)
PCP Cooperation in Enhancing Controls
175(1)
Conclusion
175(2)
Chapter 7 Management of Managed Care Information for Modeling Purposes
177(16)
Introduction
177(1)
Data Elements and Sources
178(5)
Data Captured from Claims Processing
179(1)
Data Captured from Case and Utilization Management
179(1)
Enrollment Data Sources
180(1)
Provider/Practitioner Data Sources
181(1)
Authorization Data Sources
181(2)
Definition of Database and Claims Payment Information Flows
183(2)
Basic MCO Database Information for Authorizations
184(1)
Concurrent Review Information Flows
184(1)
Episodes-of-Care Information Flows
185(1)
Distinction Between Logical and Physical Units of Managed Care Data
185(1)
Data and System Security Issues for MCOs
186(1)
Differences among Managed Care Reports
186(3)
Statistical Indicators Obtainable from Standard MCO Reports
186(1)
Planwide Statistics
187(1)
Service-Specific (e.g., Psychiatric, Surgical, Obstetric) Statistics
187(1)
Provider-Specific Statistics
188(1)
Other MCO Statistics
188(1)
Integration of Managed Care Databases
189(1)
Electronic Connectivity of Managed Care Information
190(1)
Conclusion
191(2)
Chapter 8 Managed Care Legal and Regulatory Compliance
193(28)
Introduction
193(1)
Federal Regulatory Compliance in Managed Care
193(18)
Payer Compliance
193(8)
Operational Compliance
201(1)
Managed Care Department
201(2)
Illegal Gain Sharing
203(4)
Illegal Downcoding
207(1)
Practitioner Compliance
208(1)
Physician Marketers
208(1)
Illegal Hospitalist Relationships
209(2)
Other Federal Issues
211(1)
State Issues
211(3)
Typical State Regulatory Requirements of Provider Contracts
212(1)
Variable State Regulatory Requirements of Provider Contracts
213(1)
State Insolvency Protections
213(1)
Compliance in Electronic Transmission of Member Records and Encounters
214(3)
Capitation Contractual Issues
217(1)
Model HMO Act
218(1)
Conclusion
219(2)
Chapter 9 Innovative Managed Care Modeling for the 21st Century
221(28)
Part A Modeling for Accountable Care Organizations Focusing on Medicare
221(1)
Needs Identification for Process Improvement ("Find" Phase)
222(1)
Establishing a Team Approach for Process Improvement ("Organize" Phase)
222(1)
Establishing Rationales for Process Improvement ("Clarify" Phase)
223(4)
Primary Care Access of All Medicare-Certified Physicians
223(1)
Inappropriate Primary Care Exclusion of Optometric Physicians
224(3)
Root Cause Analyses of Rationales for Process Improvement ("Understand" Phase)
227(5)
Biases Against Optometry
227(1)
Ignoring the Wellness Model Paradigm
228(1)
Underutilization of Eye Examinations for Systemic Diagnoses
228(3)
Ability of Eye Examinations to Reduce Primary Care Fragmentation
231(1)
Selection of Implementation Approach to Improve Care Deficits and Cost Savings ("Select" Phase)
232(2)
Care Deficits Leading to Potentially Avoidable Expenditures
233(1)
Promoting Greater Outpatient Service Efficiencies and Timely Access
233(1)
Selected Process Improvement to Implement
234(1)
Plan and Program Development to Implement Selected Process Improvement ("Plan" Phase)
234(5)
Program Development to Implement Selected Process Improvement
234(1)
Medically-Necessary Eye Examinations
234(1)
Optometrist Conformance to State Licensure Restrictions
234(1)
Establishment of Wellness Components to Individualized Care Plans
234(1)
Integrating Optometric Diagnostics with Respective PCMHs
234(1)
Importance of Integrating Optometrists with PCMH Team Conferences
234(4)
Integrating Optometric Diagnostics with Traditional EHR Archival Data
238(1)
Implementation Plan of Selected Process Improvement
238(1)
Phased Roll-Out of Implementation Plan Selected for Process Improvement ("Do" Phase)
239(2)
Validation of Process Improvement ("Check" Phase)
241(1)
Additional Criteria for Program Evaluation
242(1)
Action Steps to Re-Initiate the Deming Cycle ("Act" Phase)
242(1)
Part B An At-Risk Disease Management Approach for SSI Recipients
242(7)
Background
242(1)
Recommended ACO (Or Other At-Risk Approach) for SSI-Funded Chronic Disease Patients
243(1)
Medicaid Costs
243(1)
Cost-Structuring for Capitated Assumption of SSI Risk
243(2)
Positively Impacting Disease Adaptation
245(2)
Intended Outcomes of Innovative SSI Risk Approach
247(1)
Conclusion
247(2)
Chapter 10 Innovative MCO Financial Modeling for the 21st Century
249(18)
Introduction
249(1)
Future Value of Managed Care Contracting: PART 1
250(8)
Veracity of Charges in Managed Care Contracts
253(5)
Future Value of Managed Care Contracting: PART 2
258(5)
The Elephant in the Room: How Health Plans Can Compete with State Health Exchanges
259(3)
Coming Clean about "Health Maintenance"
262(1)
Conclusion---A Final (?) Stroll Down Memory Lane
263(4)
Index 267
David I. Samuels is the president and CEO of EthiCare Breakthrough Solutions/EthiCare Revenue Cycle Management, Inc., a consulting firm that specializes in sales and marketing activities tied to risk-free/net-recovery relationships and that identifies hospital undercharges by selecting specific charges for which services were rendered but never billed.