Managed health care in the new millennium : innovative financial modeling for the 21st century

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 book's multidisciplinary focus puts the spotlight on core concepts from the standpoints of health plans, hospitals, physician practice, and their respective integrated network models. You'll learn what happened when a country's national health care plan is developed with problematic underwriting, why hospitals will always be victimized at their payer's 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 family's health status, and improve your differentiation in a RAPIDLY changing marketplace Content: An Updated Introduction to Managed Care and Capitation Introduction A Simple Definition-But Not So Simple History-of Managed Care and Capitation Understanding Managed Care in the Private and Public Sectors: A Reality Check Understanding Capitation-and Not Just Financially Effects of Public Policies on Capitation and Capitated Relationships A Simplified Understanding of Managed Care Models Two Basic Demand Models of Managed Care: Illness-Based Versus Wellness-Based Understanding Health Plans Understanding Managed Care Industry Operations Introduction To The Insurance Industry Understanding ERISA Implications for HMOs and Employers Introduction to Managed Care Underwriting Introduction to Commercially Insured Populations Understanding Rating Methodologies: Community Versus Experience Understanding and Predicting Medical Losses Introduction to Actuarial Mathematics Premium and Product Issues Employer Benefit Plan Design Payer-Provider Risk Relationships Stop-Loss and PMPM Relationships Other Interrelationships Risk Banding and Provider Risk-Sharing Arrangements Payer-Provider Financial Relationships Claims Management and Processing Referral Management Payer Development of Provider Panels Outcomes Reporting Advanced Studies in Capitated Managed Care Understanding of "Operational" Capitation for the Healthcare Industry Conclusion Managed Care Provider and Practitioner Operations Introduction The Board of Directors Payer Benefit Determination MCO Economics Specialty HMOs Federal Qualification Eligibility by Office for Managed Care MCO Marketing and Product Development Revenue Drivers Based on Requests for Proposal and Requests for Information Payer and Practitioner/Provider Services Strategies to Manage Provider/Practitioner Costs Payer/Provider Budgeting and Financial/Resource Estimation Conclusion Managed Care Organization Quality Benchmarking Introduction Accreditation of HMOs Under NCQA URAC Accreditation Procedures Accreditation of Preferred Provider Organizations Introduction to Six-Sigma Quality Benchmarking Methodology Quality Improvement and Benchmarking Approach for Six Sigma Utilizing Six Sigma Benchmarking in MCO Operations Learning from Clinicians: Healthcare Finance's Best Response to Six Sigma Conclusion Managing the Managed Care Enrollee Introduction Managed Care Expectations of Enrollees Managed Care Enrollee Access and Accessibility Modeling Managed Care Choice Managed Care Quality at the Enrollee Level Managed Care Enrollee Impacts on Provider/Practitioner Costs Health Guidance Services for Managed Care Enrollees Enrollee Responsibility to Comply With Strategies for Treatment, Disease Adaptation, Health Status Improvement, and Healthiness Management Appropriateness of Provider Resource Utilization of Enrollees Methods of Transforming Behavior of Capitated Enrollees Typical Member Rights and Responsibilities Conclusion Enrollee-Based Financial and Mathematical Prediction Models Introduction Overview of Case Management/Utilization Management Use of Financial Data Derived from CM/UM Incurred-But-Not-Reported Case Management Data Managed Care-Specific Financial Indicators MCO Internal Control Conclusion Management of Managed Care Information for Modeling Purposes Introduction Data Elements and Sources Definition of Database and Claims Payment Information Flows Distinction Between Logical and Physical Units of Managed Care Data Data and System Security Issues for MCOs Differences Among Managed Care Reports Integration of Managed Care Databases Electronic Connectivity of Managed Care Information Conclusion Managed Care Legal and Regulatory Compliance Introduction Federal Regulatory Compliance in Managed Care State Issues Compliance in Electronic Transmission of Member Records and Encounters Capitation Contractual Issues Model HMO Act Conclusion Innovative Managed Care Modeling for the 21st Century Part A: Modeling for Accountable Care Organizations Focusing on Medicare Needs Identification for Process Improvement ("Find Phase") Establishing Team Approach for Process Improvement ("Organize" Phase) Establishing Rationales for Process Improvement ("Clarify" Phase) Root Cause Analyses of Rationales for Process Improvement ("Understand" Phase) Selection of Implementation Approach to Improve Care Deficits and Cost Savings ("Select" Phase) Plan and Program Development to Implement Selected Process Improvement ("Plan" Phase of Deming's Cycle) Roll-Out of Implementation Plan Selected for Process Improvement ("Do" Phase) Validation of Process Improvement ("Check" Phase) Action Steps to Re-initiate the Deming Cycle ("Act" Phase) Part B: An At-Risk Disease Management Approach for SSI Recipients Conclusion Innovative MCO Financial Modeling for the 21st Century Introduction Future Value of Managed Care Contracting: Part 1 Future Value of Managed Care Contracting: Part 2 Conclusion: A Final Walk Down Memory Lane Index "Thoroughly exploring how capitation has evolved domestically and internationally in recent years, this book discusses actuarial assumptions and the difficulties in payers transitions from community-based underwriting to experience-based ratings. It explores what the future holds in the areas of clinical pathways and population-based risk assumption tools and approaches. It covers what happens when the underlying actuarial and risk assumptions are ignored or trivialized. The author also discusses the challenges capitation-based pricing faces from an international perspective, including Latin America and the Caribbean"--Provided by publisher. Thoroughly exploring how capitation has evolved domestically and internationally in recent years, this book discusses actuarial assumptions and the difficulties in payers transitions from community-based underwriting to experience-based ratings. It explores what the future holds in the areas of clinical pathways and population-based risk assumption tools and approaches. It covers what happens when the underlying actuarial and risk assumptions are ignored or trivialized. The author also discusses the challenges capitation-based pricing faces from an international perspective, including Latin America and the Caribbean. - Provided by publisher