Essentials of Managed Health Care / Edition 5

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Overview

This Is The Most Comprehensive And Widely-Used Textbook On Managed Care. The Fifth Edition Of This Authoritative Text Provides Practical Knowledge And Advice To Help You Master The Complexities Of Managed Care Today. With Learning Objectives For Each Chapter, A Glossary Of Terms And Common Acronyms, Study Questions, Tables And Charts, And The Expert Guidance Of Peter R. Kongstvedt, Essentials Of Managed Health Care Is A Perfect Introduction To The Key Concepts Of Managed Care. This Revision Includes Updates To All Chapters, As Well As New Sections On The Most Relevant Topics In Managed Care Today, Such As Pay For Performance, Consumer-Directed Healthcare Plans, Payor/Provider Collaboration, And Electronic Enablement Of Clinical Activities Supported By Health Plans. The Chapter On Medicare Has Been Completely Revised To Reflect The Recent Medicare Prescription Drug Act.

The book contains black-and-white illustrations.

This popular textbook provides the basic information needed to learn critical concepts of managed care. Derived from the best-selling Managed Health Care Handbook, 4th Edition, this text includes everything from types of managed care organizations, negotiating and contracting to controlling utilization and using data reports in medical management.

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Editorial Reviews

Margaret M. Murphy
This book provides a detailed description of the history and current trends in healthcare policy as they affect the development of managed healthcare in the United States. In addition, the operational, financial, legal, and regulatory issues affecting managed care systems and organizations are addressed. Potential sources of problems and specific solutions that could be used to abate the problems and enhance the functions and outcomes of managed healthcare are emphasized. This book is appropriately designed as a text for postgraduate study. It would be useful for students of healthcare administration, organizational design, and finance. However, it would also be of benefit to healthcare professionals who are likely to be employed by or working with managed healthcare organizations or systems. This second edition makes extensive use of current experience, data, and resources. The tables and exhibits are reflective of the latest information available on national and selected state/regional levels. The references and suggested additional readings are of recent vintage and enhance the expert resources available to the reader. The design is an educational one, with learning objectives heading each chapter, followed by study questions and references at the end of the chapter. This format assists the reader to focus on the essential content contained in each chapter. In addition, the glossary provided assists the reader with technical terms and the myriad of acronyms used throughout the text. This book is well designed and developed in an organized and logical manner. It is well worth consideration as a text for graduate study. Moreover, it would serve as an excellent basic referencetext for healthcare professionals working in today's changing healthcare environment.
Daniel K. Bixler
This is the latest edition of the editor's popular text, a companion to his now classic The Managed Health Care Handbook, 4th edition (Aspen Publishers, Inc. 2000). In this book he reviews key concepts of the evolving managed care system in America. The book is organized into six parts, and the editor offers a broad, if not deep, discussion of most relevant issues in managed care. The editor offers this work to provide the reader with a solid understanding of the fundamental concepts, purposes, organization, and function of managed healthcare. The book is geared toward physicians and others exploring the world of managed care and managers in any healthcare sector. It is appropriate for graduate students in healthcare administration. The content ranges far and wide in the managed care field. In Part I the basics of the managed care system are included, both facts and myths. In Part II contributors explore the organization and financing of healthcare delivery and in Part III they explain the various tactics used to manage the access to, cost of, and quality of healthcare. In Part IV details of the marketing and management for a managed care organization are presented. Part V is an illumination of recent trends in managing the care of Medicaid and Medicare patients. Finally, in Part VI contributors explore the current legal and regulatory environment of healthcare. In each chapter the reader is guided with study objectives, study questions, and an up-to-date bibliography. Chapters are cross-referenced to each other and to the parent text. There are black-and-white illustrations, useful tables and graphs, and a glossary of terms and acronyms. The editor describes theU.S. healthcare system as a "complexly adapting system." The information in this text is needed to reach beyond the notion of managed care as a "simplistic monolith," or as the final answer for our current dilemmas. This is a comprehensive primer on the subject of managed care. As with the other books in this series, in this new edition the editor once again strives to keep up with the fluid nature of managed care. His works have become the standard by which similar books will be measured.
Booknews
Provides practical knowledge and advice on the complexities of managed care. Part I overviews the history of managed health care and describes basic types of managed care plans and integrated health care delivery systems. Part II reviews basic provider sectors and how managed care works within them, and Part III addresses how managed care actually manages health care. Part IV looks at nonmedical operations of a health plan, and Part V covers Medicare and Medicaid. Part VI offers a brief overview of legal and regulatory topics. Learning features include chapter objectives, a glossary, and study questions. This is a companion to the parent text, . The editor is a partner in an international accounting and consulting firm. Annotation c. Book News, Inc., Portland, OR booknews.com
Doody's Review Service
Reviewer: Daniel K. Bixler, MD, MMM, FAAP (Creighton University Medical Center)
Description: This is the latest edition of the editor's popular text, a companion to his now classic The Managed Health Care Handbook, 4th edition (Aspen Publishers, Inc. 2000). In this book he reviews key concepts of the evolving managed care system in America. The book is organized into six parts, and the editor offers a broad, if not deep, discussion of most relevant issues in managed care.
Purpose: The editor offers this work to provide the reader with a solid understanding of the fundamental concepts, purposes, organization, and function of managed healthcare.
Audience: The book is geared toward physicians and others exploring the world of managed care and managers in any healthcare sector. It is appropriate for graduate students in healthcare administration.
Features: The content ranges far and wide in the managed care field. In Part I the basics of the managed care system are included, both facts and myths. In Part II contributors explore the organization and financing of healthcare delivery and in Part III they explain the various tactics used to manage the access to, cost of, and quality of healthcare. In Part IV details of the marketing and management for a managed care organization are presented. Part V is an illumination of recent trends in managing the care of Medicaid and Medicare patients. Finally, in Part VI contributors explore the current legal and regulatory environment of healthcare. In each chapter the reader is guided with study objectives, study questions, and an up-to-date bibliography. Chapters are cross-referenced to each other and to the parent text. There are black-and-white illustrations, useful tables and graphs, and a glossary of terms and acronyms.
Assessment: The editor describes the U.S. healthcare system as a "complexly adapting system." The information in this text is needed to reach beyond the notion of managed care as a "simplistic monolith," or as the final answer for our current dilemmas. This is a comprehensive primer on the subject of managed care. As with the other books in this series, in this new edition the editor once again strives to keep up with the fluid nature of managed care. His works have become the standard by which similar books will be measured.

5 Stars! from Doody
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Product Details

  • ISBN-13: 9780763739836
  • Publisher: Jones & Barlett Learning
  • Publication date: 3/28/2007
  • Edition description: 5E
  • Edition number: 5
  • Pages: 841
  • Sales rank: 600,425
  • Product dimensions: 7.04 (w) x 10.05 (h) x 1.67 (d)

Table of Contents

About the Editor
Contributors
Preface
Acknowledgments
Pt. I Introduction to Managed Care 1
Ch. 1 An Overview of Managed Care 3
Ch. 2 Types of Managed Care Organizations 17
Ch. 3 Integrated Health Care Delivery Systems 31
Ch. 4 Elements of the Management Control and Governance Structure 63
Ch. 5 Examining Common Assertions about Managed Care 71
Pt. II The Health Care Delivery System 83
Ch. 6 Primary Care in Managed Health Care Plans 85
Ch. 7 Compensation of Primary Care Physicians in Managed Health Care 103
Ch. 8 Contracting and Reimbursement of Specialty Physicians 141
Ch. 9 Negotiating and Contracting with Hospitals, Institutions, and Ancillary Services 157
Pt. III Medical Management 177
Ch. 10 Care Management and Clinical Integration Components 179
Ch. 11 Managing Basic Medical-Surgical Utilization 197
Ch. 12 Clinical Services Requiring Authorization 235
Ch. 13 Case Management and Managed Care 249
Ch. 14 Fundamentals and Core Competencies of Disease Management 281
Ch. 15 Prescription Drug Benefits in Managed Care 293
Ch. 16 Managed Behavioral Health Care and Chemical Dependency Services 332
Ch. 17 Quality Management in Managed Care 361
Ch. 18 Using Data and Provider Profiling in Medical Management 379
Ch. 19 Physician Behavior Change in Managed Health Care 419
Pt. IV Operational Marketing and Management 439
Ch. 20 Information Systems in Managed Health Care Plans 441
Ch. 21 Claims and Benefits Administration 461
Ch. 22 Member Services and Consumer Affairs 507
Ch. 23 Sales and Marketing in Managed Health Care Plans: The Process of Distribution 535
Ch. 24 The Employer's View of Managed Health Care: Show me the Value 555
Ch. 25 The Impact of Consumerism on Managed Health Care 566
Ch. 26 Accreditation and Performance Measurement Programs for Managed Care Organizations 587
Ch. 27 Common Operational Problems in Managed Health Care Plans 609
Ch. 28 Operational Finance and Budgeting 628
Ch. 29 Underwriting and Rating Functions Common to Most Markets 643
Pt. V Medicare and Medicaid 655
Ch. 30 Medicare and Managed Care 657
Ch. 31 Medicaid Managed Care 684
Pt. VI Regulatory and Legal Issues 703
Ch. 32 Legal Issues in Provider Contracting 705
Ch. 33 Legal Liability Related to Medical Management Activities 743
Ch. 34 The Health Insurance Portability and Accountability Act of 1996 764
Ch. 35 State Regulation of Managed Care 786
Ch. 36 Managed Care's Regulatory Evolution: Driving Change in the New Century 810
Epilogue - Managed Health Care at the Millennium 822
Glossary of Terms and Acronyms 833
Index 855
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