Managed Care : Practice and Progress

The concept of managed care evolved in the USA as a way of containing costs and promoting quality in health care. Some vital lessons can be learned from this experience, and many of its benefits can be applied to the UK as the NHS internal market develops. However, there are also pitfalls which it is equally important to avoid. This is the first book to provide an in-depth analysis of the contracting techniques seen in managed care. The author is in the rare position of being an NHS manager with practical experience of the US health care system, and has produced a first hand contemporary guide to managed care, highlighting its strengths and weaknesses and its relevance to the UK. To set the current debate about the future of the internal market and GP fundholding in context, the author offers a critical review of the NHS reforms and current management and clinician competencies. Citing American experience of the role of doctors in management, he demonstrates both the power and limitations of such initiatives. MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict MuPDF error: syntax error: invalid key in dict Cover 1 Title Page 2 Copyright Page 3 Contents 4 Preface 8 Abbreviations 10 1 Why study managed care? 12 Managed care: a product of history? 13 2 Managed care: the basic models 26 Key characteristics 28 Transatlantic misconceptions 29 Definitions 32 3 The anatomy of a managed care company 40 Sentara alternative delivery system - an overview 40 Summary of health plans 41 Claims/benefits and member services 44 Provider relations 49 Credentialling 54 Medical care management 55 Human resources 55 Health education 55 Marketing and sales 56 Administration and office operations 57 Management information systems 58 Finance 58 Underwriting 58 Conclusion 70 4 Reimbursement mechanisms - paying doctors and hospitals 72 Discounted fees 73 Capped fee schedule 74 Capped fee schedule with a withhold 75 Primary care capitation 76 Full/global capitation 77 Hospital payment strategies 78 Discount from charges 78 Per diem reimbursement 80 Per stay reimbursement 82 Capitation payments 87 Ancillary services payment systems 87 Contracting for mental health, learning disabilities and substance abuse services 88 Coverage limits 90 Utilization management 91 Case management 91 Adjusting payments for risk-sharing 94 Risk pools 95 Settlements 96 Stop-loss reinsurance 98 UK applications 99 Conclusion 112 5 Quality and utilization review 113 Utilization review techniques 114 Provider selection 115 Provider education 117 The utilization review process 118 Control methods 121 Moving forward on quality issues 122 Conclusion 126 6 Management information systems 127 Board level key indicators 132 The plan 133 7 The business process 139 Meetings 141 Management philosophy 142 Organizational structure 143 Management development 145 Sutton's law 146 The corporate role 147 Strategic planning 148 Capital planning 150 Economies of scale 152 Is current practice relevant? 153 Some simple lessons 154 8 Strategic issues in cost-containment 155 Overcapacity 157 Salary costs 161 Medical practice variation 163 Introduction of new drugs and technologies 164 The drive to improve quality of life and defeat death 165 The drowned and the saved 166 Conclusion 168 Appendix I: US hospital contract 169 Appendix II: US physician contract 175 Appendix III: NHS contracts 177 Appendix IV: HMO benefit packages 199 Appendix V: Examples of Sentara's treatment authorization protocols 209 Appendix VI: Reengineering Sentara 214 Appendix VII: Glossary 221 Appendix VIII: Refining current contracts - illustrations 235 References 238 Index 242 This book examines the principal methods by which managed care in the USA operates and considers its relevance to the embryonic National Health Service 'internal market'. It provides a greater focus to observations about US health care, management and techniques. First Published in 2018. CRC Press is an imprint of Taylor & Francis, an Informa company.