Understanding Managed Care

A unique series of cases based on a fictional family selecting and using a health plan is presented and a glossary is provided which defines basic concepts frequently encountered in the managed care field.

Physicians and allied health care professionals are graduating with in-depth knowledge of disease states and therapeutics, but little, if any practical knowledge of managed care systems. Nevertheless, managed care is so prevalent that in 1998 85% of the US working population was in some form of managed care network and one third of the physicians in practice were enrolled in managed care panels. There are few structured educational opportunities for individuals who are entering health care fields that help in understanding the different managed care systems. Instead, the managed care environment confronts the new physician with an unknown language, a novel management structure, and an expanding scope of rules and regulations. This book is designed to rectify this situation and to serve as a resource for teaching or independent self-paced study. It provides a historical overview, basic structure and components of managed care organizations, and future challenges. A unique series of cases based on a fictional family selecting and using a health plan is presented and a glossary is provided which defines basic concepts frequently encountered in the managed care field.

Managed care has produced dramatic changes in the treatment of mental health and substance abuse problems, known as behavioral health. Managing Managed Care offers an urgently needed assessment of managed care for behavioral health and a framework for purchasing, delivering, and ensuring the quality of behavioral health care. It presents the first objective analysis of the powerful multimillion-dollar accreditation industry and the key accrediting organizations. Managing Managed Care draws evidence-based conclusions about the effectiveness of behavioral health treatments and makes recommendations that address consumer protections, quality improvements, structure and financing, roles of public and private participants, inclusion of special populations, and ethical issues. The volume discusses trends in managed behavioral health care, highlighting the emerging role of the purchaser. The committee explores problems of overlap and fragmentation in the delivery of behavioral health care and discusses the issue of access, a special concern when private systems are restricted and public systems overburdened. Highly applicable to the larger health care system, this volume will be of particular interest to all stakeholders in behavioral healthâ€"federal and state policymakers, public and private purchasers, health care providers and administrators, consumers and consumer advocates, accrediting organizations, and health services researchers.

Pamphlet from the vertical file.

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.