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Managed Care

"The term managed care encompasses a diverse array of institutional arrangements, which combine various sets of mechanisms, that, in turn, have changed over time. The chapter reviews these mechanisms, which, in addition to the methods employed by traditional insurance plans, include the selection and organization of providers, the choice of payment methods (including capitation and salary payment), and the monitoring of service utilization."

The Managed Care Backlash on Health Care Costs: Evidence From State Regulation of Managed Care Cost Containment Practices

"During the late 1990s, there was a substantial cultural, media and legal backlash against the cost-containment practices of managed care organizations (particularly, HMOs).... [T]he backlash had a strong effect on health care costs, and can statistically explain much of the rise in health spending as a share of U.S. GDP between 1993 and 2005 (amounting to 1% to 1.5% of GDP).... [The author concludes that] managed care was largely successful in keeping health care costs on a sustainable path relative to the size of the economy."

Conversations on the Changing Face of Managed Care: Insights from the 2006-2007 Podcast Series (PDF)

34 pages. Excerpt: Managed care executives are inundated almost daily with information, which they need to read and process to keep up with the rapid changes taking place in health care. This supplement is based on a series of 10 podcasts that were conducted in late 2006 and the first half of 2007 to give health care professionals an opportunity to learn about new developments in managed care. The host for the series was Ian Morrison,PhD, an internationally known author, consultant, and futurist specializing in long-term forecasting and planning. Each podcast consisted of a discussion between Morrison and an expert on an issue important to the business and bottom line of managed care organizations.

'Principles of Managed Care' Based on Policy Developed by AMA's Council on Medical Service (PDF)

34 pages. Excerpt: Principles of Managed Care,' a booklet largely based on policy developed by the AMA's Council on Medical Service, provides guidelines for establishing equitable and effective policies and procedures for managed care practices to ensure high-quality health care services for patients and fairness for physicians. The AMA strongly encourages managed care organizations and payer groups to follow the guidelines; public or private entities that evaluate managed care for[.]

Health Insurance Companies and the Managed Care Roller Coaster

Excerpt: 'Managed care' is, to many, a nasty phrase. But the truth is that the insurer who understands that 'managing care' means making sure that customers get the high-quality care they need, when they need it, will save money. When it comes to health care, low cost and high quality go hand-in-hand. At the same time, 'managing care' means avoiding ineffective care.

Conversations on The Changing Face Of Managed Care: Insights from Managed Care Magazine's Podcast Series (PDF)

34 pages. Articles include 'Seeing Through Transparency [from the Employer's Perspective],' 'Electronic Health Information,' 'The Future of Disease Management' and 'Consumer-Directed Health Plans.

Seeing Through Transparency: The Managed Care Evolution (PDF)

35 pages. Excerpt: The year 2006 marked the fifth consecutive Medical Director Colloquy. This year's theme 'Seeing Through Transparency: The Managed Care Evolution' probed, challenged, and stimulated rich discussion among participants and faculty about how health plans, employer groups, clinicians, and consumers gather, assess, and use data to evaluate, select, and pay for health care services.

Bars to Managed Care Lawsuits

Excerpt: Historically, managed care companies have been afforded immunity from negligence and malpractice lawsuits. Several state and federal bars, including ERISA (Employee Retirement Income Security Act of 1974), have insulated managed care companies from liability relating to the treatment of patients. Likewise, managed care companies have historically been immune from malpractice committed by a health care member of its panel of providers.

From Managed Care to Higher Costs for Patients to Insurer's Provider-Cost-Containment Measures to Provider Backlash

Excerpt: Insurers have focused on business practices that include delaying payments to providers, 'bundling' several procedures and then reimbursing at a lower rate, and underpayment of services provided outside the network. These newer cost-containment measures have now raised the ire of providers. According to an article written by Maureen Glabman in the February 2009 issue of Managed Care, class-action lawsuits filed by providers against all of the major health plans have nearly tripled from the late nineties to the first five years of this century. According to Glabman, these suits already have resulted in combined, multi-billion dollar settlements-- and there are many similar cases still working their way through the court system. Angry providers, backed up by the American Medical Association (AMA) and state medical societies, are 'empowered as nearly anonymous members of class action lawsuits,' observes Glabman, to try and fight carrier business practices they feel are depriving them of income.

Managed Care State Laws & Regulations, Including Consumer & Provider Protections – Updated April '06

The information is presented in seven tables: 2005 Managed Care Laws, Access to Services (2 tables), Appeals and Remedies, Provider Flexibility and Report Cards, Mandates, and Comprehensive Consumer Rights Statutes with citations.