Managed Health Care in the New Millennium : Innovative Financial Modeling for the 21st Century book cover
1st Edition

Managed Health Care in the New Millennium
Innovative Financial Modeling for the 21st Century

ISBN 9781439840306
Published December 5, 2011 by Productivity Press
306 Pages 3 B/W Illustrations

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Book Description

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.

Table of Contents

An Updated Introduction to Managed Care and Capitation
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

Managed Care Provider and Practitioner Operations
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

Managed Care Organization Quality Benchmarking
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

Managing the Managed Care Enrollee
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

Enrollee-Based Financial and Mathematical Prediction Models
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

Management of Managed Care Information for Modeling Purposes
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

Managed Care Legal and Regulatory Compliance
Federal Regulatory Compliance in Managed Care
State Issues
Compliance in Electronic Transmission of Member Records and Encounters
Capitation Contractual Issues
Model HMO Act

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

Innovative MCO Financial Modeling for the 21st Century
Future Value of Managed Care Contracting: Part 1
Future Value of Managed Care Contracting: Part 2
Conclusion: A Final Walk Down Memory Lane

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David I. Samuels is the president and CEO of EthiCare Breakthrough Solutions/EthiCare Revenue Cycle Management, Inc., a consulting firm that specializes in sales and marketing activities tied to risk-free/net-recovery relationships and that identifies hospital undercharges by selecting specific charges for which services were rendered but never billed.


Managed Health Care in the New Millennium is elegant in both the simplicity of its premise, as well as the detail in which David Samuels lays out a prescription for navigating the uncharted, murky waters of Health Care’s future. His rational, plausible take on the complex problems, and possible solutions, while not offered as a panacea for an industry in turmoil, is fresh and bold. For once, consumers are not ignored as hapless victims, or un-savvy consumers. Instead, they are given practical tools and a voice, which may just be the future path to simultaneously cut costs and improve the quality of the care they so well deserve. Well done David!
—Andre B. Van Niekerk, PhD, Dean, School of Business, Woodbury University, President, (LBR) Luxury Branding Research, Los Angeles

Managed Care in the New Millennium is more than a very readable future history of managed healthcare. It’s a call to action for those who must make decisions on how healthcare services should be delivered and how the financing on managed care should be carefully structured towards common medical and financial goals. Managed Care in the New Millennium should be required reading for everyone needing to understand how managed healthcare worked in the past, is now "working" in the present and how managed care will evolve in the future. Mr. Samuels presents valuable information for medical and hospital administrators, healthcare insurance companies, legislators, human resource managers, consultants, and individual patients that is long overdue.
—Lawrence R. Lievense, FHFMA, FACMPE, Healthcare FINANCIAL Experts, Inc.,

David Samuels’ book comes to the market just in time for health plans, physicians and hospitals to consider new options in a post reform environment. An expert in reimbursement and the mathematical fundamentals of prospective payment for over three decades, David has updated his original book, Capitation, in line with the refocused needs of providers and payers to collaborate over value instead of fighting one another over manipulated fees schedules and volume. In short order we get a 15-year update on where managed care went wrong in its reimbursement and how the use of performance data and more thoughtful application of care management techniques can build accountability into a mutual framework of payment and service for purchasers and providers. The author then goes one step further into offering innovation upon a theme to expand the thinking and capabilities of providers and purchasers to share savings and put in place key performance indicators using predictable formulas. David’s work can help many healthcare executives do a better job of understanding and planning for the future. We recommend his publications to our clients and believe his innovation offers insight into what accountable care means and how the consumer will eventually benefit through a more rational and defined care system.
William J De Marco MA, CMC, President and Chief Executive Officer, De Marco & Associates, Inc.

David Samuels offers great insight into the health care insurance markets and the enormous potential of capitation to contribute to the solutions our Nation so sorely needs. Capitation will inevitably impact the industry's evolution and I know of no more comprehensive and detailed a depiction of its strengths and opportunities than Managed Health Care in the New Millennium.
Carl Heard, MD, MMM, Independent Locums Physician, Consultant for Medical Management