MANAGED HEALTH CARE – Jones & Bartlett Learning

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               ESSENTIALS OF
            MANAGED
           HEALTH CARE
                                  FIFTH EDITION



             Peter R. Kongstvedt, MD, FACP
                   Accenture Health & Life Sciences Consulting
                                   Reston, VA
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         Copyright  2007 by Jones and Bartlett Publishers, Inc.

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         Production Credits
         Publisher: Michael Brown
         Production Director: Amy Rose
         Associate Production Editor: Daniel Stone
         Associate Editor: Katey Birtcher
         Marketing Manager: Sophie Fleck
         Manufacturing Buyer: Therese Connell
         Composition: Auburn Associates, Inc.
         Cover Design: Kate Ternullo
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         Library of Congress Cataloging-in-Publication Data
         Essentials of managed health care / [edited by] Peter R. Kongstvedt. -- 5th ed.
              p. ; cm.
          Rev. ed. of: The managed health care handbook. 4th ed. 2001. Also rev. ed. of: Essentials of managed health care. 4th
         ed. 2001.
          Includes bibliographical references and index.
          ISBN-13: 978-0-7637-3983-6
          ISBN-10: 0-7637-3983-9
          1. Managed care plans (Medical care)--Management. I. Kongstvedt, Peter R. (Peter Reid) II. Managed health care
         handbook.
           [DNLM: 1. Managed Care Programs--organization & administration--United States. 2. Delivery of Health Care--
         economics--United States. W 130 AA1 E7 2007]
          RA413.E87 2007
          362.104258--dc22
                                                2006028835
         6048

         Printed in the United States of America
         11 10 09 08 07 10 9 8 7 6 5 4 3 2 1


         This publication is designed to provide accurate and authoritative information in regard to the subject matter covered.
         It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional
         service. If legal advice or other expert assistance is required, the service of a competent professional person should be
         sought.
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                                            To my son David
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                                                                          TABLE OF CONTENTS



         Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
         About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
         Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
         Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
         Keeping Current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

         Part 1: Introduction to Managed Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
         Chapter 1          The Origins of Managed Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   3
                            Peter D. Fox and Peter R. Kongstvedt
         Chapter 2          Types of Managed Care Plans and Integrated Healthcare Delivery Systems . . .                                       19
                            Eric R. Wagner and Peter R. Kongstvedt
         Chapter 3          Elements of the Management Control and Governance Structure . . . . . . . . .                                      41
                            Peter R. Kongstvedt
         Chapter 4          Common Myths and Assertions about Health Plans . . . . . . . . . . . . . . . . . . .                               51
                            Brian J. McKenna

         Part 2: The HealthCare Delivery System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
         Chapter 5          Physician Networks in Managed Health Care . . . . . . . . . . . . . . . . . . . . . . . .                          63
                            Peter R. Kongstvedt
         Chapter 6          Basic Compensation of Physicians in Managed Health Care . . . . . . . . . . . . .                                  93
                            Peter R. Kongstvedt
         Chapter 7          Hospitals, Facilities, and Ancillary Services . . . . . . . . . . . . . . . . . . . . . . . . .                  135
                            Peter R. Kongstvedt
         Chapter 8          Performance-Based Incentives in Managed Health Care:
                            Pay-for-Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          165
                            Peter R. Kongstvedt

         Part 3: Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
         Chapter 9 Managing Basic Medical-Surgical Utilization . . . . . . . . . . . . . . . . . . . . . . . . 189
                      Peter R. Kongstvedt and Kimberley A. Mentzer
         Chapter 10 Fundamentals and Core Competencies of Disease Management . . . . . . . . . 233
                      David W. Plocher


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