Law and Practice of Private Health Insurance and Managed Care
- Art: Diplomarbeit
- Autor: Christian Funk
- Abgabedatum: Januar 2000
- Umfang: 143 Seiten
- Dateigröße: 6,3 MB
- Note: 1,0
- Institution / Hochschule: Technische Universität Darmstadt Deutschland
- ISBN (eBook): 978-3-8324-2321-6
-
ISBN (Paperback) :
978-3-8324-2321-6 P - ISBN (CD) :978-3-8324-2321-6 CD
- Sprache: Englisch
- Prämierung:
- Arbeit zitieren: Funk, Christian Januar 2000: Law and Practice of Private Health Insurance and Managed Care, Hamburg: Diplomica Verlag
- Schlagworte: Disease Management, Health Maintenance Organization, Managed Care, Medical Savings Account, Utilization Review
In den Warenkorb
48,00 €
Diplomarbeit von Christian Funk
Abstract:
A true revolution has taken place in the financing of health care in America. Today, managed care is dominating the way Americans receive and pay for their health care.
With the rise of managed care medicine has been wrenched out of its atomized world of solo physician practices and community hospitals and has been transformed into a modern industry of giant for-profit companies traded on Wall Street. The current marketplace is characterized by mergers, acquisitions and the establishment of giant multi-billion dollar healthcare networks. Hospitals and managed care plans run big advertisement campaigns in the media, praising their products and services in order to get the biggest share possible of the $1.1 trillion America spends on health care each year. All parties involved in providing health care lobby for their interests at all levels of political decision-making in order to influence legislators and policymakers.
Today’s health care market changes quickly and at a high rate. New variations of managed care arise constantly making any analysis of managed care an ongoing game of "catch-up" with the marketplace. While writing this paper, for example, UnitedHealthcare dropped one of the major managed care instruments, utilization review, to address public’s concerns and pending legislation. This paper will take a “snapshot” of managed care on the eve of the new millennium by using the most recent information available.
After this introduction, the paper will give a description of the current American health care system in chapter two (The U.S. Health Care System). Then, the paper will focus on two aspects: A detailed description of managed care in chapter three (Managed Care) and an introduction of the main issues connected with this way of providing health care in chapter four (Managed Care issues). The paper will argue in chapter five (Results and Future Developments), that managed care of the future will be a “light” version of what is currently existing, resulting in less strict restrictions and more freedom for patients and doctors.
Finally, the report will focus on recent developments in Germany, where policy-makers have started to adopt particular elements of managed care. In chapter six (Managed Care Approaches in Germany), the paper will argue, that Germany should pay more attention to the American experiences regarding managed care in order to prevent harm for patients in Germany.
Inhaltsverzeichnis:
| Acknowledgements | V | |
| Tables and Figures | VI | |
| Abbreviations | VII | |
| 1. | Introduction | 1 |
| 2. | The U.S. Health Care System | 3 |
| 2.1 | History of U.S. Health Insurance | 3 |
| 2.2 | Health Plan Options | 6 |
| 2.2.1 | Indemnity Insurance | 6 |
| 2.2.2 | Managed Care | 7 |
| 2.2.3 | Medical Savings Account | 8 |
| 2.2.4 | Medicare | 11 |
| 2.2.5 | Medicaid | 14 |
| 2.3 | Coverage | 16 |
| 2.3.1 | Employer-Sponsored Coverage | 16 |
| 2.3.2 | Individual Insurance | 19 |
| 2.3.3 | Government Sponsored Coverage | 20 |
| 2.3.4 | The Uninsured | 20 |
| 2.4 | The Rise of Managed Care | 21 |
| 2.5 | Current Marketplace | 24 |
| 2.6 | Summary | 26 |
| 3. | Managed Care | 27 |
| 3.1 | Definitions | 27 |
| 3.1.1 | Managed Care | 27 |
| 3.1.2 | Managed Care Organization | 28 |
| 3.1.3 | Purchaser | 29 |
| 3.1.4 | Members | 29 |
| 3.1.5 | Heath Care Professionals | 29 |
| 3.1.6 | Administrative Organizations | 30 |
| 3.2 | Managed Care Organizations | 31 |
| 3.2.1 | Health Maintenance Organization | 31 |
| 3.2.2 | Preferred Provider Organization | 36 |
| 3.2.3 | Provider-Sponsored Organization | 37 |
| 3.3 | Managed Care Products | 38 |
| 3.3.1 | Closed-Panel HMO | 38 |
| 3.3.2 | Exclusive Provider Organization | 39 |
| 3.3.3 | Open-Access HMO | 39 |
| 3.3.4 | Point of Service Plan | 39 |
| 3.3.5 | Open-Access PPO | 40 |
| 3.3.6 | Other Products | 40 |
| 3.3.7 | Summary | 41 |
| 3.4 | Techniques for Managing Care | 41 |
| 3.4.1 | Gatekeeping and Primary Care Physician | 42 |
| 3.4.2 | Provider Payment | 42 |
| 3.4.3 | Utilization Management | 45 |
| 3.4.4 | Disease Management and Clinical Guidelines | 48 |
| 3.5 | Sales Process for Managed Care Plans | 50 |
| 3.6 | Summary | 52 |
| 4. | Managed Care Issues | 54 |
| 4.1 | Legal Framework | 55 |
| 4.1.1 | McCarren-Ferguson Act | 55 |
| 4.1.2 | Health Maintenance Organization Act | 56 |
| 4.1.3 | Mandated Benefits | 56 |
| 4.1.4 | ERISA | 58 |
| 4.1.5 | Health Insurance Portability and Accountability Act | 59 |
| 4.2 | Cost Issues | 60 |
| 4.2.1 | For-Profit Orientation | 60 |
| 4.2.2 | Administration Costs | 62 |
| 4.2.3 | Adverse Selection | 63 |
| 4.3 | Quality Issues | 64 |
| 4.3.1 | Doctor-Patient Relationship | 64 |
| 4.3.2 | Liability | 66 |
| 4.3.3 | Administrative Burdens | 71 |
| 4.3.4 | Medical Privacy | 72 |
| 4.3.5 | Scope of Insurance Coverage | 73 |
| 4.4 | Access Issues | 74 |
| 4.4.1 | Continuity of Coverage | 74 |
| 4.4.2 | Provider Restrictions | 77 |
| 4.4.3 | Access to Emergency Care | 78 |
| 4.5 | Recent Legal Development | 79 |
| 4.5.1 | Anti-Managed Care Legislation | 80 |
| 4.5.2 | Patient’s Bill of Rights | 84 |
| 4.6 | Summary | 86 |
| 5. | Results and Future Developments | 88 |
| 5.1 | Medical Darwinism | 88 |
| 5.2 | The Industry is Changing | 89 |
| 5.3 | Managed Care “light” | 91 |
| 5.4 | Summary | 93 |
| 6. | Managed Care Approaches in Germany | 94 |
| 6.1 | The German Health Care System | 95 |
| 6.2 | Recent Changes and Developments | 96 |
| 6.2.1 | Vernetzte Praxen | 97 |
| 6.2.2 | Disease Management and Clinical Guidelines | 98 |
| 6.2.3 | Case Management | 99 |
| 6.3 | Evaluation of Germany’s Managed Care Approach | 99 |
| 6.4 | Summary | 101 |
| 7. | Summary | 102 |
| Appendix A: Individual Health Plan | 104 | |
| Appendix B: Group Health Plan | 117 | |
| Appendix C: Services Covered Under Medicare Part A | 122 | |
| Appendix D: Services Covered Under Medicare Part B | 123 | |
| Appendix E: Medicare Supplemental Policies | 124 | |
| Appendix F: Managed Care Related Legislation | 125 | |
| Appendix G: Industry Leaders | 126 | |
| Literature | 127 |
In den Warenkorb
48,00 €
Link zur Arbeit:
http://www.diplom.de/ean/9783832423216
Arbeit zitieren:
Funk, Christian Januar 2000: Law and Practice of Private Health Insurance and Managed Care, Hamburg: Diplomica Verlag
Schlagworte:
Disease Management, Health Maintenance Organization, Managed Care, Medical Savings Account, Utilization Review
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