Course: Managed Care and Health Insurance
Required Textbook: Kongstvedt PR, editor. Essentials of Managed Health Care, 4th edition. Bartlett & Jones, 2001.
Full Reading List: Includes required readings and additional suggested readings.
|1. Overview of Insurance/Managed Care Principles and History||
Weiner JP, deLissovoy G. Razing a Tower of Babel: A Taxonomy for Managed Care and Health Insurance Plans. J Health Polit Policy Law 1993;18: 75-103.
Chollet DJ and Lewis M. Private Insurance: Principles and Practice. In Schieber G, editor. Innovations in Health Care Financing: Proceedings of a World Bank Conference, March 10-11, 1997. Washington DC: World Bank, p. 77-114.
|2. HMOs and Integrated Delivery Systems||
Kongstvedt Chapter 2, Types of Managed Care Organizations, p.17.
Kongstvedt Chapter 5, Examining Common Assertions about Managed Care, p.71.
Kongstvedt Chapter 3, Integrated Health Care Delivery Systems, p.31
Miller R, Luft H. HMO Plan Performance Update: An Analysis of the Literature, 1997-2001. Health Affairs 2002;21:63-86.
|3. Risk, Capitation, and other Financial Issues||
Kongstvedt Chapter 7, Compensation of Primary Care Physicians in Managed Health Care, p.103.
Kongstvedt Chapter 8, Contracting and Reimbursement of Specialty Physicians, p.141.
|4. PPOs and CDHPs and other non-HMO models|
5. Medical Management in IPA/Network HMOs
7. Medical Management in Group/Staff HMOs
Kongstvedt Chapter 11, Managing Basic Medical Surgical Utilization, p.197.
Kongstvedt Chapter 12, Clinical Services Requiring Authorization, p.179.
6. Quality & Accountability I
9. Quality & Accountability II
Kongstvedt Chapter 17, Quality Management in Managed Care, p.361.
Kongstvedt Chapter 26, Accreditation and Performance Measurement Programs for Managed Care Organizations, p.587.
Also see www.ncqa.org
|8. Organizational and Provider Network Challenges in an Academic Integrated System||
Kongstvedt Chapter 27, Common Operational Problems in Managed Health Care Plans, p.609.
|10. Managed Care and Public Policy I: Medicare & Medicaid Managed Care|
|11. Managed Care and Public Sector Plans II : Medicaid and Health Reform for Uninsured|
|12. Managed Care in a Global Context||Kongstvedt Chapter 29, Managed Care in Global Context|
|13. Ethical Issues in Managed Care & Health Insurance|
|14. Pharmaceuticals: PBMs and Medicare Part D||
Kongstvedt Chapter 15, Prescription Drug Benefits in Managed Care, p.293.
|15. Managed Behavioral/Mental Health Services||
Kongstvedt Chapter 16, Managed Behavioral Health Care and Chemical Dependency Services, p.332.