Course: Managed Care and Health Insurance

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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.

Topic 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.

Claxton G, Gabel J, Gil I et al. Health benefits in 2006: premium increases moderate, enrollment in
consumer-directed health plans remains modest. Health Affairs 2006 Nov-Dec;25(6):w476-85.

Robinson J. The commercial insurance industry in an era of eroding employer coverage. Health Affairs 2006;25:1475-1486.

Kaiser Family Foundation. How Private Insurance Works: A Primer. April 2002.

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.

Grossman J, Ginsburg P. As the Health Insurance Underwriting Cycle Turns: What Next? Health Affairs 2004;23:91-102.

4. PPOs and CDHPs and other non-HMO models

Hurley R, Strunk B, White J. The Puzzling Popularity of the PPO. Health Affairs 2004;23:56-68.

Gabel J, Pickreign J, Whitmore H. Behind the slow enrollment growth of employer-based consumer-directed health plans. Issue Brief. Center for Studying Health System Change. 2006 Dec;(107):1-4.

Bloche MG. Consumer-directed health care. NEJM 2006;355:1756-1759.

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.

Christianson J, Wholey D, Warrick L, Henning P. How Are Health Plans Supporting Physician Practice? The Physician Perspective. Health Affairs 2003;22:181-189.

Mays GP, Claxton G, White J. MarketWatch: Managed Care Rebound? Recent Changes In Health Plans' Cost Containment Strategies. Health Affairs Suppl Web Exclusives:W4-427-36

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

Rosenthal M, Fernandopulle R, Ryu Song H, Landon B. Paying for Quality: Providers' Incentives for Quality Improvement. Health Affairs 2004;23:127-141.

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

Kaiser Family Foundation. Medicaid At A Glance Fact Sheet, May, 2006.

Kaiser Family Foundation. Medicare Fact Sheets (Medicare At A Glance, Medicare Advantage, Medicare Prescription Drug Benefit), June 2006.

Biles B, Dallek G, Nicholas L. Medicare Advantage: Deja vu All Over Again? Health Affairs Web Exclusive, December 15, 2004.

Draper D, Hurley R, Short A. Medicaid Managed Care: The Last Bastion of the HMO? Health Affairs 2004;23:155-167.

Hurley RE, Retchin SM. Medicare and Medicaid managed care: a tale of two trajectories. Am J Manag Care. Jan 2006;12(1):40-44.

11. Managed Care and Public Sector Plans II : Medicaid and Health Reform for Uninsured

Kaiser Family Foundation. The Uninsured and Their Access to Health Care. October 2006.

McDonough JE, Rosman B, Phelps F, Shannon M. The third wave of Massachusetts health care access reform. Health Aff (Millwood). Nov-Dec 2006;25(6):w420-431.

Holahan J, Blumberg L. Massachusetts Health Care Reform: A Look At The Issues. Health Aff. November 1, 2006 2006;25(6):w432-443.

Etheredge LM. Massachusetts Reform Plus President Bush's Tax Credits: A National Model? Health Aff. November 1, 2006 2006;25(6):w444-446.

12. Managed Care in a Global Context Kongstvedt Chapter 29, Managed Care in Global Context
13. Ethical Issues in Managed Care & Health Insurance

Randel L, et al. How Managed Care Can Be Ethical. Health Affairs 2001;20:43-56.

Daniels & Sabin. The ethics of accountability in managed care reform. Health Affairs 1998;17:50-64.

Cookson R & Dolan P. Principles of justice in health care rationing. J Med Ethics 2000;26:323-329.

14. Pharmaceuticals: PBMs and Medicare Part D

Kongstvedt Chapter 15, Prescription Drug Benefits in Managed Care, p.293.

Cubanski J, Neuman P. Status Report On Medicare Part D Enrollment In 2006: Analysis Of Plan-Specific Market Share And Coverage. Health Affairs 2007;26:w1-w12

Kaiser Family Foundation. Prescription Drug Trends Fact Sheet. November 2005.

Kaiser Family Foundation. Medicare Prescription Drug Benefit Fact Sheet. November 2006.

15. Managed Behavioral/Mental Health Services

Kongstvedt Chapter 16, Managed Behavioral Health Care and Chemical Dependency Services, p.332.

Coleman M, Schnapp W, Hurwitz D, Hedberg S, Cabral L, Laszlo A, Himmelstein J. Overview of publicly funded managed behavioral health care. Adm Policy Ment Health 2005;32:321-40.