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At least 1,153 records · Page 64Linked to original sources
PubMed1999

The future of managed care: integration of financing, risk management, and delivery.

The most significant transformation of health-care delivery and the health insurance industry is under way in the United States. It will change forever, and for the better, the way the delivery and financing of our nation's health-care is structured. We are witnessing the industrialization and consolidation of what was once a fragmented cottage industry. The new system--we call it wave III--will result in the re-establishment of the physician/providers as the key decision makers in our health-care system of the future. In this next phase of change, organized groups of physicians and hospitals will replace the current HMO insurance structure. This Third Wave will witness the integration of technology, managerial skills, marketing, sales, and negotiating acumen that were previously in the domain of health insurance companies (HMOs) into a delivery system where physicians and hospitals become partners focusing their coordinated efforts in managing health-care and the associated premiums.

Delivery of Health Care, Integrated↗
PubMed2000

Provider terminations: strategies for risk management.

Managed care organizations should protect themselves from possible legal action by providers whom they have terminated, whether because of professional incompetence or for reasons related to the organization's business goals. Risk management begins by being aware of state and Federal laws regarding contracts, peer review, restraint of trade, discrimination, and retaliation against a provider. Managed care organizations should adopt a set of criteria for providers' professional competence as well as a list of business objectives that might necessitate the deselection of a provider. Because some courts have upheld a provider's right to a "fair procedure," managed care organizations also should consider offering providers an opportunity to respond to the termination decision.

Documentation↗
PubMed1999

Regulating through information: disclosure laws and American health care.

Efforts to reform the American health care system through direct government action have failed repeatedly. Nonetheless, an alternative strategy has emerged from these experiences: requiring insurance organizations and health care providers to disclose information to the public. In this Article, Professor Sage assesses the justifications for this type of regulation and its prospects. In particular, he identifies and analyzes four distinct rationales for disclosure. He finds that the most commonly articulated goal of mandatory disclosure laws--improving the efficiency of private purchasing decisions by giving purchasers complete information about price and quality--is the most complicated operationally. The other justifications--which he respectively terms the agency, performance, and democratic rationales--hold greater promise, but make different, sometimes conflicting assumptions about the sources and uses of information. These insights have implications not only for health care, but also for other regulated practices and industries.

Decision Making↗
PubMed1999

[Risk management in the USA].

In the US and even within healthcare, Risk Management as a concept has existed for a long time--however, never as formally as it exists today. The change in how risk is identified and managed in hospitals and within medical care has evolved considerably in just the last 25 years. Risk management took on increased importance with the medical malpractice crisis the US experienced in the mid-1970s. Up until then, it appears its primary function had been to economically transfer risk. With the advent of managed care, risks have been recognized as generators of considerable potential cost to the healthcare system and one that must be proactively managed. Today, the successful management of risk is an essential part of healthcare administration.

Humans↗