Understanding Managed Care

Physicians and allied health care professionals are graduating with in-depth knowledge of disease states and therapeutics, but little, if any practical knowledge of managed care systems. Nevertheless, managed care is so prevalent that in 1998 85% of the US working population was in some form of managed care network and one third of the physicians in practice were enrolled in managed care panels. There are few structured educational opportunities for individuals who are entering health care fields that help in understanding the different managed care systems. Instead, the managed care environment confronts the new physician with an unknown language, a novel management structure, and an expanding scope of rules and regulations. This book is designed to rectify this situation and to serve as a resource for teaching or independent self-paced study. It provides a historical overview, basic structure and components of managed care organizations, and future challenges. A unique series of cases based on a fictional family selecting and using a health plan is presented and a glossary is provided which defines basic concepts frequently encountered in the managed care field.