Kongstvedt - Health insurance and managed care: what they are and how they work

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To order this product, use ISBN: 978-1-284-04325-9

Library of Congress Cataloging-in-Publication Data

Kongstvedt, Peter R. (Peter Reid), author, editor.

[Managed care]

Health insurance and managed care : what they are and how they work / Peter R. Kongstvedt. -- Fourth edition.

p. ; cm.

Preceded by Managed care : what it is and how it works / Peter R. Kongstvedt. 2009.

Some of the chapters are adapted from previously published works by the same author.

Includes bibliographical references and index.

ISBN 978-1-284-08711-6 (paper)

I. Title.

[DNLM: 1. Managed Care Programsorganization & administrationUnited States. 2. W 130 AA1]

RA413.5.U5

362.10425dc23

2014047770

6048

Printed in the United States of America

19 18 17 16 15 10 9 8 7 6 5 4 3 2 1

Contents

Preface

This fourth edition of Health Insurance and Managed Care: What They Are and How They Work is significantly changed and updated from the third edition, beginning with the title. The reason for the changed title is not because health insurance was not addressed in prior editionsit always has been part of the texts contentbut rather because the terms health insurance and managed care are now commonly used to refer to the same thing, to the point that many people simply call any type of health benefits plan health insurance.

High-level descriptions of what is new in this edition and what has changed are found in the New to This Edition section that follows this Preface. First, however, it is necessary to point out the biggest change affecting every single chapter: the Patient Protection and Affordable Care Act (ACA), which was passed by the U.S. Congress and signed into law by President Barack Obama on March 23, 2010. The ACA is addressed specifically in the Laws and Regulations in Managed Care chapter, but it is also covered throughout the entire text wherever it applies, which is pretty much everywhere.

Like this industry overall, the history of the ACA, including its current state, has been subject to many political forces and regulatory changes, meaning certain elements of the ACA described in this text may, in fact, change or no longer apply after the texts publication. Changes continue to take place outside the ACA as well, which is why I have provided some sources from which to obtain updated information (see the Keeping Current section that follows).

As we continue to add new laws, new regulations, new plan designs, new payment methodologies, and new means of managing utilization and quality, it becomes increasingly challenging to keep the overall size of this text down. The only way I have found to address this issue is to focus only on the most important aspects, and to keep most descriptions at about the same level. As a result, readers who have no knowledge of how health insurance and managed care actually work will at times feel overwhelmed with detail. In some cases it may make sense to complete a chapter and then go back and reread any confusing sections, which will have become more understandable in the context of the rest of the material. In contrast, readers who are veterans of the industry will be struck by how much has been left out. If that second group of readers wants more detail, they can find it in this texts big sister, The Essentials of Managed Health Care, Sixth Edition, also published by Jones & Bartlett Learning.

Change is a constant, and whenever you hear someone complain about how the healthcare system in the United States is undergoing turbulent times, you should recognize that it has actually been in a state of flux for close to a century. As one acquaintance of mine remarked, Health care is in permanent white water. Wishing we could return to the calm and placid times in the past is the same as wishing we could return to the world of Leave It to Beaver; both are fiction and never actually existed.

The causes of this ongoing turbulence also continue to change, and not just as the result of new laws and regulations. Health costs keep rising, but where once that trend was due primarily to overutilization, it now reflects a great many factors, including pricing, advances in technology, and changing demographics and consumer demands. The industrys dynamic nature is the reason that health insurance and managed care are now so difficult to distinguish from each other. It is also the reason for this text, and the reason you are reading it.