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Published by: Kalorama Information
Published: Jul. 1, 1997 - 202 Pages Now 50% off the original sale price of $3,250.
Table of Contents
Chapter One: Executive Summary
- Introduction
- Market Size And Growth
- Overall Market: From $74.2 Billion Market In 1996 To $461.3 Billion In 2003
- 1993-1996 Activity
- 1996-2003 Activity
- Managed Medicare Market: $131.9 Billion In Sales In 2003
- Managed Medicaid Market: $504.7 Billion In Sales In 2003
- Share Of The Total Market: Comparing The Managed Medicare And Managed Medicare Segments
- Industry Structure And Leading Competitors
- Overview
- Size Of Provider Organizations
- Categories Of Ownership
- Critical Success Factors
- Ability To Offer Attractive Products
- New Products In Managed Medicare
- New Products In Managed Medicaid
- Ability To Achieve Operational Efficiencies
- Merger And Acquisition Activity
- Privatization
- Ability To Understand And Address Enduser Issues
- Legal Issues
- Risk Issues
- Abuse Issues
- Appeals Process
- Gag Rules
- Ability To Market Effectively
- Ability To Address Changing Demographics
- An Aging Population
- Family Vs. Nonfamily Households
- Diversity
- Scope And Methodology
- Scope
- Methodology
Chapter Two: Introduction To Managed Care
- Overview
- Transforming The Nation's Health-Care Delivery System
- Forms Of Managed Care
- Implications
- Industry Background
- Medicare
- Part A: Hospitalization Insurance
- Part B: Medical Insurance
- Medicare Hmos
- Medicaid
- Industry Definitions And Demographics
- Plan Similarities And Differences
- Case Management Approach
- Industry Structure
- Managed Care Organizations
- Three Types Of Contracts
- Industry Organizations
- Office Of Managed Care
- Health Care Financing Administration
- American Association Of Managed Care Nurses
- Families Usa Foundation
Chapter Three: Innovations In Managed Care
- Overview
- Health-Care Reform
- Background
- Impact Of Health-Care Reform On The Market For Medicare/Medicaid
- Escalating Costs, Unmet Needs
- Approaches By Clinton Administration
- Projected Administration Activity Through 2000
- National Expenditures For Health
- Background
- Medicare And Medicaid Spending
- Changes In Health Care
- Impact Of Market Forces
- Managed Medicare And Medicaid: Unprecedented Growth
- Movement To Three Organizational Models
- Public Utilities
- For-Profit Businesses
- Loose Alliances
- Making The Transition: Strategic Approaches
- Emphasis As Of 1996-1997
- Principles Of Managed Care
- Financing Mechanisms For Managed Care
- Introduction
- Capitation
- Fee-For-Service
- Partial Capitation
Chapter Four: Managed Medicare
- Introduction
- Overview Of Medicare
- Part A: Hospital Insurance
- Benefit Period
- Hospital Services Covered
- Skilled Nursing Facilities Covered
- Home Care Coverage
- Part B: Medical Supplies And Services
- The Move To Managed Medicare
- Introduction
- Cost Containment: The Compelling Force
- Benefits And Services
- Beneficiary Rights
- Advantages Of Medicare Hmos
- Managed Medicare: Demographics And Geographic Distribution
- Types Of Contracts
- Risk Plans
- Exceptions
- Enrollment
- Cost Plans
- Health Care Prepayment Plans
- Other Program Options
- Medigap Insurance
- Medicare Select Program
- Out-Of-Network/Point-Of-Service Option Program
- Medicare HEDIS
- Overview
- Utilization Restriction
- Medicare Hmos: Differing Options And Concerns
- Appeals Process: Anything But Simple
- Excessive Time Consumed
- Beneficiary Vs. Managed Care Plan Responsibilities
Chapter Five: Managed Medicaid
- Introduction
- Overview Of Medicaid
- Eligibility
- Federal Requirements
- State Requirements
- Mandatory Benefits Required Of States
- Optional Services Offered By States
- Buy-Ins
- Changes In Medicaid
- Determining Success
- Enrollment Trends
- Medicaid Health Plans
- Health Insuring Organization (Hio)
- Health Maintenance Organization (Hmo)
- Prepaid Health Plan
- Primary Care Case Management (Pccm)
- Hmo Risk Contracts
- Capitations
- Medicaid Hedis
- Waivers
- Section 1915(B)
- Section 1115
- Substate Medicaid Demonstration Projects
Chapter Six: Issues And Trends
- Overview
- Legal And Legislative Issues
- Federal Actions
- Medicare Modernization And Patient Protection Act Of 1997 (S386)
- Other Proposed Legislation
- State Actions
- Impact Of Managed Medicare/Medicaid On Long-Term Care
- Overview
- Impact Of Managed Care On Low-Income And Elderly
- Medicaid Managed Care Plans: Key Success Criteria
- Delivery Systems
- Marketing
- Outreach Programs
- Provider Contracting
- Risk Limitations
- Emergency Room Utilization
- Stop-Loss Insurance Coverage
- Exclusion Of High-Risk Patients
- Medicare Expansion: Devastating Results
- Marketing Issues
- Medicare
- Medicaid
- Elements Of Successful Marketing
- Managed Care Consumer Issues
- Medicaid Consumer Issues
- Increased Participation Essential For Customer Satisfaction
- Risk Issues
- Medicare Consumer Issues
- Options
- Duplicate Coverage
- Physicians And Managed Care
- Risk Issues
- Managed Medicare And Retirement Issues
- Abuses By Managed Care Plans
- Addressing Abuses
- Hmo Gag Rules
- Issues Concerning The Medicare Appeals Process
- Role Of The Federal Government
- Trends In Product Development
- Point-Of-Service Products
- Private Managed Care Plans
- Open-Model Access
- Physician Incentive Plans
- Demographic Trends
- An Aging Population
- A More Diverse Population
- Family Vs. Nonfamily Households
- A Greater Minority Population
Chapter Seven: The Market
- Background
- Scope And Methodology
- Scope
- Methodology
- Factors Leading To Increased Demand
- Government-Administered Medicare
- Government-Administered Medicaid
- Market Size And Forecast
- Total Market: $74.2 Billion In 1996
- 1993-1996 Activity
- 1996-2003 Activity
- Managed Medicare Market: $131.9 Billion In 2003
- Managed Medicaid
- Comparing The Managed Medicare And Managed Medicare Segments
- Success Factors Leading To Market Growth
- Ability To Achieve Operational Efficiencies
- Responsiveness Of Providers To Demographic Changes
- Rising Median Age
- Other Factors
- Ability To Market Effectively
- Ability To Offer Attractive Product Choices
- Point-Of-Service Products
- Private Managed Care Plans
Chapter Eight: Competitor Profiles
- Overview
- Consolidations And Alliances
- Ownership Trends
- Cigna Corp.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Columbia/Hca Healthcare Corp.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Fhp, Inc.
- History And Lines Of Business
- Financial Information
- Membership
- Company Analysis
- Foundation Health Corp.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Mergers And Acquisitions
- Company Analysis
- Healthcare Compare Corp.
- History And Lines Of Business
- Products
- Financial Information
- Company Analysis
- Healthsource, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Health Systems International
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Humana Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Mergers And Acquisitions
- Kaiser Permanente
- History And Lines Of Business
- Products
- Membership
- Company Analysis
- Oxford Health Plans, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Pacificare Health Systems, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Physician Corp. Of America
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Physicians Health Services, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Prudential Healthcare
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Sierra Health Services, Inc.
- History And Lines Of Business
- Sierra Family Of Operations
- Products
- Financial Information
- Membership (Hmo Type)
- Mergers And Acquisitions
- Company Analysis
- United Healthcare
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Wellcare Management Group, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Company Analysis
- Wellpoint Health Networks, Inc.
- History And Lines Of Business
- Products
- Financial Information
- Membership
- Mergers And Acquisitions
- Company Analysis
Appendix: Company Names And Addresses
AbstractThis Kalorama Information report analyzes the progress of the transition to managed care. Comparing and contrasting the size, growth, and success factors associated with the managed Medicare and managed Medicaid segments, the report describes the relationship between changing demographics and revenues, details product development initiatives, and presents innovative marketing techniques. Novel programs are highlighted, and large and small HMOs are profiled. Individual sections are available.
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