Abstract
One of the most important preconditions for high-quality and economically effective treatment results is the selection of suitable service providers with whom an MCO concludes supply contracts (selective contracting). The conclusion of selective contracts is so significant for managed care and healthcare management that it is considered crucial to the definition of managed care.
Selective contracting means that a service purchaser is not required to cover the costs for the use of any doctor, hospital or nursing facility. On the contrary, only the services of those providers who have concluded a supply contract with the MCO are compensated. Thus, the insured’s freedom of choice is restricted when selecting service providers. On the other hand, the restriction of the freedom of choice of the service provider depends on the design of the contract. The service provider can conclude an exclusive contract, according to which they can only treat the insured from a certain MCO (closed panel). The contract, however, can also enable patients from other insurance companies and MCOs to be treated (open panel).
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Notes
- 1.
The JCAHO (www.jointcommission.org) is the oldest and largest standard-setting and accredited organisation in the US healthcare system. Along with MCOs it monitors a wide spectrum of facilities for outpatient care, nursing and laboratory facilities.
- 2.
The NCQA (www.ncqa.org) is an independent, non-profit organization, which was established in 1979 to promote quality and certification, particularly of HMOs, in order to aid employers in selecting insurance providers.
- 3.
The PRO is an organisation run by physicians, which evaluates the quality and use of healthcare services in the Medicare programme.
Literature
Amelung, V. E. (2007). Integrierte Versorgung – von Pilotprojekten zur “wirklichen” Regelversorgung. Gesundheits- und Sozialpolitik, 1(2), 10–13.
Andre, F. E., Booy, R., Bock, H. L., et al. (2008). Vaccination greatly reduces disease, disability, death and inequity worldwide. Bulletin of the World Health Organization, 86(2), 140–146.
Bindman, A. B., Grumbach, K., Vranizan, K., et al. (1998). Selection and exclusion of primary care physicians by managed care organizations. JAMA: The Journal of the American Medical Association, 279, 675–679.
Blum, J. D. (1997). Economic credentialing moves from the hospital to managed care. In P. R. Kongstvedt (Ed.), Readings in managed health care (pp. 108–115). Gaithersburg: Aspen.
Bodenheimer, T. S., & Grumbach, K. (1995). Understanding health policy – A clinical approach. Norwalk: Appleton & Lange.
Brooke, S., Perler, A., Dmonici, F., et al. (2008). Reduction of in-hospital mortality among California hospitals meeting Leapfrog evidence-based standards for abdominal aortic aneurysm repair. Journal of Vascular Surgery, 47(6), 1155–1164.
Claxton, G., DiJulio, B., Whitmore, H., et al. (2011). Health benefits in 2010: Premium rise modestly, workers pay more toward coverage. Health Affairs, 29(10), 1942–1950.
Crossen, F. J., & Tollen, L. A. (2010). Partners in health, how physician and hospitals can be accountable together. San Francisco: Jossey-Bass.
Feldman, R., Chan, H., Kralewsky, J., et al. (1990). Effects of HMOs on the creation of competitive markets for hospital services. Journal of Health Economics, 9, 207–222.
Feldman, H. R., Alexander, R., Greenberg, M. J., Jaffee-Ruiz, M., McBride, A., McClure, M., & Smith, T. D. (2012). Nursing leadership: A concise encyclopaedia (2nd ed.). New York: Springer.
Feldstein, P. J. (1993). Health care economics (4th ed.). Albany: Delmar Publishers.
Goldman, D. P., Joyce, G. F., Escarce, J. J., et al. (2004). Pharmacy benefits and the use of drugs by chronically ill. JAMA: The Journal of the American Medical Association, 291(19), 2344–2350.
Hajen, L., Paetow, H., & Schuhmacher, H. (2011). Gesundheitsökonomie: Strukturen – Methoden – Praxis (6th ed.). Stuttgart: Kohlhammer.
Henderson, J. W. (2011). Health economics and policy (5th ed.). South Western: Educational Publishing.
IOM [Institute of Medicine]. (1999). To err is human: Building a safer health system. Washington, DC: Institute of Medicine.
IOM [Institute of Medicine]. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine.
Janus, K. (2003). Managing health care in private organizations. Transaction costs, cooperation and modes of organization in the value chain. Frankfurt am Main: P. Lang.
Jensen, G. A., Morrisey, M. A., & Gaffney, S., et al. (1997, January/February). The new dominance of managed care: Insurance trends in the 1990s. Health Affairs, 16(1), 125–136.
Kazmir, J. L. (2008). Health care law. New York: Delmar Publications.
KFF [Kaiser Family Foundation]. (2012). Employer health benefits 201, annual survey. Menlo Park/Chicago: Kaiser Foundation & HRET. http://ehbs.kff.org/pdf/2012/8345.pdf. Accessed 21 Jan 2013.
Knight, W. (1998). Managed care – What is it and how it works. Gaithersburg: Aspen.
Koenig, H. G., King, D. E., & Carson, V. B. (2012). Handbook of religion and health (2nd ed.). New York: Oxford University Press.
Kongstvedt, P. R. (2013). Essentials of managed health care (6th ed.). Burlington: Jones & Bartlett Learning.
Kühn, H. (1997). Managed care – Medizin zwischen kommerzieller Bürokratie und Integrierter Versorgung (WZB-Paper), Berlin.
Leapfrog Group. (2013). What does Leapfrog ask hospitals? http://www.leapfroggroup.org/patients/hospitals_asked_what. Accessed 15 Feb 2013.
McGlynn, E. A., Asch, S. M., Adams, J., et al. (2003). The quality of health care delivered to adults in the United States. The New England Journal of Medicine, 348(26), 2635–2645.
Newhouse, J. P. (1993). Free for all? Lessons from the RAND health insurance experiment (2nd ed.). Boston: Harvard University Press.
OECD [Organisation for Economic Cooperation and Development]. (2011). OECD reviews of health systems: Switzerland. Paris: OECD.
OECD [Organisation for Economic Cooperation and Development]. (2012). OECD statistics on health. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT. Accessed 23 Feb 2012.
Peden, A. H. (2012). Comparative health information management (3rd ed.). Delmar: Cengage Learning.
Porter, M. E., & Guth, C. (2012). Chancen für das deutsche Gesundheitssystem: Von Partikularinteresse zu mehr Patientennutzen. Berlin/Heidelberg: Springer/Gabler.
Porter, M., & Teisberg, E. (2006). Redefining health care – Creating value-based competition on results. Boston: Harvard Business School Press.
Pronovost, P., Thompson, D. A., Holzmueller, C. G., et al. (2006). Impact of the Leapfrog Group’s intensive care unit physician staffing standard. Journal of Critical Care, 22, 89–96.
Shi, L. (2007). Managing human resources in health care organizations. Sudbury: Jones and Bartlett.
Shi, L., & Singh, D. A. (2012). Delivering healthcare in America: A systems approach (5th ed.). Sudbury: Jones and Bartlett.
Solberg, L. I. (1998). Prevention in managed care. In P. R. Kongstvedt & D. W. Plocher (Eds.), Best practice in medical management. Gaithersburg: Aspen.
Sorkin, A. L. (1992). Health economics (3rd ed.). New York: Lexington Books.
Waldman, J. D., Yourstone, S. A., & Smith, H. L. (2003). Learning curves in health care. Health Care Management Review, 28(1), 41–54.
Zelman, W., & Berenson, R. A. (1998). The managed care blues & how to cure them. Washington, DC: Georgetown University Press.
Zwanziger, J., & Meirowitz, A. (1998). Strategic factors in hospitals for HMO and PPO networks. In M. A. Morsey (Ed.), Managed care and changing health care markets (pp. 77–94). Washington, DC: AEI Press.
Zweifel, P., Breyer, F., & Kifmann, M. (2009). Health economics (2nd ed.). Berlin/Heidelberg: Springer.
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Amelung, V.E. (2013). Contract Design. In: Healthcare Management. Springer Texts in Business and Economics. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-38712-8_9
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