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Health Insurance and Managed Care: What They Are and How They Work (formerly titled Managed Care: What It Is and How It Works) is a concise introduction to the foundations of the American managed health care system. Written in clear and accessible language, this handy guide offers an historical overview of managed care and then walks the reader through the organizational structures, concepts, and practices of the managed care industry.
The Fourth Edition is a thorough update that addresses the impact of the Affordable Care Act throughout the industry including:
– New underwriting requirements
– New marketing and sales channels
– Limitations on sales, governance, and administrative (SG&A) costs and profits
– New provider organizations such as Patient Centered Medical Homes (PCHMs) and Accountable Care Organizations (ACO’s)
– New payment mechanisms such as shared savings with ACOs, and severity-adjusted diagnosis related groups
– Changes to Medicare Advantage
– Medicaid expansion and reliance on Medicaid managed care
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