Health Hippo: Facilities
|| CFR/FR ||
CASE LAW ||
NEWS || RELATED LINKS
[T]he incentives under managed care are to
create and maintain healthy populations. Epidemiology and
public health provide the tools to optimize the health of
populations. The following list presents some of these applications.
- Defining populations of interest.
- Understanding the character and dynamics of these populations.
- Determining the patterns of population health status, needs,
risks, and demands over time and space.
- Linking these patterns to service delivery configurations to
understand and enhance access within the system.
- Determining points of responsibility in providing medical or
health (health promotion or prevention) services.
- Examining the practice variations of physicians with regard to
services or geographic area and link these variations to case-mix,
health status, costs, etc.
- Performing outcomes studies to assess the effectiveness or
efficacy of medical or health services.
- Assisting in the identification of competitors and/or
potential collaborators within specific product and geographic
- Assisting in the negotiation of capitated contracts with
respect to the incentive systems, accountability, and periodic
evaluation of the appropriateness of both the capitation rate as
well as the risk and liability allocation and future network
- Evaluating purchaser groups with regard to occupational and
environmental risks and negotiating these risks into capitated
- Providing support services to purchaser groups with regard to
health promotion, education, and prevention efforts.
- Benchmarking and comparing current system characteristics to
other similar system characteristics.
- Examining the performance of providers and practitioners under
different incentive plans as well as assessing the health status
of their respective patients or enrollees.
- Assisting in data and information needs assessments as well as
system development to meet these needs.
The potential value demonstrated by this type of
approach is compelling. Managed care organizations,
specifically their management intermediaries (i.e., third party
administrators, health plans, medical services organizations, or
practice management associations) will need to view these functions
as a core competency along with claims management, information
systems, and contracting.
- Full Text of Article:
The Application of
Epidemiology to Managed Care
- Author information:
- Copyright © 1997,
Co. All rights reserved.
- Revised: June 27, 1997.
Good News for health care partnerships! On August 28, 1996,
DOJ and FTC issued important joint
of Antitrust Enforcement Policy in Health Care. The statements
cover nine areas, including an
and a Separate
Statement of Commissioner Christine A. Varney:
The two new statements on Physician Network
Joint Ventures and Multiprovider Joint Ventures should be welcomed
the health care industry, which has long criticized antitrust laws
for impinging on collaborations that could improve patient care and
competition between providers. See
of AMA on Antitrust Enforcement Policy.
FTC offers a variety of additional
health-related antitrust information at its site, including:
Health Care Policy Statements ~
for Managed Care at Global Competition Hearings ~
Hearings on Healthcare Issues ~
of the Antitrust Laws to Health Care Provider Networks ~
Pitofsky Outlines How Antitrust Enforcement can Adapt to Rapidly
Changing Health ~
Antitrust Enforcement Issues ~
Medicare Reform and Health Care Competition ~
Health Care Antitrust Enforcement ~
Topic and Yearly
Indice of Health Care Antitrust Advisory ~
the Health Care Policy Statements ~
The Health Care
and Antitrust Interface in an Era of Fundamental Industry-Wide
In Integrated Health Care Delivery Systems ~
Current Issues in Health Care Antitrust Enforcement ~
Progress Report for the FTC: Past, Present and Future
Program; Schedule of Limits on Home Health Agency Costs Per Visit
for Cost Reporting Periods Beginning on or After July 1, 1997;
Notice, [Federal Register: July 1, 1997 (Volume 62, Number
126)] [Notices] [Page 35607-35634].
Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 1998 Rates; Proposed Rule, [Federal
Register: June 2, 1997 (Volume 62, Number 105)] [Proposed Rules]
of the OIG Model Compliance Plan for Clinical Laboratories,
[Federal Register: March 3, 1997 (Volume 62, Number 41)] [Notices]
[Page 9435-9441]. This Federal Register notice sets forth the
recently issued model compliance plan for clinical laboratories
developed by the Office of Inspector General in cooperation with,
and input from, several provider groups and industry
Care Programs: Fraud and Abuse; Revised PRO Sanctions for Failing
To Meet Statutory Obligations, [Federal Register: April 29,
1997 (Volume 62, Number 82)] [Rules and Regulations] [Page
23140-23144]. This final rule addresses revised procedures
governing the imposition and adjudication of program sanctions,
based on recommendations from State utilization and quality
control peer review organizations (PROs), resulting from enactment
of sections 214 and 231(f) of the Health Insurance Portability and
Accountability Act (HIPAA) of 1996.
Program; Establishment of an Expedited Review Process for Medicare
Beneficiaries Enrolled in Health Maintenance Organizations,
Competitive Medical Plans, and Health Care Prepayment Plans,
[Federal Register: April 30, 1997 (Volume 62, Number 83)] [Rules
and Regulations] [Page 23368-23376]. This final rule with comment
period establishes a new administrative review requirement for
Medicare beneficiaries enrolled in health maintenance
organizations (HMOs), competitive medical plans (CMPs), and health
care prepayment plans (HCPPs).
and Medicaid Programs: Use of the OASIS as Part of the Conditions
of Participation for Home Health Agencies, [Federal Register:
March 10, 1997 (Volume 62, Number 46)] [Proposed Rules] [Page
11035-11064]. Specifically, this proposed rule would require that
HHAs use a standard core assessment data set, the ``Outcomes and
Assessment Information Set'' (OASIS), when evaluating adult,
and Medicaid Programs; Revision of Conditions of Participation for
Home Health Agencies and Use of Outcome Assessment Information Set
(OASIS); Proposed Rules, [Federal Register: March 10, 1997
(Volume 62, Number 46)] [Proposed Rules] [Page 11003-11005]. We
are publishing two notices of proposed rulemaking relating to
revised conditions of participation that home health agencies must
meet to participate in the Medicare and Medicaid programs. This
introduction explains the background for the two proposed rules
and the interrelationship of the two documents.
Program; Electronic Cost Reporting for Skilled Nursing Facilities
and Home Health Agencies, [Federal Register: January 2, 1997
(Volume 62, Number 1)] [Rules and Regulations] [Page 26-31].
Code of Federal Regulations
- 42 CFR PART 406 - HOSPITAL INSURANCE ELIGIBILITY AND
ENTITLEMENT SUBPART A - GENERAL PROVISIONS Selected provisions
- 42 CFR PART 412 - PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT
HOSPITAL SERVICES Selected provisions follow.
- 42 CFR PART 482 - CONDITIONS OF PARTICIPATION FOR HOSPITALS
SUBPART A - GENERAL PROVISIONS
- 42 CFR PART 483 - CONDITIONS OF PARTICIPATION AND REQUIREMENTS
FOR LONG TERM CARE FACILITIES Selected provisions follow.
- 42 CFR PART 488 - SURVEY AND CERTIFICATION PROCEDURES SUBPART
A - GENERAL PROVISIONS Selected provisions follow.
- 42 CFR PART 489 - PROVIDER AGREEMENTS UNDER MEDICARE SUBPART A
- GENERAL PROVISIONS Selected provisions follow.
- 42 CFR PART 491, SUBPART A: RURAL HEALTH CLINICS
v. MEDICAL CENTER OF SOUTHWEST LOUISIANA (5th Cir. , June 14,
1994) (patient never came to hospital within the meaning of EMTALA
v. TOURO INFIRMARY (5th Cir., June 4, 1993) (plaintiffs failed
to offer evidence contradicting the hospital's contention that it
had fulfilled its obligations under EMTALA statute, resulting in
grant of summary judgment)
Hospitals: Conversion Issues Prompt Increased State Oversight.
HEHS-98-24. 35 pp. plus 4 appendices (16 pp.) December 16, 1997.
Reviews the process that some not-for-profit hospitals have used
in converting to for-profit status, focusing on: (1) the method
used to value assets; (2) the process used to solicit interest and
obtain bids; (3) the terms negotiated as part of the sales
agreement, including provisions for continued charity care; (4)
the extent of community involvement in the process; (5) how the
proceeds from the sale were used to fulfill charitable missions;
and (6) the role state and federal governments play in regulating
and monitoring hospital conversions.
Managed Care: HMO Rates, Other Factors Create Uneven Availability
of Benefits (Testimony, 05/19/97, GAO/T-HEHS-97-133). GAO
discussed aspects of Medicare managed care, including greater
choice and equity across the program.
Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort (Letter Report, 05/16/97,
GAO/HEHS-97-86). Pursuant to a congressional request, GAO reviewed
state efforts to hold managed care plans accountable for meeting
Medicaid program goals and for providing beneficiaries enrolled in
capitated managed care plans the care they need.
Insurance: Management Strategies Used by Large Employers to
Control Costs (Chapter Report, 05/06/97, GAO/HEHS-97-71).
Pursuant to a congressional request, GAO reviewed the strategies
of large, innovative purchasers who have attempted to stem the
rapid escalation in health insurance costs while maintaining or
enhancing the quality of care for their employees.
HMO Enrollment: Area Differences Affected by Factors Other Than
Payment Rates (Letter Report, 05/02/97, GAO/HEHS-97-37).
Pursuant to a congressional request, GAO reviewed the factors
affecting Medicare risk health maintenance organization (HMO)
HMOs: HCFA Can Promptly Eliminate Hundreds of Millions in Excess
Payments (Letter Report, 04/25/97, GAO/HEHS-97-16). Pursuant
to a congressional request, GAO provided information on Medicare's
rate-setting method for paying risk contract health maintenance
Managed Care: HCFA Missing Opportunities to Provide Consumer
Information (Testimony, 04/10/97, GAO/T-HEHS-97-109). GAO
discussed: (1) Medicare beneficiaries' need for comparative
information on health maintenance organizations (HMO); and (2)
steps the Health Care Financing Administration (HCFA) could take
to meet that need promptly.
Fraud and Abuse: Stronger Action Needed to Remove Excluded
Providers From Federal Health Programs (Letter Report,
03/31/97, GAO/HEHS-97-63). Pursuant to a congressional request,
GAO reviewed the Department of Health and Human Services (HHS)
Inspector General's (OIG) process for excluding providers from
federal health care programs.
Recent Spending Experience and the Administration's Proposed
Program Reform (Testimony, 03/11/97, GAO/T-HEHS-97-94). GAO
discussed recent Medicaid spending trends and their potential
implications for future outlays.
HMOs: Potential Effects of a Limited Enrollment Period Policy
(Letter Report, 02/28/97, GAO/HEHS-97-50). Pursuant to a
congressional request, GAO reviewed how a limited enrollment
period would affect the Medicare program, private health plans,
beneficiaries, and employers who provide Medicare supplemental
benefits to retirees.
HMOs: Rapid Enrollment Growth Concentrated in Selected States
(Letter Report, 01/18/96, GAO/HEHS-96-63). Pursuant to a
congressional request, GAO provided information on the: (1) number
of Medicare beneficiaries enrolling in health maintenance
organizations (HMO); and (2) factors that influence beneficiaries'
decisions to enroll in HMO.
Guidelines: Managed Care Plans Customize Guidelines to Meet Local
Interests (Letter Report, 05/30/96, GAO/HEHS-96-95). Pursuant
to a congressional request, GAO reviewed how managed health plans
make use of existing clinical practice guidelines.
Managed Care: Serving the Disabled Challenges State Programs
(Chapter Report, 07/31/96, GAO/HEHS-96-136). Pursuant to a
congressional request, GAO examined state efforts to include
disabled Medicaid beneficiaries in prepaid managed care programs.
Private Payer Strategies Suggest Options to Reduce Rapid Spending
Growth (Testimony, 04/30/96, GAO/T-HEHS-96-138). GAO discussed
strategies to curb Medicare spending, which has grown by over 10
percent a year since 1989, twice the rate of the national economy.
Health Insurance: Millions Relying on Individual Market Face Cost
and Coverage Tradeoffs (Chapter Report, 11/25/96,
GAO/HEHS-97-8). Pursuant to a congressional request, GAO provided
information on the private individual health insurance market.
Hospital Mortgage Insurance Program: Health Care Trends and
Portfolio Concentration Could Affect Program Stability (Letter
Report, 02/27/96, GAO/HEHS-96-29). Pursuant to a legislative
requirement, GAO reviewed the Federal Housing Administration's
(FHA) Hospital Mortgage Insurance Program.
Claims: Commercial Technology Could Save Billions (Letter
Report, 05/05/95, GAO/AIMD-95-135). Pursuant to a congressional
request, GAO reviewed the Health Care Financing Administration's
(HCFA) potential use of commercial technology to detect Medicare
Liability: Impact on Hospital and Physician Costs Extends Beyond
Insurance (Letter Report, 09/29/95, GAO/AIMD-95-169). As
Congress considers proposals to reduce to tort liability in the
health care industry, little consensus exists on the extent to
which medical liability-related spending boosts hospital and
physician expenditures, a central issue in the debate over health
Care: Employers Urge Hospitals to Battle Costs Using Performance
Data Systems (Letter Report, 10/03/94, GAO/HEHS-95-1). Many
large employers have become increasingly concerned about the wide
variation in hospital costs across their communities.
Managed Care: More Competition and Oversight Would Improve
California's Expansion Plan (Letter Report, 04/28/95,
GAO/HEHS-95-87). Pursuant to a congressional request, GAO reviewed
California's Medicaid managed care program, focusing on: (1) state
oversight of managed care contractors; (2) state plans for
expansion; and (3) key issues in implementing the expanded
Increased HMO Oversight Could Improve Quality and Access to
Care (Letter Report, 08/03/95, GAO/HEHS-95-155). The Congress
is considering ways to attract Medicare beneficiaries to health
maintenance organizations (HMO) and other forms of managed care in
hopes of containing cost growth while preserving or improving
quality and access to care.
Insurance Regulation: Variation in Recent State Small Employer
Health Insurance Reforms (Fact Sheet, 06/12/95,
GAO/HEHS-95-161FS). Pursuant to a congressional request, GAO
provided information on state legislation to improve portability,
access, and rating practices for the small-employer and individual
health insurance markets.
Care: Employers and Individual Consumers Want Additional
Information on Quality (Letter Report, 09/29/95,
GAO/HEHS-95-201). Pursuant to a congressional request, GAO
provided information on health care quality issues, focusing on:
(1) how consumers use health care performance reports that contain
comparative data on the quality of health care providers; and (2)
what information consumers consider most important.
Managed Care: Growing Enrollment Adds Urgency to Fixing HMO
Payment Problem (Letter Report, 11/08/95, GAO/HEHS-96-21).
Pursuant to a congressional request, GAO reviewed Medicare
payments to health maintenance organizations.
Health Care: Effect on Employers' Costs Difficult to Measure
(Letter Report, 10/19/93, GAO/HRD-94-3). Many employers believe
that, in principle, managed care plans save money, but little
empirical evidence exists to support this view.
Costs: Cost Control Efforts at 17 Texas Hospitals (Letter
Report, 12/09/94, GAO/AIMD-95-21). This report provides
information on how the increased use of managed care may have
influenced cost control efforts at 17 urban hospitals in Texas.
Changes to HMO Rate Setting Method Are Needed to Reduce Program
Costs (Chapter Report, 09/02/94, GAO/HEHS-94-119). During the
1980s, the per capita costs of providing health care to the
elderly under Medicare increased 59 percent, even after adjusting
Care Alliances: Issues Relating To Geographic Boundaries
(Letter Report, 04/08/94, GAO/HEHS-94-139). A common feature of
many health reform bills is the creation of public or private
health purchasing groups, known as alliances.
to Health Insurance: Public and Private Employers' Experience With
Purchasing Cooperatives (Letter Report, 05/31/94,
GAO/HEHS-94-142). One of the few areas of widespread agreement in
the health care debate is that small businesses and other small
organizations have a tough time buying and keeping health
insurance for their employees.
Compensation: Nationally Representative Data on Chief Executives'
Compensation (Letter Report, 08/16/94, GAO/HEHS-94-189).
Hospital-reported data showed that chief executives received an
average of $129,000 in compensation for overseeing hospital
operations in 1991.
Care Reform: "Report Cards" Are Useful but Significant Issues Need
to Be Addressed (Chapter Report, 09/29/94, GAO/HEHS-94-219).
As part of the debate over health care reform, Congress is
considering requiring health plans to provide prospective
purchasers with information on the quality of care they furnish.
Care: Federal and State Antitrust Actions Concerning the Health
Care Industry (Letter Report, 08/05/94, GAO/HEHS-94-220). In
response to a request to review antitrust enforcement actions
involving hospitals by the Department of Justice and the Federal
Trade Commission (FTC), GAO found that of 397 acute care hospital
mergers reviewed by Justice and the FTC in the 13 year period of
fiscal year 1981 through fiscal year 1993, less than 4 percent
Chief Executives' Compensation, 1989-1991 (Testimony,
12/07/93, GAO/T-HRD-94-70). In recent years, the media have
scrutinized the high salaries--some approaching $1 million
annually--paid to health care executives, in some cases linking
them to the rising cost of health care.
HealthPASS: An Evaluation of a Managed Care Program for Certain
Philadelphia Recipients (Chapter Report, 05/07/93,
GAO/HRD-93-67). Federal and state policymakers believe that
managed care programs are less expensive than traditional
fee-for-service medical care, but critics express concern that
cost-control measures may harm patient access to care and the
quality of care.
News & Reports
CONNECTION FOR MEDICAL INSTITUTIONS To accelerate the pace
with which health-related institutions become part of the
electronic information web, NLM is offering grants to support
institution-wide Internet connections.
Press Releases The latest from the Justice Department.
- FedWorld: Health
Care U. S. Government health care links.
- FTC News
Releases The latest from the Federal Trade Commission.
- Health Care Financing
Administration HCFA's Home Page.
- HCFA: Nursing
- HCFA: Medicare
& Home Health Care
- HCFA: Skilled
- HCFA: Managed
Care in Medicare and Medicaid
- HCFA: Managing
- HCFA Health
- HCFA: Press
Releases The latest news from the Health Care Financing
Testimony Testimony from the Health Care Financing
Press Releases The latest from the Department of Health &
Speeches Speeches issued by the Office of the Assistant
Secretary For Public Affairs.
Policy Forum Department of Health and Human Services policy
Care Antitrust: A Manual for Changing Provider Organizations
Succeeding in the current health care environment requires
innovative integration strategies. Yet hospital mergers, provider
groups and integrated delivery systems are coming under increased
antitrust scrutiny by federal and state enforcement agencies.
- Health Law:
firstname.lastname@example.org Health Law list. Send the following
message: subscribe healthlaw-L Your Name
Law Listserv Archives Threads from Washburn University's Heath
- Home Health Care Management:
email@example.com Home Health Care Management issues list. Send
the following message: subscribe homehlth Your Name
- HSR - The Health
Service Research Journal The official journal of the
Association for Health Services Research.
- HSR: Local
Markets and Systems: Hospital Consolidations in Metropolitan
Areas This study examines the formation of local hospital
systems (LHSs) in urban markets through the year 1992. We argue
that a primary reason why hospitals join LHSs is to achieve
improved positions of market power relative to threatening rivals.
HEALTH CARE INDUSTRY Sponsored by infoMCI: a product of
HEALTH LAW NEWS Health law offerings from Law Journal Extra.
Health & Science News Nando Times top health stories of
Clearinghouse on Managed Care and Disabilities
- National Health
Information Center The National Health Information Center
(NHIC), formerly the National Health Information Clearinghouse,
was established in 1979 to help both professionals and the general
public locate health information.
Health Insurance & Managed Care Top stories from Newspage,
an information service from Individual.
Healthcare Top stories from Newspage, an information service
- NLM HyperDOC The
National Library of Medicine (NLM), located on the southeast
corner of the campus of the U.S. National Institutes of Health
(NIH) in Bethesda, Maryland, is the world's largest library
dealing with a single scientific/professional topic.
- OMC Monthly
Report - Prepaid Health Plans The Medicare Prepaid Health
Plans Monthly Report provides the status of active and terminated
Communications' HealthWave - Headlines The headlines listed
below are taken from this week's Executive Briefings on Hospital
Regulations. This "Monday Morning Eye-Opener," is faxed to
subscribing health care facilities by 6 a.m. every Monday morning.
The Effects of Competition and Regulation on Hospital Bed
Supply This article uses a simple queuing model to examine
several factors that affect hospital bed supply decisions and the
reservation quality of the hospital.
HIPPOTALK // STILL
Health Hippo ©1996-2000: firstname.lastname@example.org
Medicine Index ~
HCIA home ~
HealthGate - Home
HospitalWeb ~ JCAHO Home
Mayo Clinic ~ Medical
Library Association ~
Directory of Internet Health ~
Information Center ~
Professionals Network ~
NY TIMES: Your
Health Daily ~
Communications' HealthWave ~
Sokrates : Medical
Related Newsgroups ~
Non-Profit Organizations Law ~