Springer Texts in Business and Economics

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Volker Eric Amelung

Healthcare ManagementManaged Care Organisationsand Instruments

Second Edition

With collaboration of Charity M. Agbor, Mirella Cacace,Axel Mühlbacher, Ulla Tangermann, Anika Meißner,Andreas Domdey, Christian Krauth, Susanne Bethge,Peter Berchtold, and Christoph Wagner

Volker Eric AmelungInstitute for Epidemiology, SocialMedicine and Health Systems ResearchHannover Medical SchoolHannover, Germany

Institute of Health Sciences ResearchINAV GmbHBerlin, Germany

ISSN 2192-4333 ISSN 2192-4341 (electronic)Springer Texts in Business and EconomicsISBN 978-3-662-59567-1 ISBN 978-3-662-59568-8 (eBook)https://doi.org/10.1007/978-3-662-59568-8

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Foreword

Not long ago, “management” of healthcare seemed pretty much to begin and endwith hospital administration. In the last four decades, the situation has changeddramatically and for three main reasons. First, healthcare costs that rise steadily as ashare of stagnant national economies call attention to who is running the show and tothe importance of getting “provider dominance” and “professional sovereignty”under control in order to achieve better value for money. Second, accumulatingresearch and evidence that disclose mysteries and dysfunctions (for instance, prac-tice variations among small areas) show that caregiving is not simply a matter ofpristine professional judgement but rather can be not only costly but also inexplica-ble, indeed indefensible and dangerous. Third, the rise of consumerism, the advanceof patients’ rights, and scepticism about the wisdom of deference to professionalmonopolies and guilds have fuelled determination in many quarters to redress thebalance of power between providers and the patients and payers they serve. Thesethree complementary and converging forces have sent to policymakers a messageboth consistent and insistent, namely, it is long past time to learn to “manage care”,to seek to redesign the structures, processes, and outcomes of care by the light ofevidence about effectiveness and efficiency.

The organisational structures and processes that came to be called managed carehave venerable roots in prepaid group practices (PGP) such as the Kaiser Permanenteplans that won heavy market penetration in California after World War II. PGPsproceed on the premise that achieving healthcare that is at once accessible, of highquality, and reasonably priced requires sound management of systems that integratethe delivery and financing of care, functions usually separated in traditional systems.Before 1970, PGPs were important players in California and in a few other USvenues but remained idiosyncratic and underdeveloped in the US system at large. InWestern Europe, meanwhile, a kind of social contract within national systems ofuniversal coverage held that providers who agreed to bargain over the price term inthe equation “cost ¼ price � volume” would be spared extra-professional interfer-ence in their management of the volume term.

In 1970, the US picture began to change. The enactment of Medicare andMedicaid in 1965 thrust the US federal government into the health financing“game” in a big way and for the first time. As the Nixon administration broodedon its options for addressing the “soaring” costs of the new programs, a policy

v

entrepreneur, Paul Ellwood, pinpointed the purported essence of the problem—theunmanaged conjunction of fee-for-service medical practice and third-party paymentfor medical care assured fiscal disaster—and identified the antidote, namely, the PGPmodel, which integrated financing and delivery in a unified organisational frame-work and thereby reversed the faculty incentives of the traditional system. TheNixonians embraced this reasoning and PGPs were born again, as it were, thistime as “Health Maintenance Organisations”. After a slow start, this organisationalmodel diffused rapidly, though the dilution of strong management structures, whichwas the price of this diffusion, meant that most of the “managed care organisations”that had become mainstream in the USA by the end of the 1980s bore but a weakresemblance to the Kaiser Permanente plans that had inspired the government’spolicy innovation in 1970.

In Europe too, the widening gap between the growth of healthcare costs and thatof GDP, the stream of studies suggesting that those costs sustained no small measureof excessive (anyway questionable) use, and declining deference to the autonomy ofthe judgements of medical professionals combined to argue that allowing the“volume” term in the cost equation to continue to go largely unconstrained wasbad public policy. Health experts from several European nations visited the USA tolearn what “managed care”was all about, and although few returned home enthralledwith the US system as a whole, many selectively imported specific managerialstrategies that, they hoped, would enhance the efficiency of their systems withoutdamaging the impressive access, quality, equity, and solidarity these systems ofaffordable and universal coverage cherished. Some nations (Germany, for example)went beyond ad hoc picking and choosing of managerial tools to legislation thatpromoted competition among payers as a vehicle to encourage managerial effi-ciency. Others (the Netherlands and Switzerland, for instance), wary of the risksthat accompanied unmanaged competition among health plans (managed care orother), raised the ante to rigorously managed competition: within a firm frameworkof government rules, purchasers would bargain hard with health plans which, eagerto preserve or expand market share, could satisfy the purchasers’ requirements onlyby ensuring strong management of the providers who supplied the care.

In the second decade of the twenty-first century, then, managed care is both a faitaccompli and a work in progress on both sides of the Atlantic. Variations on themanaged care theme abound: how to define “it”, how to set priorities among itsmyriad managerial elements, how to adjust and adapt strategies in the light ofexperience and evidence, and how better to manage healthcare systems that perpet-ually overflow their existing boundaries as innovations in technology, organisation,and payment methods advance. The sheer scope of managed care and the multiplic-ity of its strategic components can be dizzying to those who seek to make sense of,not to mention work successfully within, this “field”.

No scholar is better suited to illuminate these challenges than Volker Amelung,and those in search of essential information and sound theoretical grounding,whatever their orientation and piece of the action in healthcare, can do no betterthan to consult this, the first English edition of a book already established in theGerman market.

vi Foreword

The book has carefully kept pace with both continuities and innovations inmanaged care and with evidence on how managed care works in an impressiverange of national healthcare systems. Well before the sharp economic downturn thatarrived in 2008, leaders in Western nations had come to view managerialimprovements in healthcare as imperative. Volker Amelung’s learned, meticulous,and sophisticated exploration of the ever-widening world of managed care—fromutilisation review to integrated systems with much in between—remains indispens-able to scholars and practitioners of healthcare policy and management.

Columbia UniversityNew York, NY, USAJuly 2018

Lawrence D. Brown

Foreword vii

Preface

Within the international discussion on the structure of healthcare systems, managedcare is an increasingly important topic. Over more than 20 years, managed careapproaches have fundamentally influenced healthcare systems in terms of patientorientation, efficiency, and quality. Experts assume that up to 20% of healthcareexpenses can be saved by applying high-quality managed care approaches. By usingsuitable organisational forms and management principles, not only can costs bereduced, but the quality of medical service provision can be augmented. Managedcare is therefore much more than a cost-cutting strategy. The goal of this book is tooffer a systematic overview of the organisational forms and managementinstruments implemented in managed care.

Managed care remains a topic of controversial discourse. Advocates of managedcare consider it to be a logical and necessary developmental step in modernhealthcare systems. They recognise the central problem of the fragmentation ofsupply structures and call for the breaking out of stagnated structures. In this light,simultaneous quality improvements and cost reduction are viewed as consistentresults of managed care rather than a contradiction. On the other hand, opponentsof managed care consider it to be the “downfall of healthcare” and purecommercialisation that reduces quality and access to healthcare. This unfairlyequates managed care with striving for profit, two-class or multi-class medicine,and diminishing solidarity. In view of these two schools of thought, managed caremust offer a response to changed challenges in the provision of healthcare.

As is often the case, reality is more complex. Managed care is not a self-containedtheory but rather a bundle of widely differing organisational models and manage-ment instruments which can be used in different combinations. Thus, it is notpossible to be “in favour” or “against” managed care; instead, one has to scrutiniseorganisational forms or management instruments individually.

It is particularly fascinating that the general attitude towards managed care isoften negative, while classic managed care institutions and instruments are widelyaccepted. The best example of this is integrated care, a core concept of managedcare. While all players recognise the necessity for more cross-sectoral and interdis-ciplinary care concepts, overall implementation often lacks in continuity, profes-sionalism, and evaluation. The same is true for a number of other managed careinstruments and institutions.

ix

Over the last years, there has been a significant increase in the internationalorientation of healthcare systems. However, the focus is not on the classic question“Is the German or the British healthcare system better?” but rather on individualinstitutions. What can we learn from the Dutch experience? How does pay-for-performance work in the USA or in Great Britain? Which risk managementinstruments have proven valuable in Switzerland? There is a much higher potentialto learn from comparisons on the meso or micro level (e.g. best practices) than tocomparatively examine whole systems. We have thus included several case studiesfrom different countries.

This book is directed at a very broad and heterogeneous target audience. We aimto address students from different courses of study in the areas of health economicsand healthcare management, practitioners from various fields, representatives ofhealth insurances, as well as policymakers. With this broad spectrum of theaddressees in mind, we have tried not to presuppose background knowledge of ourreaders. This book should be understandable for economists, sociologists, andphysicians as well as for political scientists. We are convinced that the challengesin our healthcare system can only be overcome together, whereas a “solo effort” iscounterproductive and doomed to failure.

The original German version of our textbook has been on the market for eighteenyears. The following people contributed to this or previous German and/or Englisheditions: PD Dr. Peter Berchtold, Anika Meißner, Dr. Susanne Bethge, Prof.Dr. Mirella Cacace, Dr. Andreas Domdey, Joy Hawley, Prof. Dr. Katharina Janus,Prof. Dr. Christian Krauth, Prof. Dr. Axel Mühlbacher, Dr. Ulla Tangermann, andChristoph Wagner.

I would like to thank Dr. Martina Bihn from Springer, who very patiently assistedus in the creation of this new edition. Her continual support allowed us to completethis edition successfully. Special thanks are due to Joy Hawley, Courtney Metz,Dr. Ulla Tangermann, Dr. Florian Stache, Dr. Charity M. Agbor, and Maria Manovafor the revision of this and the previous edition.

I naturally take responsibility for all the remaining deficiencies in the content andform of this book. Accordingly, I gladly welcome responses and suggestions fromour readers. I can be contacted at the Department of Epidemiology, Social Medicineand Health Systems Research, Hannover Medical School, or directly via email(amelung@berlin.de).

Berlin, GermanyApril 2019

Volker Eric Amelung

x Preface

Contents

Part I Basic Ideas of Managed Care

1 Definitions and Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31.1 Supporting and Inhibiting Factors of Managed Care . . . . . . . . . 31.2 Definitions of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . 61.3 Which Instruments and Organisational Forms Belong

to Managed Care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.4 What Changes for Those Involved in the Managed Care

Context? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2 Main Characteristics of the American Healthcare System . . . . . . . . 172.1 Funding Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2.1.1 Government and Compulsory Contribution Schemes . . . 182.1.2 Private Healthcare Coverage Plans . . . . . . . . . . . . . . . . 20

2.2 Delivering Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . 222.3 Receiving Healthcare Services . . . . . . . . . . . . . . . . . . . . . . . . . 23Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

3 Theoretical Concepts for the Assessment of Managed Care . . . . . . . 273.1 Transaction Cost Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.1.1 Fundamental Ideas . . . . . . . . . . . . . . . . . . . . . . . . . . . 273.1.2 Transaction Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

3.2 Reasons for Market Failure: Williamson’s Organisational FailureFramework of 1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293.2.1 Market, Hierarchy or Cooperations . . . . . . . . . . . . . . . 313.2.2 The Suitability of Transaction Cost Theory

in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323.3 Principal-Agent Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333.4 Information Asymmetries and Behavioural Uncertainties . . . . . . 35

3.4.1 Coordination Patterns . . . . . . . . . . . . . . . . . . . . . . . . . 373.4.2 Principal-Agent Theory for the Analysis of Steering

Elements in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . 40Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

xi

Part II Managed Care Organisations and Products

4 Preliminary Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

5 Insurance-Based Managed Care Organisations and Products . . . . . 495.1 Staff, Group, IPA and Network Model HMOs . . . . . . . . . . . . . . 49

5.1.1 Basic Idea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495.1.2 Staff Model HMOs . . . . . . . . . . . . . . . . . . . . . . . . . . . 515.1.3 Group Model HMOs . . . . . . . . . . . . . . . . . . . . . . . . . 535.1.4 IPA Model HMOs . . . . . . . . . . . . . . . . . . . . . . . . . . . 585.1.5 Network Model HMOs . . . . . . . . . . . . . . . . . . . . . . . . 58

5.2 Consumer-Driven Health Plans (CDHPs) and Health SavingsAccounts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605.2.1 Guidelines and Health Policy Goals . . . . . . . . . . . . . . . 605.2.2 Forms and Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . 615.2.3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

6 Provider-Based Managed Care Organisations and Products . . . . . . 676.1 Independent Practice Associations (IPA) . . . . . . . . . . . . . . . . . . 676.2 Preferred Provider Organisations (PPO) . . . . . . . . . . . . . . . . . . 686.3 Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696.4 Integrated Delivery Systems (IDS) . . . . . . . . . . . . . . . . . . . . . . 726.5 Accountable Care Organisations (ACO) . . . . . . . . . . . . . . . . . . 806.6 Patient-Centred Medical Homes (PCMH) . . . . . . . . . . . . . . . . . 81Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

7 Institutions in the Managed Care Environment . . . . . . . . . . . . . . . . 877.1 Management Service Organisations (MSO) . . . . . . . . . . . . . . . . 877.2 Physician Practice Management Companies (PPMC) . . . . . . . . . 897.3 Pharmacy Benefit Management (PBM) . . . . . . . . . . . . . . . . . . . 90

7.3.1 Elements of Pharmacy Benefit Management (PBM) . . . 917.3.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Part III Managed Care Instruments

9 Contract Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1039.1 Selective Contracting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

9.1.1 Introductory Remarks . . . . . . . . . . . . . . . . . . . . . . . . . 1039.1.2 Selective Contracts with Physicians . . . . . . . . . . . . . . . 1049.1.3 Selective Contracts with Hospitals . . . . . . . . . . . . . . . . 1069.1.4 Assessment of Selective Contracting . . . . . . . . . . . . . . 107

xii Contents

9.2 Structuring the Insurance Contracts . . . . . . . . . . . . . . . . . . . . . 1089.2.1 Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1089.2.2 Options for Managing Pre-contract Risks . . . . . . . . . . . 1089.2.3 Options for Managing Post-contract Risks . . . . . . . . . . 1099.2.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

10 Compensation Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11910.1 Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11910.2 Forms of Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

10.2.1 Salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12310.2.2 Factor Cost Reimbursement . . . . . . . . . . . . . . . . . . . . 12310.2.3 Fee-for-Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12410.2.4 Daily Rates (Per Diem) . . . . . . . . . . . . . . . . . . . . . . . . 12510.2.5 Case Rates and Diagnosis Related Groups (DRGs) . . . . 12610.2.6 Bundled Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . 12810.2.7 Capitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

10.3 Pay-for-Performance (P4P) and Public Reporting . . . . . . . . . . . 13310.3.1 Pay-for-Performance . . . . . . . . . . . . . . . . . . . . . . . . . . 13310.3.2 Design of the Model . . . . . . . . . . . . . . . . . . . . . . . . . . 13510.3.3 Public Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13910.3.4 Basic Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13910.3.5 Negative Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . 141

10.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

11 Quality Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14911.1 Guidelines and Clinical Pathways . . . . . . . . . . . . . . . . . . . . . . . 149

11.1.1 Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14911.1.2 Forms and Objectives of Guidelines . . . . . . . . . . . . . . . 15111.1.3 Areas of Application for Guidelines . . . . . . . . . . . . . . . 15211.1.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

11.2 Disease Management and Chronic Care . . . . . . . . . . . . . . . . . . 15611.2.1 Introductory Remarks . . . . . . . . . . . . . . . . . . . . . . . . . 15611.2.2 Elements of Disease Management . . . . . . . . . . . . . . . . 15711.2.3 Stages of Disease Management . . . . . . . . . . . . . . . . . . 15811.2.4 Chronic Care Model . . . . . . . . . . . . . . . . . . . . . . . . . . 16111.2.5 Critical Assessment of Disease Management

and Chronic Care Management . . . . . . . . . . . . . . . . . . 16411.3 Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

11.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16611.3.2 Range of Tasks of the Case Manager . . . . . . . . . . . . . . 16811.3.3 Case Management Procedure . . . . . . . . . . . . . . . . . . . . 17011.3.4 Evaluating Case Management . . . . . . . . . . . . . . . . . . . 171

11.4 Patient Coaching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

Contents xiii

11.4.1 Specifications of Patient Coaching . . . . . . . . . . . . . . . . 17311.4.2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

11.5 Principles of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 17711.5.1 Preliminary Remarks . . . . . . . . . . . . . . . . . . . . . . . . . 17711.5.2 Quality Planning (“Plan”) . . . . . . . . . . . . . . . . . . . . . . 17811.5.3 Quality Implementation (“Do”) . . . . . . . . . . . . . . . . . . 18311.5.4 Quality Inspection (“Check”) . . . . . . . . . . . . . . . . . . . 18311.5.5 Implementation of Quality Improvement Measures

(“Act”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18611.5.6 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

12 Cost Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19512.1 Gatekeeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195

12.1.1 Basic Idea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19512.1.2 Forms of Gatekeeping . . . . . . . . . . . . . . . . . . . . . . . . . 19612.1.3 Significance and Mechanisms . . . . . . . . . . . . . . . . . . . 19712.1.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

12.2 Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19912.2.1 Fundamental Concepts and Effective Mechanisms . . . . 19912.2.2 Goals of Implementing Formularies . . . . . . . . . . . . . . . 20112.2.3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

12.3 Utilisation Review and Management . . . . . . . . . . . . . . . . . . . . 20312.3.1 Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20412.3.2 Forms of Utilisation Review and Utilisation

Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20512.3.3 Importance and Effective Mechanisms . . . . . . . . . . . . . 20712.3.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

13 Evaluation Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21313.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21313.2 Health Economic Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . 214

13.2.1 Cost Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21513.2.2 Cost-Effectiveness Analysis . . . . . . . . . . . . . . . . . . . . 21613.2.3 Cost-Utility Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 21713.2.4 Cost-Benefit Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 21913.2.5 Sensitivity Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . 220

13.3 Preference Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22113.3.1 Patient Benefits and Preferences . . . . . . . . . . . . . . . . . 22113.3.2 Measurement of Preferences . . . . . . . . . . . . . . . . . . . . 22213.3.3 The Foundational Methods: The Conjoint

Analysis (CA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22313.3.4 The Discrete Choice Experiment . . . . . . . . . . . . . . . . . 22313.3.5 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

xiv Contents

13.4 Evidence-Based Medicine (EBM) . . . . . . . . . . . . . . . . . . . . . . . 22813.4.1 Systematic Acquisition of Information . . . . . . . . . . . . . 22913.4.2 Analysis of the Evidence . . . . . . . . . . . . . . . . . . . . . . . 23013.4.3 Application of Evidence Found in Individual Cases . . . 230

13.5 Health Services Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23113.6 Health Technology Assessment (HTA) . . . . . . . . . . . . . . . . . . . 233Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Part IV Evaluation of Managed Care

14 Preliminary Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

15 Cost Effects of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

16 Quality Effects of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . 247Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

17 Access Effects of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 251Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

18 Acceptance of Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25318.1 Acceptance from the Insured and Patients . . . . . . . . . . . . . . . . . 25318.2 Acceptance from Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . 254Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

19 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Contents xv

About the Authors

Charity M. Agbor, PhD, is project manager at the Institute of Health ScienceResearch (inav, Privates Institut für angewandte Versorgungsforschung) in Berlin.Prior to this, she worked for an IT consulting company and a Pharmacy BenefitManagement (PBM) Company.

She contributed to several parts of the book and provided the technical andscientific revision of this edition.

Volker Amelung is Professor for International Healthcare System Research at theMedical University of Hannover, Germany. He is also the president of the GermanManaged Care Association (BMC), Berlin. In 2011, he founded the Private HealthServices Research Institute (inav) in Berlin. Volker Amelung is a member of severalhealthcare associations and internationally affiliated with healthcare managementprofessionals. His research focuses on healthcare policy, managed care, andhealthcare systems.

Peter Berchtold is a medical doctor by training and worked for more than 20 yearsin leading positions in hospitals in Switzerland. He founded the College M, aresearch-orientated consultancy company based in Bern, Switzerland, in 1999.Peter Berchtold is also president of the Swiss Managed Care Association “ForumManaged Care”.

Dr. Berchtold wrote the case study 2 on Swiss physician networks (Sect. 6.3,pp. 69–72).

Susanne Bethge, PhD, MSc in Public Health and Administration, was researchassistant for health economics at the University of Applied SciencesNeubrandenburg, Germany, and is now working for the German Innovation Fundsat the Federal Joint Committee (GB-A). Her research focuses on discrete choiceanalysis.

Together with Axel Mühlbacher, Susanne Bethge wrote the section on preferencemeasurement and the corresponding case study 7 (Sect. 13.3, pp. 221–228).

Mirella Cacace is Professor of Health Care Systems and Health Policy at theCatholic University of Applied Sciences in Freiburg, Germany, and leading a project

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on the transformation of the healthcare systems in Central and Eastern EuropeanCountries at the Collaborative Research Center 1342 at the University of Bremen.She is a 2008/09 Commonwealth Fund Harkness Fellow and spent her fellowshipyear at Columbia University, New York. Her main research interest is internationalcomparisons of healthcare systems. Her PhD thesis analyses the changing gover-nance structures in the American healthcare system.

Professor Cacace wrote the section on consumer-driven health plans and healthsavings accounts (Sect. 5.2, pp. 60–64) as well as the subsection on bundledpayments (Sect. 10.2, pp. 122–133).

Andreas Domdey, PhD, MPH is a dentist by training. He worked for a largeGerman sickness fund and pharmaceutical companies.

Andreas Domdey wrote the section on disease management and chronic care(Sect. 11.2, pp. 156–166) and contributed the entire chapter on quality management(Sect. 13.3, pp. 221–228).

Christian Krauth is Head of the Health Economics Research Unit at the MedicalUniversity of Hannover, Germany, and board member of the Centre for HealthEconomics Research Hannover, Germany. His research focuses on health econom-ics, experimental economics, health services research, and health economicevaluation.

Christian Krauth contributed to the section on health economic evaluation (Sect.13.2, pp. 214–221) and also wrote the section evidence-based medicine (Sect. 13.4,pp. 228–231).

Anika Meißner, MPH, is Teamleader Contract for the HÄVG, the organisationthat manages the contracts for the German Association of General Practitioners,Baden-Wuerttemberg, Germany.

Anika Meißner wrote the sections on ACO and PCMH (Sects. 6.5 and 6.6,pp. 80–81) and the case study on Wagner’s chronic care model (Case Study 6, pp.81–83) and contributed to several other parts of the book.

Axel Mühlbacher is Professor for Health Economics and Health Systems Researchat the Hochschule Neubrandenburg, Germany. Axel Mühlbacher is a SeniorResearch Fellow at the Center for Health Policy and Inequities Research at DukeGlobal Health Institute. He was a 2010–2011 Harkness fellow from the Common-wealth Fund at the Duke Clinical Research Institute and the Fuqua Business School.

Professor Mühlbacher wrote the section on preference measurement and thecorresponding case study 7 (Sect. 13.3, pp. 221–228).

Ulla Tangermann, PhD, is a Market Access Manager at Roche. She worked as aresearch assistant for health economics and health policy at the Medical Universityof Hannover, Germany, where she earned her Master’s in Public Health.

Ulla Tangermann wrote the case study on the quality and outcomes framework(case study 5, pp. 137–138). She also contributed significantly to several otherportions of the book and revised the first edition.

xviii About the Authors

Christoph Wagner, PhD, graduated in music therapy (diploma), business admin-istration (diploma), and health economics (PhD). He works as a strategic data analystat the AOK Nordost statutory health insurance fund in Berlin, Germany.

Christoph Wagner wrote the section on patient coaching (Sect. 11.4, pp. 172–176).

To a previous German edition of this book, Prof. Katharina Janus contributedsignificantly. The case studies on Kaiser Permanente (pp. 54–57) and Leapfrog(pp. 113–115) are still based on this work.

The entire research project on managed care was started many years ago togetherwith my colleague Harald Schumacher, who passed away far too early in 2002. Itried to keep his way of thinking by continuing the research.

About the Authors xix