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The Handbook of Employee Benefits: Health and Group Benefits 7/E by Jerry Rosenbloom

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CHAPTER 6Managing and Measuring Care Management Intervention Programs

Ian Duncan

BACKGROUND

Early insurance approaches to the financing of health care focused on hospital reimbursement and were characterized by two key assumptions. The first assumption was that providers would exercise reasonable professional judgment in the provision of services to patients. The second assumption was that patients would tend to be conservative regarding their use of services (since these services often involved both discomfort and uncertain outcomes).

In this model, the insurance company’s role was limited to “traditional” insurance functions, such as underwriting and pricing, verification of insurance eligibility, and claim payment. Cost was restrained through ...

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