Regulating Managed Care: Theory, Practice, and Future Options

By Stuart H. Altman; Uwe E. Reinhardt et al. | Go to book overview

based on failure to provide a service, which is necessarily a retrospective determination, mesh with treatment decisions based on prospective payment mechanisms? Will expanded MCO liability actually encourage more defensive medicine by MCOs and their providers—and how will a capitated system that strives to reduce unnecessary care deal with this pressure?

Can traditional approaches to liability coexist with organized cost containment—and if so, how? Some may believe (or hope) that they cannot. Others may believe that the courts, given the opportunity, will provide answers to these questions. Or that the “mark et” will eventually iron out whatever thorny problems consumers and their attorneys may throw at MCOs. Still others may prefer that these issues be the province of policy analysts and legislators who may (some will argue) be better able to shape a coherent, conscious, and systematic response to what are ultimately policy, as well as legal, questions.

The answers to these questions will depend on a continued assessment and debate about how health care is delivered, financed, and organized. Most importantly, those answers must be based on a determination of which policy, regulatory, and legal approaches can best assure and protect patients' interests in a rapidly changing health care system.


Notes
1
The “corporate practice of medicine doctrine” refers to state laws, originating in the early 1930s, that “ban unlicensed individuals and companies from engaging in the practice of medicine, and thus controlling patient care, by employing licensed professionals such as doctors or dentists. Its intent was to assure that only persons with medical licenses could actually deliver medical care and that lay persons would not influence professional decisions regarding treatment” (National Health Lawyers Association–American Academy of Hospital Attorneys, 1997, 5). Most states currently do not have such statutes; those that have them may interpret their specific applications differently. The existence of these statutes has prevented (and often continues to prevent) hospitals and other nonphysician employers in some states, but not all, from directly employing physicians.
2
Another question in examining allocation of legal risk and accountability for managed care plans is whether employers who contract with health plans to administer benefits to employees can be

-185-

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Regulating Managed Care: Theory, Practice, and Future Options
Table of contents

Table of contents

  • Title Page *
  • Contents vii
  • Foreword ix
  • Acknowledgments xiii
  • The Editors xv
  • The Contributors xvii
  • Introduction - The Philosophy of Regulation xxi
  • Notes xxxii
  • Regulating Managed Care xxxiv
  • Section I - The Role of Regulation in a Market-Oriented Health Care System 1
  • Chapter One - An Overview 5
  • Notes 27
  • Chapter Two - The Current Status of State and Federal Regulation 29
  • References 51
  • Chapter Three - Why Should Managed Care Be Regulated? 53
  • Chapter Four - Macro-Versus Microregulation 75
  • Reference 85
  • Section II - Regulatory Issues 87
  • Chapter Five - Consumer Choice Under “private Health Care Regulation” 91
  • Notes 114
  • Chapter Six - A Model for Health Care Consumers 117
  • Notes 133
  • Reference 133
  • Chapter Seven - Ensuring Equal Access to Care 135
  • Notes 143
  • Chapter Eight - Regulating Quality and Clinical Practice 145
  • Chapter Nine - The Scope of Managed Care Liability 160
  • Notes 185
  • Reference 186
  • Chapter Ten - Erisa and the Regulation of Group Health Plans 189
  • Notes 200
  • References 203
  • Section III - Perspectives on Regulation 205
  • Chapter Eleven - Understanding the Managed Care Backlash 209
  • Notes 224
  • Chapter Twelve - Core Principles for Regulating Health Care Quality 229
  • Notes 237
  • Chapter Thirteen - Balancing Market Forces and Regulation 239
  • Notes 262
  • Chapter Fourteen - Regulation from a Consumer's Perspective 263
  • Notes 274
  • Chapter Fifteen - Regulation from an Insurance Industry Perspective 276
  • Notes 281
  • Chapter Sixteen - Regulation Misses the Big Issue—the Uninsured 282
  • Notes 297
  • Section IV - Managed Care Regulation in Practice 299
  • Chapter Seventeen - A Practical Approach 301
  • Chapter Eighteen - California's Struggle with Regulation 312
  • Notes 329
  • Chapter Nineteen - How the Estimates Vary 331
  • Notes 343
  • Index 345
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