Regulating Managed Care: Theory, Practice, and Future Options

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

As this concept is developed, a number of issues undoubtedly will need to be addressed. First, none of the ombudsman funding should be used for policymaking advocacy but instead should be used exclusively to provide direct services to consumers. Second, the creation of publicly supported consumer assistance programs should complement, not supplant, already existing services—such as those currently provided by some employers and public agencies. And third, a balance needs to be drawn so that consumer assistance programs, on the one hand, serve all consumers, no matter the source of the health coverage, and on the other hand, have the capability and specialized expertise to serve people with significantly divergent needs.


Conclusion

The revolution in health care has been unsettling for the American public. As more and more people experience denials of care or learn about such denials from friends, relatives, and the news media, the public becomes increasingly apprehensive. Consumers who have lost the right to choose their physicians or health plans experience or hear about improper denials of care and are bewildered and don't know what they can do to protect their families.

Consumers need a set of uniform national protections that are guaranteed to them as purchasers of insurance. Such protections are affordable and would add little to the cost of providing care. They would provide predictability and uniformity by establishing a floor of national standards applicable to everyone. They would restore public confidence in the health care system. Finally, they would enable managed care to realize its potential for simultaneously controlling health care costs while providing high-quality care to all consumers.


Notes
1
The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. “Quality First: Better Health Care for All Americans.” Final report to the President of the United States, March 1998.
2
Families USA Foundation. HMO Consumers at Risk: States to the Rescue. Washington, D.C.: Author, 1996; Families USA Foundation. Hit and Miss: State Managed Care Laws. Washington, D.C.: Author, 1998.

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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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