Regulating Managed Care: Theory, Practice, and Future Options

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

has become increasingly less so as the industry has grown to the largest in the state, now covering well over half of all Californians. The regulatory structure it imposes was primarily designed in 1975 when the original Knox-Keene Act was passed, and the industry has evolved significantly since then. Given the size, the complexity, and the degree of public interest in managed care, the task force recommended the creation of a new regulatory agency, one devoted specifically to managed care organizations, whose leadership would have the expertise and vision necessary for effective regulation.

As we have seen, government need not and should not attempt to regulate the health care industry alone. Neither should a completely free market be left to distribute health care; because of market failures, it cannot do so in a morally acceptable way. But the market, made up of purchasers and competitors, the industry, and government together can structure an appropriate set of incentives that will create accessible, quality health care for consumers.


Notes
1
Pear, R. “Business Coalition to Fight Legislation Protecting Patients' Rights.” The New York Times, January 21, 1998, p. A18.
2
Freudenheim, M. “Progress on Health Costs, But Nagging Woes Persist.” The New York Times, January 5, 1998, p. D10.
3
Sinton, P., and Russell, S. “Kaiser Raising Rates Up to 11 Percent.” San Francisco Chronicle, March 31, 1998, p. D1.
4
“Medicare and Medicaid Statistical Supplement” (Table 21). Health Care Financing Review, 1997, pp. 56–58.
5
California Department of Health Services, Managed Care Division, 1997.
6
According to a study by the Barents Group, 86 percent of workers who are offered one plan only are offered a plan with a nonnetwork component. Barents Group. “Health Care Choices.” Report commissioned by American Association of Health Plans, December 1997.
7
California Managed Health Care Improvement Task Force. “Exp anding Consumer Choice: Background Paper.” Sacramento, Calif.: Author, 1998. Data for 1996 were provided by KPMG Peat Marwick, Tysons Corner, Va., 1997.
8
California Managed Health Care Improvement Task Force. “Public Perceptions and Experiences with Managed Care: Background Paper.” Sacramento, Calif.: Author, 1998.

-329-

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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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