Regulating Managed Care: Theory, Practice, and Future Options

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

Chapter Six
The Long-Term Care
Ombudsman Program

A Model for Health Care Consumers
William F. Benson

Ombudsman: (1) a government official (as in Sweden or New Zealand) appointed to receive and investigate complaints made by individuals against abuses or capricious acts of public officials; (2) one that investigates reported complaints (as from students or consumers), reports findings, and helps achieve equitable settlements. —WEBSTER'S NINTH NEW COLLEGIATE DICTIONARY

Few would disagree that our highly complex health care world is rapidly becoming even more complex. The technology of health care is complex, as are its organizational and delivery models and its financing. For consumers, successfully navigating through a health care organization or system to obtain appropriate, timely, and high-quality health care can be a difficult if not daunting chore. At times it can be overwhelming. If the consumer is dissatisfied or unhappy with the care received or feels aggrieved in some way, the effort anticipated or expended in trying to resolve the source of discontent or to settle the grievance may be overwhelming, particularly in the absence of mechanisms for resolving problems.

-117-

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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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