ABSTRACT
One of the major issues pertaining to the pending legislation for Patient's Bill of Rights is the potential of liability health care plans, particularly when they decline coverage they consider not medically necessary. We call these contracts "managed health care" plans. But, realistically, when is it managing? When is it medicine? When, if at all, does management undermine medicine? And if it does, should managed care organizations--and their representatives--be held legally liable for medical decisions that go wrong? A panel of seven experts examines these questions from medical, payment, patient, legal, insurance, and governing viewpoints.
Subject(s)
Managed Care Programs/organization & administration , Professional Practice , Clinical Trials as Topic , Delivery of Health Care/organization & administration , Humans , Insurance Carriers/legislation & jurisprudence , Managed Care Programs/standards , Medical Oncology/organization & administration , Medical Oncology/standards , Neoplasms/prevention & control , Patient Education as Topic , Practice Management, MedicalABSTRACT
As both public and private health plans move increasingly to managed care, a vigorous debate is occurring about how to ensure health care quality for the American public, while at the same time managing the cost of that care. Health plans generate large volumes of data related to their networks and providers, plan sponsors, member care, and medical protocols. This data can help assure quality, and at the same time help managed care organizations deal with one of the most critical tasks facing them--risk management. This paper may be helpful in providing an outline of two key areas--managed care liability for quality of patient care, and privacy and confidentiality concerns from a managed care organization perspective--followed by suggestions to avoid or minimize liability.
