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Volumn 33, Issue 1, 2003, Pages 34-42

Managed care organizations and the rationing problem

(1)  Baily, Mary Ann a  

a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BIOETHICS; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE ORGANIZATION; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH INSURANCE; HUMAN; MORALITY; PHYSICIAN ATTITUDE; UNITED STATES;

EID: 0038750554     PISSN: 00930334     EISSN: None     Source Type: Journal    
DOI: 10.2307/3527912     Document Type: Review
Times cited : (6)

References (42)
  • 1
    • 4644328260 scopus 로고
    • Policies for the 1990s: Rationing Health Care
    • See, ed. R. Arnould, R. Rich and W. White Washington, D.C, Urban Institute Press, and the references thetein for further discussion of rationing definitions and the reasons for choosing this one
    • See M.A. Baily, "Policies for the 1990s: Rationing Health Care," in Competitive Approaches to Health Care Reform, ed. R. Arnould, R. Rich and W. White (Washington, D.C.: Urban Institute Press, 1993), 313-40 and the references thetein for further discussion of rationing definitions and the reasons for choosing this one.
    • (1993) Competitive Approaches to Health Care Reform , pp. 313-340
    • Baily, M.A.1
  • 2
    • 61449119338 scopus 로고    scopus 로고
    • See also P. Ubel, Pricing Life: Why It's Time for Health Care Rationing (Cambridge, Mass.: MIT Press, 2000), chaptet 2, and M. Hall, Making Medical Spending Decisions: The Law, Ethics and Economics of Rationing Mechanisms (New Yotk: Oxford University Press, 1997), chapter 1.
    • See also P. Ubel, Pricing Life: Why It's Time for Health Care Rationing (Cambridge, Mass.: MIT Press, 2000), chaptet 2, and M. Hall, Making Medical Spending Decisions: The Law, Ethics and Economics of Rationing Mechanisms (New Yotk: Oxford University Press, 1997), chapter 1.
  • 3
    • 61449161669 scopus 로고    scopus 로고
    • This phenomenon is called moral hazard in insurance terminology. A homely analogy is the situation that arises when people dining out togethet decide in advance to split the bill evenly. Each person has a financial incentive to otder a more expensive meal, yet the group as a whole must pay the total cost. If the check is to be evenly divided, it would be wise to agree to choose from a limited menu, i.e. to submit to some (non-price) tationing
    • This phenomenon is called moral hazard in insurance terminology. A homely analogy is the situation that arises when people dining out togethet decide in advance to split the bill evenly. Each person has a financial incentive to otder a more expensive meal, yet the group as a whole must pay the total cost. If the check is to be evenly divided, it would be wise to agree to choose from a limited menu, i.e. to submit to some (non-price) tationing.
  • 4
    • 61449131982 scopus 로고    scopus 로고
    • Fot detailed discussion of the arguments for and the nature of this societal obligation to ensure universal access to an adequate level of health care, see, for example, President's Commission for the Study of Ethical Problems in Medicine, Securing Access to Health Care, One: Report (Washington, D.C, U.S. Government Printing Office, 1983) and A. Buchanan, Health-Care Delivery and Resource Allocation, in Medical Ethics, ed. R. Veatch Sudbury, Mass, Jones and Bartlett Publishers, 1997, 321-61
    • Fot detailed discussion of the arguments for and the nature of this societal obligation to ensure universal access to an adequate level of health care, see, for example, President's Commission for the Study of Ethical Problems in Medicine, Securing Access to Health Care, Volume One: Report (Washington, D.C.: U.S. Government Printing Office, 1983) and A. Buchanan, "Health-Care Delivery and Resource Allocation," in Medical Ethics, ed. R. Veatch (Sudbury, Mass.: Jones and Bartlett Publishers, 1997), 321-61.
  • 5
    • 0010352691 scopus 로고
    • Rationing Medical Care: Processes for Defining Adequacy
    • ed. G. Agich and CD. Begley Dordrecht, The Netherlands: D. Reidel Publ. Co
    • MA. Baily, "Rationing Medical Care: Processes for Defining Adequacy," in The Price of Health, ed. G. Agich and CD. Begley (Dordrecht, The Netherlands: D. Reidel Publ. Co., 1986), 165-84.
    • (1986) The Price of Health , pp. 165-184
    • Baily, M.A.1
  • 6
    • 61449114351 scopus 로고    scopus 로고
    • The best-known real world example of this type of rationing comes from the first dialysis program in Seattle in the early 1960s, in which a small group of people from different walks of life used social worth criteria to decide which patients should be admitted to the ptogtam and thereby saved from certain death
    • The best-known real world example of this type of rationing comes from the first dialysis program in Seattle in the early 1960s, in which a small group of people from different walks of life used social worth criteria to decide which patients should be admitted to the ptogtam and thereby saved from certain death.
  • 7
    • 61449118374 scopus 로고    scopus 로고
    • See R. Fox and J. Swazey, The Courage to Fail: A Social View of Organ Transplants and Dialysis, 2nd ed., revised (Chicago: The University of Chicago Ptess, 1978) for a classic discussion of this so-called God Committee and R. Rettig, Historical Perspective, in Ethics and the Kidney, ed. N. Levinsky (Oxford, U.K.: Oxford University Press, 2001), for the history of the rationing of kidney dialysis and kidneys for transplant from 1960-99.
    • See R. Fox and J. Swazey, The Courage to Fail: A Social View of Organ Transplants and Dialysis, 2nd ed., revised (Chicago: The University of Chicago Ptess, 1978) for a classic discussion of this so-called "God Committee" and R. Rettig, "Historical Perspective," in Ethics and the Kidney, ed. N. Levinsky (Oxford, U.K.: Oxford University Press, 2001), for the history of the rationing of kidney dialysis and kidneys for transplant from 1960-99.
  • 9
    • 0028472465 scopus 로고
    • Four Unsolved Rationing Problems: A Challenge,
    • For discussion of the difficulties see, for example, 24, no. 4 , 27-29;
    • For discussion of the difficulties see, for example, N. Daniels, "Four Unsolved Rationing Problems: A Challenge," Hastings Center Report 24, no. 4 (1994): 27-29;
    • (1994) Hastings Center Report
    • Daniels, N.1
  • 11
    • 0028473739 scopus 로고
    • The Aggregation Problem,
    • 24, no. 4 , 33-36;
    • E. Rakowski, "The Aggregation Problem," Hastings Center Report 24, no. 4 (1994): 33-36;
    • (1994) Hastings Center Report
    • Rakowski, E.1
  • 12
    • 0028470624 scopus 로고
    • Fairness versus Doing the Most Good,
    • 24, no. 4 , 36-39;
    • J. Broome, "Fairness versus Doing the Most Good," Hastings Center Report 24, no. 4 (1994): 36-39;
    • (1994) Hastings Center Report
    • Broome, J.1
  • 13
    • 0028470723 scopus 로고
    • The Democracy Problem,
    • 24, no. 4 , 39-42
    • M.A. Baily, "The Democracy Problem," Hastings Center Report 24, no. 4 (1994): 39-42.
    • (1994) Hastings Center Report
    • Baily, M.A.1
  • 14
    • 0003454870 scopus 로고
    • For example, M. Strosberg et al, eds, Washington, D.C, Brookings Institution
    • For example, M. Strosberg et al., eds. Rationing America's Medical Care: The Oregon Plan and Beyond, (Washington, D.C.: Brookings Institution, 1992);
    • (1992) Rationing America's Medical Care: The Oregon Plan and Beyond
  • 15
    • 0025765922 scopus 로고
    • Is the Otegon Rationing Plan Fair?
    • N. Daniels, "Is the Otegon Rationing Plan Fair?" JAMA 265, no. 17 (1991): 2232-35;
    • (1991) JAMA , vol.265 , Issue.17 , pp. 2232-2235
    • Daniels, N.1
  • 16
    • 0028491061 scopus 로고
    • Just Caring: Oregon, Health Care Rationing, and Informed Democratic Deliberation
    • Fleck, "Just Caring: Oregon, Health Care Rationing, and Informed Democratic Deliberation," Journal of Medicine & Philosophy 19, no. 4 (1994): 367-88;
    • (1994) Journal of Medicine & Philosophy , vol.19 , Issue.4 , pp. 367-388
    • Fleck1
  • 17
    • 84985261714 scopus 로고
    • Justice, Politics and Community: Expanding Access and Rationing Health Services in Otegon
    • Garland, "Justice, Politics and Community: Expanding Access and Rationing Health Services in Otegon," Law, Medicine & Health Care 20, nos. 1 and 2 (1992): 67-81.
    • (1992) Law, Medicine & Health Care , vol.20 , Issue.1 AND 2 , pp. 67-81
    • Garland1
  • 18
    • 0033041277 scopus 로고    scopus 로고
    • The Oregon Health Plan and the Political Paradox of Rationing: What Advocates and Critics Have Claimed and What Oregon Did
    • See
    • See L. Jacobs, T. Marmor and H. Oberlander, "The Oregon Health Plan and the Political Paradox of Rationing: What Advocates and Critics Have Claimed and What Oregon Did," Journal of Health Politics, Policy and Law 24, no. 1 (1999): 161- 79.
    • (1999) Journal of Health Politics, Policy and Law , vol.24 , Issue.1 , pp. 161-179
    • Jacobs, L.1    Marmor, T.2    Oberlander, H.3
  • 19
    • 0004285239 scopus 로고    scopus 로고
    • 2nd ed, Gaithetsburg, MD: Aspen Publishers, Inc, The book, by the way, has 557 pages
    • P. Kongstvedt, Essentials of Managed Health Care, 2nd ed. (Gaithetsburg, MD: Aspen Publishers, Inc., 1997). The book, by the way, has 557 pages.
    • (1997) Essentials of Managed Health Care
    • Kongstvedt, P.1
  • 20
    • 0031217084 scopus 로고    scopus 로고
    • Limits to Health Care: Fair Procedures, Democratic Deliberation, and the Legitimacy Problem for Insurers
    • N. Daniels and J. Sabin, "Limits to Health Care: Fair Procedures, Democratic Deliberation, and the Legitimacy Problem for Insurers," Philosophy & Public Affairs 26, no. 4 (1997): 303-50;
    • (1997) Philosophy & Public Affairs , vol.26 , Issue.4 , pp. 303-350
    • Daniels, N.1    Sabin, J.2
  • 21
    • 0031906503 scopus 로고    scopus 로고
    • Closure, Fair Procedures, and Setting Limits within Managed Care Organizations
    • N. Daniels and J. Sabin, "Closure, Fair Procedures, and Setting Limits within Managed Care Organizations," Journal of the American Geriatrics Society 46 (1998): 351-54.
    • (1998) Journal of the American Geriatrics Society , vol.46 , pp. 351-354
    • Daniels, N.1    Sabin, J.2
  • 23
    • 0032018391 scopus 로고    scopus 로고
    • Last Chance Therapies and Managed Care: Pluralism, Fair Procedures, and Legitimacy,
    • 28, no. 2 , 27- 41
    • N. Daniels and J. Sabin, "Last Chance Therapies and Managed Care: Pluralism, Fair Procedures, and Legitimacy," Hastings Center Report 28, no. 2 (1998): 27- 41.
    • (1998) Hastings Center Report
    • Daniels, N.1    Sabin, J.2
  • 25
    • 61449181776 scopus 로고    scopus 로고
    • See Baily, Policies for the 1990s, and the references therein for a full discussion.
    • See Baily, "Policies for the 1990s," and the references therein for a full discussion.
  • 26
    • 61449180776 scopus 로고    scopus 로고
    • The classic economics article on the role of market imperfections in health care and health insurance markets is K. Arrow, Uncertainty and the Welfare Economics of Medical Care, American Economic Review 53, no, 5 1963, 941-73
    • The classic economics article on the role of market imperfections in health care and health insurance markets is K. Arrow, "Uncertainty and the Welfare Economics of Medical Care," American Economic Review 53, no, 5 (1963): 941-73.
  • 27
    • 61449186958 scopus 로고    scopus 로고
    • U.S. Congress, Congressional Budget Office, The Tax Treatment of Employment-Based Health Insurance (Washington, D.C.: CBO Publications Office, March, 1994).
    • U.S. Congress, Congressional Budget Office, The Tax Treatment of Employment-Based Health Insurance (Washington, D.C.: CBO Publications Office, March, 1994).
  • 28
    • 61449250183 scopus 로고    scopus 로고
    • For further discussion, see Baily, Policies fot the 1990s.
    • For further discussion, see Baily, "Policies fot the 1990s."
  • 29
    • 61449210393 scopus 로고    scopus 로고
    • Economists are as committed to individual autonomy as bioethicists. The main difference between the two perspectives is that economists give gteater attention to who is bearing the resource costs associated with an individual's autonomous choice.
    • Economists are as committed to individual autonomy as bioethicists. The main difference between the two perspectives is that economists give gteater attention to who is bearing the resource costs associated with an individual's autonomous choice.
  • 30
    • 61449186959 scopus 로고    scopus 로고
    • Baily, Policies for the 1990s, and references therein;
    • Baily, "Policies for the 1990s," and references therein;
  • 31
    • 0027414310 scopus 로고    scopus 로고
    • also, A. Enthoven, The History and Principles of Managed Competition, Health Affairs 12, Supplement (1993): 24-46.
    • also, A. Enthoven, "The History and Principles of Managed Competition," Health Affairs 12, Supplement (1993): 24-46.
  • 32
    • 61449099999 scopus 로고    scopus 로고
    • It is intetesting to note that what actually happened in Oregon resembled this pictute of rationing care to Medicaid recipients more closely than it resembled the stylized picture of rationing in terms of ranked condition-treatment pairs. Most of the people covered by the reform were enrolled in existing managed care plans. Reimbursement rates were high enough and the people enrolled were similar enough in health status to the regular managed care population that the plans could provide their usual standard of care and ignore the condition-treatment rankings. For most of those covered by the reform, the resulting access to care was as good as or better than their previous situation. See Jacobs, et al, The Otegon Health Plan
    • It is intetesting to note that what actually happened in Oregon resembled this pictute of rationing care to Medicaid recipients more closely than it resembled the stylized picture of rationing in terms of ranked condition-treatment pairs. Most of the people covered by the reform were enrolled in existing managed care plans. Reimbursement rates were high enough and the people enrolled were similar enough in health status to the regular managed care population that the plans could provide their usual standard of care and ignore the condition-treatment rankings. For most of those covered by the reform, the resulting access to care was as good as or better than their previous situation. See Jacobs, et al., "The Otegon Health Plan."
  • 33
    • 0004174333 scopus 로고    scopus 로고
    • For an excellent survey of the bioethics literature on the pure patient advocate view, with references and representative quotes, see, chaptet
    • For an excellent survey of the bioethics literature on the pure patient advocate view, with references and representative quotes, see Hall, Making Medical Spending Decisions, chaptet 4.
    • Making Medical Spending Decisions , pp. 4
    • Hall1
  • 34
    • 0028395394 scopus 로고
    • Health Care Reform and the Future of Physician Ethics,
    • See, for example, 24, no. 2 , 28-41
    • See, for example, S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41.
    • (1994) Hastings Center Report
    • Wolf, S.1
  • 35
    • 0033085028 scopus 로고    scopus 로고
    • This quote is from a superb analysis and ultimate rejection of the physician/lawyer analogy, W. Sage, Physicians as Advocates, Houston Law Review 35 1999, 1529-1630, at 1621
    • This quote is from a superb analysis and ultimate rejection of the physician/lawyer analogy, W. Sage, "Physicians as Advocates," Houston Law Review 35 (1999): 1529-1630, at 1621.
  • 38
    • 0037022219 scopus 로고    scopus 로고
    • Medical Professionalism in the New Millennium: A Physician Charter
    • See, for example, Medical Professionalism Project
    • See, for example, Medical Professionalism Project, ABIM Foundation, "Medical Professionalism in the New Millennium: A Physician Charter," Annals of Internal Medicine 136, no. 3 (2002): 243-46.
    • (2002) Annals of Internal Medicine , vol.136 , Issue.3 , pp. 243-246
    • Foundation, A.B.I.M.1
  • 39
    • 61449187913 scopus 로고    scopus 로고
    • The MCO need not be assigned responsibility for the entire standard. Some kinds of care might be guaranteed through separate social mechanisms. Of course, careful attention would have to be given to the boundaries between delivery systems to avoid the inefficiencies and perverse incentives that can arise
    • The MCO need not be assigned responsibility for the entire standard. Some kinds of care might be guaranteed through separate social mechanisms. Of course, careful attention would have to be given to the boundaries between delivery systems to avoid the inefficiencies and perverse incentives that can arise.
  • 40
    • 0031876776 scopus 로고    scopus 로고
    • Managed Care: Rationing without Justice, But Not Unjustly
    • on the importance of defining the morally required standard of care. See also
    • See also A. Buchanan, "Managed Care: Rationing without Justice, But Not Unjustly," Journal of Health Politics, Policy and Law 23, no. 4 (1998): 617-34 on the importance of defining the morally required standard of care.
    • (1998) Journal of Health Politics, Policy and Law , vol.23 , Issue.4 , pp. 617-634
    • Buchanan, A.1
  • 41
    • 61449136416 scopus 로고    scopus 로고
    • See Baily, Policies for the 1990s, for further discussion of this point.
    • See Baily, "Policies for the 1990s," for further discussion of this point.
  • 42
    • 61449125449 scopus 로고    scopus 로고
    • Given the widespread belief that it is impossible to define the morally required level of health care, it is ironic that we do not see the contradiction in maintaining institutional structures that only make sense on the assumption that we already have defined it. The malpractice system, civil litigation over insurance contracts, and the external review systems being proposed to allow patients to appeal allocation decisions implicitly assume a normative standard of care that can be applied in individual cases. For discussion, see, for example, M. Hall and G. Anderson, Models of Rationing: Health Insurers' Assessment of Medical Necessity, University of Pennsylvania Law Review 140 1992, 1637
    • Given the widespread belief that it is impossible to define the morally required level of health care, it is ironic that we do not see the contradiction in maintaining institutional structures that only make sense on the assumption that we already have defined it. The malpractice system, civil litigation over insurance contracts, and the external review systems being proposed to allow patients to appeal allocation decisions implicitly assume a normative standard of care that can be applied in individual cases. For discussion, see, for example, M. Hall and G. Anderson, "Models of Rationing: Health Insurers' Assessment of Medical Necessity," University of Pennsylvania Law Review 140 (1992): 1637.


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