Who Is Holding Whom Accountable for Quality?

Health Affairs

Volumn 16, Issue 3, 1997, Pages 26-40

  Gosfield, Alice G ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ACCREDITATION; HEALTH CARE QUALITY; HEALTH INSURANCE; HUMAN; LEGAL ASPECT; LEGAL LIABILITY; OUTCOME ASSESSMENT; REVIEW; SOCIAL BEHAVIOR; STANDARD; UNITED STATES;

ACCREDITATION; HUMANS; LIABILITY, LEGAL; MANAGED CARE PROGRAMS; OUTCOME ASSESSMENT (HEALTH CARE); QUALITY ASSURANCE, HEALTH CARE; SOCIAL RESPONSIBILITY; UNITED STATES;

EID: 0342437201     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.3.26     Document Type: Article

References (27)

1. The Health Plan Employer Data and Information Set (HEDIS), a system of performance measures, now in its third iteration, was developed and published under the auspices of the National Committee for Quality Assurance (NCQA).
2. For a more detailed consideration of all these issues see, A.G. Gosfield, Guide to Key Legal Issues in Managed Care Quality (New York: Faulkner and Gray, 1996).
3. Fox v Health Net (Ca. Super. Ct., December 1993); and Ching v Gaines (Ca. Super. Ct., November 1995).
4. "Ostensible agency" is the theory that the treating physician is perceived by the patient as the agent for the plan, and his actions are then attributed to the plan as having been on its behalf. See, for example, Boyd v Einstein, 574 A2d 1229 (Pa. Super., 1988). Respondent superior is a principle, primarily in employment relationships, that the employer is responsible for the actions of the employee. See Schleier v Kaiser Foundation Health Plan, 876 F2d 174 (DC App., 1989).
5. The motion for summary judgment is that point at which the defendant tries to convince the judge that there is no need for a trial because as a matter of law the managed care organization cannot be held liable.
6. Widline v State, 239 Cal. Rptr. 810 (1986).
7. Wilson v Blue Cross of Southern California (1990 Cal. Lexis 4574).
8. See Teti v U.S. Healthcare [1989 WL 143274 (E.D. Pa.)]; Anderson v Humana, 24 F 3d. 889 (7th Cir., 1994); and Bush v Dake (Mich. Saginaw County Ct., 1989).
9. See Teti v U.S. Healthcare [1989 WL 143274 (E.D. Pa.)]; Anderson v Humana, 24 F 3d. 889 (7th Cir., 1994); and Bush v Dake (Mich. Saginaw County Ct., 1989).
10. See Teti v U.S. Healthcare [1989 WL 143274 (E.D. Pa.)]; Anderson v Humana, 24 F 3d. 889 (7th Cir., 1994); and Bush v Dake (Mich. Saginaw County Ct., 1989).
11. See, for example, Corcoran v Blue Cross of Louisiana, 965 F2d 1321 (5th Cir.) cert den 113 S.Ct 812 (1992); and Kuhl v Lincoln National, 999 F2d 298 (8th Cir., 1993).
12. See, for example, Corcoran v Blue Cross of Louisiana, 965 F2d 1321 (5th Cir.) cert den 113 S.Ct 812 (1992); and Kuhl v Lincoln National, 999 F2d 298 (8th Cir., 1993).
13. See, for example, Corcoran v Blue Cross of Louisiana, 965 F2d 1321 (5th Cir.) cert den 113 S.Ct 812 (1992); and Kuhl v Lincoln National, 999 F2d 298 (8th Cir., 1993).
14. 1995 WL 361723 (3d Cir., Pa.).
15. L. Kertesz, "Data Signal Managed-Care Suits on Rise," Modern Healthcare (20 May 1996): 17.
16. D. Krane, "Assumption of Insurance Risk: Current Issues Affecting Managed Care Organizations," in Health Law Handbook, 1996 ed., ed. A.G. Gosfield (New York: Clark Boardman Callaghan, 1996), 71-88.
17. See R.L. Roth, "The Little Red Hen Syndrome: States and 'Anti-Managed Care' Laws," in Gosfield, Guide to Key Legal Issues in Managed Care Quality, 133-158.
18. This is the program under federal law that uses physician peer review organizations (PROs) across the country to monitor the quality of care provided primarily under Medicare and recommend sanctions, including exclusion from Medicare, for those hospitals and physicians who provide poor quality. 42 U.S. Code, sec. 1320c et seq.
19. The "dual-choice" option refers to the statutory requirement that where an employer offers a health benefit plan and a federally qualified HMO is available in that area, both plans must be offered.
20. Federal Register on safe harbor regulations, see 61 (25 January 1996): 2122. The physician incentive plan regulations, originally published at Federal Register 61 (27 March 1996): 13430, were significantly revised and reissued by the end of the same year. Federal Register 61 (31 December 1996): 69034.
21. Federal Register on safe harbor regulations, see 61 (25 January 1996): 2122. The physician incentive plan regulations, originally published at Federal Register 61 (27 March 1996): 13430, were significantly revised and reissued by the end of the same year. Federal Register 61 (31 December 1996): 69034.
22. Federal Register on safe harbor regulations, see 61 (25 January 1996): 2122. The physician incentive plan regulations, originally published at Federal Register 61 (27 March 1996): 13430, were significantly revised and reissued by the end of the same year. Federal Register 61 (31 December 1996): 69034.
23. On the Stark amendment, see 42 U.S. Code, sec. 1395nn et seq. On the Medicare HMO qualifications, see 42 U.S. Code, sec. 1395mm(i).
24. The AHCPR was charged with the responsibility to publish national clinical practice guidelines. See 42 U.S. Code, sec. 299b-1; and Institute of Medicine, Guidelines for Clinical Practice: From Development to Use, ed. M.J. Field and K.N. Lohr (Washington: National Academy Press, 1992).
25. It is beyond the scope of this paper to consider these differences, but patient-centered measures look to patient surveys and interviews as a primary technique to determine the outcomes of care. This is a new and developing concept.
26. M. Gold et al., "A National Survey of the Arrangements Managed-Care Plans Make with Physicians," The New England Journal of Medicine (21 December 1995): 1678-1683.
27. J.P. Robinson and L.P. Casalino, "The Growth of Medical Groups Paid through Capitation in California," The New England Journal of Medicine (21 December 1995): 1684-1687.