Consumer Protection and Managed Care: The Need for Organized Consumers

Health Affairs

Volumn 15, Issue 3, 1996, Pages 110-123

  Rodwin, Marc A ^a  

^a INDIANA UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BOARD OF TRUSTEES; CONSUMER; CONSUMER ADVOCACY; FINANCIAL MANAGEMENT; HEALTH INSURANCE; HUMAN; INTERPERSONAL COMMUNICATION; LEGAL ASPECT; ORGANIZATION AND MANAGEMENT; STANDARD; UNITED STATES;

COMMUNICATION; CONSUMER ADVOCACY; CONSUMER ORGANIZATIONS; GOVERNING BOARD; HUMANS; MANAGED CARE PROGRAMS; MARKETING OF HEALTH SERVICES; UNITED STATES;

EID: 0344322190     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.15.3.110     Document Type: Article

References (62)

1. J.A. Schumpeter, Capitalism, Socialism, and Democracy (New York: Harper and Row, 1976).
2. Seven-Year Balanced Budget Reconciliation Act of 1995, 104th Cong., 1st sess., H.R. 2491 (passed by Congress and vetoed by President Clinton).
3. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Plans," Health Affairs (Summer 1995): 99-112; For scandals, see F. Schulte and J. Bergal, "The HMO Maze: How Medicare Fails Seniors," Sun-Sentinel, 7-11 November 1993; M.A. Hiltzik and D.R. Olmos, "'Kaiser Justice' System's Fairness Is Questioned," Los Angeles Times, 30 August 1995, Al; and J. Johnson, "Dad's Protest Leads to Record Fine against California HMO," American Medical News, 12 December 1994, 1, 14.
4. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Plans," Health Affairs (Summer 1995): 99-112; For scandals, see F. Schulte and J. Bergal, "The HMO Maze: How Medicare Fails Seniors," Sun-Sentinel, 7-11 November 1993; M.A. Hiltzik and D.R. Olmos, "'Kaiser Justice' System's Fairness Is Questioned," Los Angeles Times, 30 August 1995, Al; and J. Johnson, "Dad's Protest Leads to Record Fine against California HMO," American Medical News, 12 December 1994, 1, 14.
5. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Plans," Health Affairs (Summer 1995): 99-112; For scandals, see F. Schulte and J. Bergal, "The HMO Maze: How Medicare Fails Seniors," Sun-Sentinel, 7-11 November 1993; M.A. Hiltzik and D.R. Olmos, "'Kaiser Justice' System's Fairness Is Questioned," Los Angeles Times, 30 August 1995, Al; and J. Johnson, "Dad's Protest Leads to Record Fine against California HMO," American Medical News, 12 December 1994, 1, 14.
6. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Plans," Health Affairs (Summer 1995): 99-112; For scandals, see F. Schulte and J. Bergal, "The HMO Maze: How Medicare Fails Seniors," Sun-Sentinel, 7-11 November 1993; M.A. Hiltzik and D.R. Olmos, "'Kaiser Justice' System's Fairness Is Questioned," Los Angeles Times, 30 August 1995, Al; and J. Johnson, "Dad's Protest Leads to Record Fine against California HMO," American Medical News, 12 December 1994, 1, 14.
7. M. Freudenheim, "Penny-Pinching HMOs Showed Their Generosity in Executive Paychecks," The New York Times, 11 April 1995, C1.
8. R.W. Scott, Institutions and Organizations (Thousand Oaks, Calif.: Sage Publications, 1994).
9. For further discussion, see M.A. Rodwin, "Consumer Protection and Managed Care: Issues, Reform Proposals, Trade-Offs," Houston Low Review 32, no. 5 (1996): 1319-1381; and M.A. Rodwin, "Consumer Protection and Managed Care: What Are the Issues?" Seton Hall Law Review 26, no. 3 (1996): 1007-1054.
10. For further discussion, see M.A. Rodwin, "Consumer Protection and Managed Care: Issues, Reform Proposals, Trade-Offs," Houston Low Review 32, no. 5 (1996): 1319-1381; and M.A. Rodwin, "Consumer Protection and Managed Care: What Are the Issues?" Seton Hall Law Review 26, no. 3 (1996): 1007-1054.
11. See G. Dallek, C. Jimenez, and M. Schwartz, Consumer HMO Protection in State HMO Laws (Los Angeles: Center for Health Care Rights, 1995).
12. S. Sofaer, "Informing and Protecting Consumers under Managed Competition," Health Affairs (Supplement 1993): 76-86; Minimum Requirements for Consumer Information (Washington: Coalition for Consumer Protection and Quality in Health Care Reform, 1993); H.R. 2491, secs. 1851-1852; Clinton Medicare Proposal (December 1995), secs. 1851(B)(b). (E)(a); Common Sense Balanced Budget Act of 1995, 104th Cong., 1st sess., H.R. 2530 ("Blue Dog" Proposal), secs. 1805(d), 1853(a); Medicare Health Quality Act of 1995, S. 1024; and Health Care Quality and Fairness Act of 1995, S. 609, sec. 201.
13. S. Sofaer, "Informing and Protecting Consumers under Managed Competition," Health Affairs (Supplement 1993): 76-86; Minimum Requirements for Consumer Information (Washington: Coalition for Consumer Protection and Quality in Health Care Reform, 1993); H.R. 2491, secs. 1851-1852; Clinton Medicare Proposal (December 1995), secs. 1851(B)(b). (E)(a); Common Sense Balanced Budget Act of 1995, 104th Cong., 1st sess., H.R. 2530 ("Blue Dog" Proposal), secs. 1805(d), 1853(a); Medicare Health Quality Act of 1995, S. 1024; and Health Care Quality and Fairness Act of 1995, S. 609, sec. 201.
14. S. Sofaer, "Informing and Protecting Consumers under Managed Competition," Health Affairs (Supplement 1993): 76-86; Minimum Requirements for Consumer Information (Washington: Coalition for Consumer Protection and Quality in Health Care Reform, 1993); H.R. 2491, secs. 1851-1852; Clinton Medicare Proposal (December 1995), secs. 1851(B)(b). (E)(a); Common Sense Balanced Budget Act of 1995, 104th Cong., 1st sess., H.R. 2530 ("Blue Dog" Proposal), secs. 1805(d), 1853(a); Medicare Health Quality Act of 1995, S. 1024; and Health Care Quality and Fairness Act of 1995, S. 609, sec. 201.
15. S. Sofaer, "Informing and Protecting Consumers under Managed Competition," Health Affairs (Supplement 1993): 76-86; Minimum Requirements for Consumer Information (Washington: Coalition for Consumer Protection and Quality in Health Care Reform, 1993); H.R. 2491, secs. 1851-1852; Clinton Medicare Proposal (December 1995), secs. 1851(B)(b). (E)(a); Common Sense Balanced Budget Act of 1995, 104th Cong., 1st sess., H.R. 2530 ("Blue Dog" Proposal), secs. 1805(d), 1853(a); Medicare Health Quality Act of 1995, S. 1024; and Health Care Quality and Fairness Act of 1995, S. 609, sec. 201.
16. S. Sofaer, "Informing and Protecting Consumers under Managed Competition," Health Affairs (Supplement 1993): 76-86; Minimum Requirements for Consumer Information (Washington: Coalition for Consumer Protection and Quality in Health Care Reform, 1993); H.R. 2491, secs. 1851-1852; Clinton Medicare Proposal (December 1995), secs. 1851(B)(b). (E)(a); Common Sense Balanced Budget Act of 1995, 104th Cong., 1st sess., H.R. 2530 ("Blue Dog" Proposal), secs. 1805(d), 1853(a); Medicare Health Quality Act of 1995, S. 1024; and Health Care Quality and Fairness Act of 1995, S. 609, sec. 201.
17. The Medicaid Managed Care Act of 1995, S. 839, sec. 3(c)(4); Patient Protection Act of 1994, S. 2196, sec. 4(b)(l); Penn. H.B. 1866, secs. 3,5.9(a)-(e), (j), 5.1, 5.2(14), 5.5 (1993); Calif. S. 1832, sec. 8 (1994); Tex. H.B. 2766, Art. 21.104 (vetoed) (1995); and New York A.B. 6800, secs. 2, 4 (1995).
18. S. 2196, secs. 5,6; S. 609, sec. 101; and New York A.B. 6800, sec. 15.
19. National Committee for Quality Assurance, Report Card Pilot Project (New York; NCQA, 1995); and U.S. General Accounting Office, Health Care Reform: "Report Cards" Are Useful but Significant Issues Need to Be Addressed, GAO/HEHS 94-219 (Washington: GAO, September 1995).
20. National Committee for Quality Assurance, Report Card Pilot Project (New York; NCQA, 1995); and U.S. General Accounting Office, Health Care Reform: "Report Cards" Are Useful but Significant Issues Need to Be Addressed, GAO/HEHS 94-219 (Washington: GAO, September 1995).
21. J.H. Hibbard and E.C. Weeks, "Consumerism in Health Care: Prevalence and Predictors," Medical Care 25, no. 11 (1987): 1019-1032; and M. Gottlieb, "Picking a Health Plan: A Shot in the Dark," The New York Times, 14 January 1996, C1, C9.
22. J.H. Hibbard and E.C. Weeks, "Consumerism in Health Care: Prevalence and Predictors," Medical Care 25, no. 11 (1987): 1019-1032; and M. Gottlieb, "Picking a Health Plan: A Shot in the Dark," The New York Times, 14 January 1996, C1, C9.
23. M.A. Rodwin, "Managed Care and the Elusive Quest for Accountable Health Care," Widener Law Symposium Journal 1, no. 1 (1996): 65-88.
24. H.R. 2530, secs. 853 (b), (d); and Fiscal 1997 Balanced Budget Proposals, sec. 11202.
25. Medicare Beneficiary Protection Amendments of 1995, H.R. 1707, sec. 101(g); The Access to Emergency Medical Services Act of 1995, H.R. 2011, sec. 8(3); S. 1024, sec. 7; S. 609, secs. 2,404; H.R. 2491, sec. 1852(d); Tex. H.B. 2766, Art. 21.109; and Penn. H.B. 1866, sec. 4(4).
26. G.J. Annas, "Women and Children First," The New England Journal of Medicine 333, no. 24 (1995): 1647-1651.
27. H.R. 1707, sec. 101(c); and S. 1024, sec. 7.
28. S. 1024, sec. 6; S. 839, sec. 6; S. 609, sec. 303; and Penn. H.B. 1866, sec. 3.
29. Calif. A.B. 3801 (1995).
30. S. 609, sec. 402; H.R. 2491, sec. 1853(d); H.R. 2530, sec. 1851(e); and Perm. H.B. 1866, secs. 5.6, 8(d).
31. H.R. 2491, sec. 1851(h); H.R. 2530, sec. 1853(h); Fiscal 1997 Balanced Budget Proposals, sec. 11202; and Penn. H.R. 1866, sec. 5.9(f)-(h).
32. H.R. 1707, secs. 114-115.
33. S. 2196, sec. (4)(c); H.R. 1707, sec. III; S. 1024, sec. 6; S. 839, sec. 3; H.R. 2530, secs. 8401-8402; Fiscal 1997 Balanced Budget Proposals, sec. 11202; H.R. 2491 secs. 1851(j), 1857(d), (f), (g), 8012; and New York A.B. 6800, secs. 4, 5.
34. H.R. 1707, sec. 101(b).
35. H.R. 2491; and interview with Bill Vaughn, professional staff, House Ways and Means Committee, 17 April 1996.
36. S.J. Stayn, "Securing Access to Care in Health Maintenance Organizations: Toward a Uniform Model of Grievance and Appeal Procedures," Columbia Law Review 94, no. 5 (1994): 1676-1720.
37. H.R. 2491, secs. 1852(f), (g); H.R. 2530, secs. 1853(e), (f); Clinton Medicare Proposal, secs. (E)(c)-(d); S. 839, sec. 3(d); Penn. H.B. 1866, sec. 5.7; and National Association of Insurance Commissioners, Complaint Procedure Model Regulation (Washington: NAIC, 6 December 1994 draft).
38. NAIC model grievance and utilization procedures.
39. Coalition for Consumer Protection, Consumer Due Process Protection; S. 1024, sec. 4; S. 609, secs. 301,406; and New York A.B. 6800, sec. 3.
40. J.F. Handler, The Conditions of Discretion: Autonomy, Community, Bureaucracy (New York: Russell Sage, 1986).
41. For legislation on reprisals, see S. 609, sec. 406(d); and S. 1024, sec. 4(v).
42. P.J. Feldstein, The Politics of Health Legislation (Ann Arbor, Mich.: Health Administration Press, 1988).
43. M.A. Rodwin, "Patient Accountability and Quality of Care: Lessons from Medical Consumerism and the Patients' Rights, Women's Health, and Disability Rights Movements," American Journal of Law and Medicine 10, nos. 1 and 2 (1994): 147-167.
44. See R.E. Rosenblatt, "On Access to Justice, Discrimination, and Health Care Reform" (Testimony before the House Commerce Committee and Health and Environment and Energy Subcommittees, 14 February 1994); R.E. Rosenblatt, "Health Care, Markets, and Democratic Values," Vanderbilt Law Review 34, no. 4 (1981): 1067; and A. Best and B.L. Brown, "Governmental Facilitation of Consumerism: A Proposal for Consumer Action Groups," Temple Law Quarterly 50, no. 1 (1977): 253-319.
45. See R.E. Rosenblatt, "On Access to Justice, Discrimination, and Health Care Reform" (Testimony before the House Commerce Committee and Health and Environment and Energy Subcommittees, 14 February 1994); R.E. Rosenblatt, "Health Care, Markets, and Democratic Values," Vanderbilt Law Review 34, no. 4 (1981): 1067; and A. Best and B.L. Brown, "Governmental Facilitation of Consumerism: A Proposal for Consumer Action Groups," Temple Law Quarterly 50, no. 1 (1977): 253-319.
46. See R.E. Rosenblatt, "On Access to Justice, Discrimination, and Health Care Reform" (Testimony before the House Commerce Committee and Health and Environment and Energy Subcommittees, 14 February 1994); R.E. Rosenblatt, "Health Care, Markets, and Democratic Values," Vanderbilt Law Review 34, no. 4 (1981): 1067; and A. Best and B.L. Brown, "Governmental Facilitation of Consumerism: A Proposal for Consumer Action Groups," Temple Law Quarterly 50, no. 1 (1977): 253-319.
47. Interview with Diane Archer, executive director, Medicare Beneficiaries Defense Fund (now called Medicare Rights Center), June 1995.
48. L.G. Trubek, "Making Managed Competition a Social Arena: Strategies for Action," Brooklyn Law Review 60, no. 1 (1994): 275-302.
49. Older Americans Act, "Allotments for Vulnerable Elder Rights Protection Activities: Chapter 2," 42 U.S. Code, sec. 3058 et seq; and Institute of Medicine, Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act (Washington: National Academy Press, 1995).
50. A. Yarmolinsky, "Supporting the Patient," The New England of Journal of Medicine 322, no. 2 (1995); 602-604; and E. Hirshfeld, "The Case for Physician Direction in Health Plans," Annals of Health Low 3 (1994): 81-102.
51. A. Yarmolinsky, "Supporting the Patient," The New England of Journal of Medicine 322, no. 2 (1995); 602-604; and E. Hirshfeld, "The Case for Physician Direction in Health Plans," Annals of Health Low 3 (1994): 81-102.
52. But sec R. Robert, "Consciences in the Marketplace: The Role of Cooperatives in Consumer Protection," Journal of Social Issues 47, no. 14 (1991): 135; and E. Emmanuel, The Ends of Human Life (Cambridge, Mass.: Harvard University Press, 1991), chaps. 5-6.
53. But sec R. Robert, "Consciences in the Marketplace: The Role of Cooperatives in Consumer Protection," Journal of Social Issues 47, no. 14 (1991): 135; and E. Emmanuel, The Ends of Human Life (Cambridge, Mass.: Harvard University Press, 1991), chaps. 5-6.
54. "Can You Trust the AARP?" Editorial, The New York Times, 20 May 1996, A14; and M. Freudenheim, "AARP Will License Its Name to Managed Health Care Plans," The New York Times, 29 April 1996, A1, D4.
55. "Can You Trust the AARP?" Editorial, The New York Times, 20 May 1996, A14; and M. Freudenheim, "AARP Will License Its Name to Managed Health Care Plans," The New York Times, 29 April 1996, A1, D4.
56. H.R. 2491, sec. 1859(3)(A).
57. Text of conference report, joint explanation statement on H.R. 3103, Health Insurance Portability and Accountability Act of 1996, BNA's Health Care Policy Report (5 August 1996).
58. H.H. Schauffler and T. Rodriguez, "Exercising Purchasing Power for Preventive Care," Health Affairs (Spring 1996): 73-85.
59. W.A. Zelman, "Who Should Govern the Purchasing Cooperative?" Health Affairs (Supplement 1993): 49-57.
60. M.A. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993); and M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332, no. 9 (1995): 604-607.
61. M.A. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993); and M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332, no. 9 (1995): 604-607.
62. See H.R. 2491, sec. 1853.