Regulating Managed Care: Theory, Practice, and Future Options

Regulating Managed Care

In today′s market–driven health care system, issues such as consumer choice, access to specialists, denials of coverage, and "drive–through" methods of care delivery have been thrust to the forefront of the managed care debate. Wanting nothing more than to create a managed care system that is accessible and affordable to all Americans policy makers, clinicians, and consumers are working to find the right balance between competition and regulation that will insure a high quality and compassionate health care system. But regulating markets is no easy task, and individuals–even those with similar objectives–differ on the major questions to be resolved. Can managed care be effectively regulated?

Led by Stuart Altman, Uwe Reinhardt, and David Shactman, Regulating Managed Care brings together twenty–six of the foremost health policy experts, offering the rare opportunity to listen in while they debate this critical social issue. These influential contributors–including managed competition′s architect, Alain Enthoven–provide leaders essential background on the critical issues, summarize key survey findings on how Americans feel about managed care, assess what areas are thought to need regulation, and examine the effect of proposed regulation on health care access, cost, and quality.

From policy to practicality, Regulating Managed Care gives health care executives, board members, and policy makers insight into the tough choices facing policy makers and the critical issues involved in ultimately improving the quality of medical services for the communities they serve.

Managing Managed Care

What should be government′s role in a market–oriented health care system?
What′s the appropriate amount of regulation?
Who should regulate–states, federal government, or market forces?
What role do the courts play in this regulation?
Are there existing models that might guide leaders in designing an effective regulatory structure?

Welcome to the great managed care debate. In Regulating Managed Care, twenty–six of the nation′s leading health policy experts give health care administrators, clinicians, and policy makers insight into the issues behind this critical exchange and provide leaders with a road map to assess the policy options available to protect the quality of our health care delivery system.

"This collection of papers, from an extraordinary group of authors, makes a valuable contribution to the ongoing policy debate and will be of interest to anyone concerned with the future of our health care system."
Charles A. Sanders, retired chairman and CEO, Glaxo Inc., and former general director, Massachusetts General Hospital

"This balanced collection of cutting–edge papers reviewing the theory and practice of health regulation is a must read for those who regulate and for those regulated by this market–moving the debate from whether to regulate to how to do this most difficult task more effectively."
W. David Helms, CEO, Association for Health Services Research and president, Alpha Center

Foreword (Steven A. Schroeder).

Acknowledgments.

The Editors.

The Contributors.

Introduction: The Philosophy of Regulation.

Section I: The Role of Regulation in a Market–Oriented Health Care System.

1. Regulating Managed Care: An Overview (Walter Zelman).

2. The Current Status of State and Federal Regulation (Patricia Butler).

3. Why Should Managed Care Be Regulated? (Mark Pauly and Marc L. Berger).

4. Macro– Versus Microregulation (Thomas Rice).

Section II: Regulatory Issues.

5. Consumer Choice Under "Private Health Care Regulation" (Uwe E. Reinhardt).

6. The Long–Term Care Ombudsman Program: A Model for Health Care Consumers (William F. Benson).

7. Ensuring Equal Access to Care (Brian Biles and David Sandman).

8. Regulating Quality and Clinical Practice (William L. Roper).

9. The Scope of Managed Care Liability (David M. Keepnews).

10. ERISA and the Regulation of Group Health Plans (Craig Copeland and William L. Pierron).

Section III: Perspectives on Regulation.

11. The Public: Understanding the Managed Care Backlash (Robert J. Blendon, Mollyann Brodie, John M. Benson, Drew E. Altman, Larry Levitt, Tina Hoff, and Larry Hugick).

12. A Foundation Perspective: Core Principles for Regulating Health Care Quality (Karen Davis and David Sandman).

13. The Managed Care Industry: Balancing Market Forces and Regulation (Karen Ignagni).

14. Regulation from a Consumer′s Perspective (Ronald F. Pollack).

15. Regulation from an Insurance Industry Perspective (Bill Gradison).

16. Regulation Misses the Big Issue––The Uninsured (Larry S. Gage).

Section IV: Managed Care Regulation in Practice.

17. Creating Standards: A Practical Approach (Phil Nudelman).

18. California′s Struggle with Regulation (Sara J. Singer and Alain C. Enthoven).

9. The Cost of Regulation: How the Estimates Vary (Allen Dobson and Caroline Steinberg).

STUART H. ALTMAN is the Sol C. Chaikin Professor of National Health Policy and chair, Council on the Economic Impact of Health System Change, Institute for Health Policy, Heller Graduate School, Brandeis University. He has held key health policy offices for Presidents Carter, Reagan, Bush, and Clinton. UWE E. REINHARDT is James Madison Professor of Political Economy, Princeton University. He is regularly quoted in the New York Times, Wall Street Journal, Health Affairs, and other publications. DAVID SHACTMAN is project director, Council on the Economic Impact of Health System Change, Institute for Health Policy, Heller Graduate School, Brandeis University.

"This is a very useful collection of essays by some of the nation′s most influential health policy experts. Topics covered: the theory of regulation, the ways in which the HMO industry does and does not fit the standard model, and consumer and insurance industry perspectives on regulation and practical implementation issues." (Bryan E. Dowd, University of Minnesota School of Public Health, Hospital & Health Networks, March 2000)

"This collection of papers, from an extraordinary group of authors, makes a valuable contribution to the ongoing policy debate and will be of interest to anyone concerned with the future of our health care system." (Charles A. Sanders, retired chairman and CEO, Glaxo Inc., and former general director, Massachusetts General Hospital)

"This balanced collection of cutting–edge papers reviewing the theory and practice of health regulation is a must–read for those who regulate and for those regulated by this market–moving the debate from whether to regulate to how to do this most difficult task more effectively." (W. David Helms, CEO, Association for Health Services Research and president, Alpha Center)