The impact of the recent Supreme Court rulings in Pegram and Rush Prudential on state regulation of managed care organizations

Over the past two decades, the Employee Retirement Income Security Act of 1974 (ERISA) has shielded managed care organizations (MCOs) from liability for negligent treatment or coverage decisions. This Article examines the Supreme Court jurisprudence in the area of ERISA preemption, and assesses the impact of these recent decisions on state regulation of MCOs. The author concludes that recent decisions in Pegram v. Herdrich and Rush Prudential HMO, Inc. v. Moran have broadened the states' power to regulate MCOs and enhance the ability of injured plaintiffs to sue such organizations under state tort law.     

Consumer managed care appeals: are the available procedural protections fundamentally fair?

Managed care incentives to reduce costs have also resulted in incentives to deny care. Anecdotes concerning managed care denials of care have led to a consumer outcry for protection either through the use of procedural due process or by the establishment of patient rights that would include appeal and grievance protections. This Article reviews the procedural protections of constitutional due process, the Consumer Due Process Protocol, and the Patient Bill of Rights. The Article then extensively discusses the availability of these procedural protections in various public and private forums. The discussion of public forums includes proposals contained in recent national legislative initiatives. The author then reviews relevant federal and state law, as well as Uniform Law proposals. Next, the Article analyzes the protections provided by accreditation agencies, dispute resolution organizations, professional organizations, and health insurers. Finally, the author recommends criteria to be used to determine whether a procedure is fundamentally fair.     

The evolution of an innovation: variations in medicaid managed care program extensiveness

This article utilizes a theoretical framework of policy innovation, diffusion, and reinvention to investigate the evolving nature of Medicaid managed care programs over time. By estimating two separate models, one for primary care case management (PCCM) and a second for risk-based program enrollment, this study seeks to disentangle two different paths of learning (internal and external), investigate the potential effects of vertical diffusion of policy, and examine the impact of internal state characteristics on the extent of Medicaid managed care. With respect to diffusion and learning, the data reveal that earlier adopters implement more extensive programs. The data fail to reveal much internal learning, although there is evidence of some. External impacts are clear: managed care enrollments in neighboring states and changes in the federal waiver process affect states' decisions. Other policy choices are important: states with more generous Medicaid eligibility rules implement more extensive managed care programs. Complementing other studies of Medicaid, we find that politics and economics make a difference for the extent of managed care programs; unlike other Medicaid studies, we find no effect of race and ethnicity.     

Obesity, courts, and the new politics of public health

Health care politics are changing. They increasingly focus not on avowedly public projects (such as building the health care infrastructure) but on regulating private behavior. Examples include tobacco, obesity, abortion, drug abuse, the right to die, and even a patient's relationship with his or her managed care organization. Regulating private behavior introduces a distinctive policy process; it alters the way we introduce (or frame) political issues and shifts many important decisions from the legislatures to the courts. In this article, we illustrate the politics of private regulation by following a dramatic case, obesity, through the political process. We describe how obesity evolved from a private matter to a political issue. We then assess how different political institutions have responded and conclude that courts will continue to take the leading role.     

论证券市场虚假陈述公益诉讼机制的构建

证券市场上,投资者极力寻求发现并利用尽可能多的信息以作出理性的投资决策。然而,证券市场信息严重不对称,虚假陈述已经严重影响到证券市场的正常秩序。仅凭现有的防止虚假陈述的民事诉讼制度不足以保障投资者利益,应构建虚假陈述公益诉讼机制。     

The role of substitutes in policy analysis: acute care services in state Medicaid programs

Using four acute care equations (inpatient, physician, outpatient, and clinic) from a larger model of Medicaid, this research examines the "contents" of policy outcomes. This closer examination of outcomes brings to light the interactions between redistributive programs and services and the role of substitutes and complements in state-level policy analysis. (A substitute is a benefit or service that can be used instead of another to produce a similar outcome; a complement is a benefit or service that is likely to result in the use of another benefit or service.) Support is found for the inclusion of these theoretical constructs in policy analysis. Regarding Medicaid, the author concludes that physician, outpatient, and clinic services all complement hospital services; that physician and outpatient services substitute for one another; that state AFDC and SSI policy decisions have a greater impact on utilization than Medicaid-specific eligibility and service decisions do; and that the factors driving utilization (supply, demand, etc.) vary dramatically across acute care settings. The implications for Medicaid policymaking are also discussed.     

No Confidence: Confidentiality,Ethics and the Law of Academic Privilege

The law recognizes several evidentiary privileges, including a qualified privilege recognized by statute or court precedent in forty-eight states and several federal circuits that allows journalists to protect confidential sources. Meanwhile, ethical practices for social science surveys require pledging confidentiality to respondents, a practice that can conflict with subpoenas and court orders requiring revelation of such information. Only a handful of court decisions have formally recognized a privilege for scholars similar to a reporters’ privilege, and an examination of the court decisions that have either ruled on or discussed the issue reveals that while many courts recognize the interests of scholars in confidentiality, most courts decline to recognize a legal privilege for researchers. Courts do, however, often limit disclosure to accommodate these concerns. The specific circumstances and rationales of these decisions are discussed and analyzed.     

Managed care liability today: laws, cases, theories, and current issues

Managed care entities face numerous liability issues in today's changing healthcare environment. This Article provides the plaintiff with a comprehensive road map for navigating the many avenues of managed care liability. The author describes ERISA pre-emption provisions and suggests ways plaintiffs' attorneys can strive to narrow the pre-emption. The Article also provides in-depth analysis of each theory of managed care liability that has been litigated against managed care entities to date, and then goes on to explore state laws imposing liability on managed care entities, and how HMO liability is being reformed through legislative action. For plaintiffs' attorneys seeking the full spectrum of theories of managed care liability, or for defendants' attorneys wanting to remain updated on all potential claims to defend, this Article constitutes an extensive primer on the current issues.     

Releasing managed care's chokehold on healthcare providers

This article addresses the imbalance of power between managed care organizations and physicians regarding the content of treatment information given to patients. The author provides a thoughtful discussion surrounding informed consent issues in a managed care environment, and how managed care organizations maintain their control over physicians. The author concludes by offering varied and insightful methods to even out the disparity of power.     

Waiting for Godot: wishes and worries in managed care

Managed care has done a better job at reducing expenditure growth than it has in improving quality. Although reduced expenditure growth is not appreciated by many, it has real benefits. For the majority of Americans who are privately insured, it results in greater disposable income for goods and services other than health care (although the illusion of employer-paid health insurance obscures this reality for many). For Medicaid programs, slower growth of expenditures facilitates efforts at expanding coverage. For low-income workers, slower expenditure growth results in larger numbers of people retaining insurance coverage than would have been the case if premiums rose more quickly. While there are some victories to which managed care organizations can point, we cannot credibly argue that overall levels of quality and health outcomes are improving as the health care system is massively disrupted by changes in health care finance and delivery. The disruptions create real hardships for some physicians and other health care workers, and worries for many consumers. These worries fuel the managed care backlash. The danger is that politicians will respond to these worries with policies that inhibit the development of high-quality delivery systems. The opportunity is for relatively modest public policy changes--external review organizations, better public-sector purchasing capabilities, public investment in producing and publicizing information on health plan and medical group performance, and establishment of a public ombudsperson--to respond to consumer worries and lead to improvements in health care quality and outcomes. Finally, I would be remiss without a reminder that the single most effective action politicians could take to improve health care quality and outcomes would be to change the rules of health care financing to assure that all Americans are covered by managed care. Even with all of its inadequacies, managed care is much superior to the patchwork care available to the 43 million Americans who are uninsured. The managed care backlash is concerned with protecting patients who are insured (and their providers). Far more valuable would be to protect those without insurance. Sadly, no politician has yet figured out how to do this. Still waiting.     

Will pay for performance be worth the price to medical providers? A look at pay for performance and its legal implications for providers

This article explores the legal implications of pay for performance programs from the perspective of healthcare providers. The author provides an informative background on the emergence of pay for performance programs and examines the structure and operation of these programs. She then explores the liability issues of health plans and managed care organizations and delves into evidentiary issues related to pay for performance information. Her article concludes with some practical suggestions for providers in preparing for an expansion of these quality initiatives.     

The good, the bad, and the ugly: how the due process clause may limit comprehensive health care reform

This article examines atopic which has receivedlittle attention from the media or other scholarly publications: The due process concerns that arise when engaging in comprehensive federal health care reform and regulation. First, the article provides a background discussion detailing the factors necessitating health care reform in the United States. Second, it analyzes whether a constitutionally protected right to make personal health care decisions exists under the Fifth and Fourteenth Amendments' Due Process Clauses. Finally, the article analyzes the susceptibility of government-sponsored health care-specifically proposals which include a public option-to due process challenges and makes suggestions to avoid any potential fundamental rights violations.     

The Health Care Quality Improvement Act of 1986: its history, provisions, applications and implications

Congress granted qualified immunity from liability for peer review participation to physicians, osteopaths and dentists, created a national practitioner data bank to track inept, incompetent or unprofessional physicians, and enacted procedural rules for due process, privilege restrictions, and reporting and disbursement of information. The Health Care Quality Improvement Act of 1986 is now in full force, and peer review participants are anxious to cloak themselves with immunity from actions brought by health care professionals. Although its goals are worthy, HCQIA's effects remain to be seen. Serious loopholes appear to exist, warranting close monitoring and possibly early amendment of the Act. Cautious judicial assessment is needed, in order to prevent not only circumvention of the Act's requirements by artful litigants, but also use of the national data bank by health care entities as a pretext for denying privileges and escaping antitrust liability.     

The stages of managed care regulation: developing better rules

The managed care industry is at a crossroads. Belief in the ability of market forces alone to create an environment fostering quality health care at lower cost is eroding. Regulators across the country are confronted with a growing consumer backlash against managed care. As a result, states have passed managed care reform legislation at unprecedented rates. In doing so, states are confronted with a patchwork of federal intervention and preemption. We examine the stages of these recent state and federal developments and evaluate them in terms of the traditional objectives of a reasonably functioning health care system: quality care, access, and cost containment.     

Managing medical staff disability issues: liability of private hospitals under ADA Titles I and III

This Article examines the extent to which private hospital are liable for discrimination against medical staff members with disabilities, under the Americans with Disabilities Act ("ADA"). Specifically, the discussion focuses on the ways in which Title I, covering employment relationships, and Title III, covering places of public accommodation, apply to hospitals and their medical staff physicians. With respect to Title I, the author focuses on possible liability with respect to independent contractor physicians who have staff privileges at a hospital. The focus with respect to Title III involves claims filed by physicians against hospitals as places of public accommodation. The author concludes that the courts have applied the ADA in a manner broader than intended by Congress, and that private hospitals should assume that both Title I and Title III are applicable to staff privilege decisions. Therefore, any action that adversely affects a disabled physician should be supported by well-documented, objective evidence of a nondiscriminatory reason for that action.     

Quality of low secure services in the UK: development and use of the Quality of Environment In Low Secure Services (QELS) checklist

Low secure services provide care for psychiatric patients whose risk cannot be safely managed in other settings. The physical environment in these units plays an important role in supporting recovery and risk management. We developed the Quality of Environment in Low secure Services (QELS) checklist to assess the quality of the physical environment of these services. Using recommendations from previously published standards we piloted a draft checklist with a weighted scoring system reflecting the views of patients and providers. The checklist showed good criterion validity and inter-rater reliability. Data collected from 33 low secure services showed considerable variation in the quality of the physical environment. The QELS checklist provides an accessible and reliable means for managers and clinicians to assess whether the quality of the physical environment of low secure units meets recommended standards and can be used to support efforts to improve the quality of care delivered by these services.     

Price competition in hospital markets: the significance of managed care

Anticompetitive conduct in the healthcare industry is often hard to detect, and has been ignored by some courts that appear to lack an understanding of managed care and its significance in maintaining price competition. These courts have adopted an approach that is far too historical and mechanistic, and is characterized by outdated factors analyzed in isolation from each other. In order to preserve effective price competition, the courts should embrace a realistic analysis that accurately reflects the workings of health services markets. This article describes the many facets of market power and anticompetitive conduct, and how they affect healthcare prices. The author then tums to an analysis of two recent hospital antitrust decisions, and critiques them for their failure to properly analyze the dynamics of local hospital markets.     

A Perfect Prosecution: The People of the State of New York Versus Dominique Strauss-Kahn

People v. Strauss-Kahn is an ideal lens through which to examine the operation of a criminal justice system that privileges the presumption of guilt, or, to use the words of the US Supreme Court in the 2012 decisions Lafler v. Cooper and Missouri v. Frye, has become “a system of pleas, not a system of trials.” It is both an excellent example of a transparent and objective invocation of the criminal sanction, and a sharp counterpoint to the vast majority of cases where law enforcement conclusions are privileged and rarely second-guessed. As analyses of wrongful convictions have sadly but inevitably demonstrated, the screening methods of police and prosecutors are fallible. Moreover, the prevalence of “tunnel vision” once the decision to charge has been made means that few cases experience the kind of post-indictment investigation and reevaluation seen in the prosecution of Dominique Strauss-Kahn. Stage by stage, the Strauss-Kahn case illustrates how to counterbalance the presumption of guilt and give expression to the presumption of innocence in the pretrial period through vigilantly-invoked and enforced due process protections. Drawing from this examination, the paper will then explore how to approach this model process in the more standard cases, which typically see a fraction of the judicial, law enforcement, and defense resources afforded Dominique Strauss-Kahn. The Strauss-Kahn prosecution offers several insights, three of which will be sketched at the paper’s conclusion: a requirement that prosecutorial decision-making be subject to a reasonable doubt standard; vigilant and early enforcement of the prosecutor’s obligation to disclose information that is favorable to the accused; and finally, a requirement that a prosecutor explain in writing any decision to dismiss the felony charges in indicted felony cases, so that the factual, legal and policy bases of these decisions (numbering almost one quarter of New York’s superior court felony cases annually) can be analyzed and publicized.     

Will the Supreme Court finally eliminate ERISA preemption?

David Trueman's article reviews the history of ERISA preemption by analyzing seminal Supreme Court cases and predicts the future of ERISA preemption in his analysis of recent federal case law. Traditionally, the ability to hold a managed care entity responsible for its actions has been hampered by a strict interpretation of the preemption clauses of ERISA but as the Supreme Court's jurisprudence has evolved and loosened, several federal courts have allowed suits against managed care companies to go forward. Conflict among the federal circuits has arisen and the Supreme Court has granted certiorari to two cases from Texas in order to clarify ERISA preemption. Mr. Trueman discusses the future of ERISA preemption in light of these decisions.     

The political management of managed care: explaining variations in state health maintenance organization regulations

In the 1990s, strong incentives for managed care organizations to control costs, once regarded as a fortuitous confluence of interests, came to be seen as antithetical to consumers' interests in quality of care. In response to this change in political climate, many states have greatly increased their regulatory control of managed care organizations since the mid-1990s. This activity is surprising in an era when public policy on health care issues is usually described as frozen, gridlocked, and/or stalemated as a result of intense activity on the part of organized interests. We take advantage of the variation in state regulations of health maintenance organizations (HMOs) to discover why some governments are able to address policy problems that are often perceived as intractable in a political if not in a true policy sense. From the history of HMOs, the backlash against managed care, and state responses to that backlash, we first extract a number of hypotheses about state regulatory activity. We then test these hypotheses with data on regulatory adoptions by states during the late 1990s and the early 2000s. Last, we discuss the findings with special attention to the role of politics in health care.