Chapter 8.B.1: The Rise of Managed Care

To insert after Ch. 8.B.1 (p. 769):

Exercise: Your Insurance

Investigate your health plan (or your family’s health plan) and answer the following questions about your insurance.

Cost-sharing. What is the plan’s deductible? For what co-payments and co-insurance are you or your family responsible? Do the out-of-pocket payments vary for inpatient care, outpatient services, or prescription drugs?
Networks. Which physicians and hospitals are in your health plan’s network? Can you find an up-to-date provider directory? Are you allowed to visit out-of-network physicians? If so, under what circumstances and at what price?

For discussions of the history of managed care (note 2), see Developments, supra, 84 Harv. L. Rev. 887 (1971); R. Holley & R. Carlson, The Legal Context for the Development of Health Maintenance Organizations, 24 Stan. L. Rev. 644 (1972); Lawrence Brown, Politics and Health Care Organization: HMOs as Federal Policy (1983); John Iglehart, Physicians and the Growth of Managed Care, 331 New Eng. J. Med. 1167 (1994); Alain C. Enthoven & Laura A. Tollen, Toward a 21st Century Health System: The Contributions and Promise of Prepaid Group Practice (2004); Jan Coombs, The Rise and Fall of HMOs: An American Health Care Revolution (2005).

For discussions of the managed care backlash (note 6), see R. A. Dudley & H. S. Luft, Managed Care in Transition, 344 New Eng. J. Med. 1087 (2001); James C. Robinson, The End of Managed Care, 285 JAMA 2622 (2001); Mark A. Hall, The “Death” of Managed Care: A Regulatory Autopsy, 30 J. Health Pol. Pol’y & L. 427 (2005); Thomas Bodenheimer, The HMO Backlash: Righteous or Reactionary?, 335 New Eng. J. Med. 1601 (1996); Symposium, 24 J. Health Pol. Pol’y & L. 873-1257 (1999); Symposium, 16(6) Health Aff. 1 (Dec. 1997).

Both sides of the debate over managed care patient protection laws (note 6) are well represented in a series of articles: in favor of these laws, by Marc Rodwin, in 26 Seton Hall L. J. 1007 (1996), 32 Hous. L. Rev. 1319 (1996), and 15 Health Aff. 110 (1996); and against them, by David Hyman, in 73 S. Cal. L. Rev. 221 (2000), 78 N.C. L. Rev. 5 (1999), and 43 Vill. L. Rev. 409 (1998). See generally Russell Korobkin, The Efficiency of Managed Care “Patient Protection” Laws: Incomplete Contracts, Bounded Rationality, and Market Failure, 85 Cornell L. Rev. 1 (1999); Wendy K. Mariner, Standards of Care and Standard Form Contracts: Distinguishing Patient Rights and Consumer Rights in Managed Care, 15 J. Contemp. Health L. & Pol’y 1 (1998); William Sage, Regulating Through Information: Disclosure Laws and American Health Care, 99 Colum. L. Rev. 1701 (1999); Comment, 28 Cap. U. L. Rev. 685 (2000); Symposium, 47 St. Louis U. L.J. 21 (2003).

For discussions of the problem of HMO underservice (note 9), particularly in government programs, see George Anders, Health Against Wealth: HMOs and the Breakdown of Medical Trust (1996); John V. Jacobi, Canaries in the Coal Mine: The Chronically Ill in Managed Care, 9 Health Matrix 79 (1999).

For discussions of the limited evidence that HMOs harm quality, see Bruce E. Landon et al., Comparison of Performance of Traditional Medicare vs. Medicare Managed Care, 291 JAMA 1744 (2004); Joseph Gottfried & Frank A. Sloan, The Quality of Managed Care: Evidence from the Medical Literature, 65 Law & Contemp. Probs. 103 (Autumn 2002); Robert Miller & Harold Luft, HMO Plan Performance Update: An Analysis of the Literature, 1997-2001, 21(4) Health Aff. 1 (July 2002); James D. Reschovsky & Peter Kemper, Do HMOs Make a Difference?, 36 Inquiry 374 (2000); Symposium, 30 J. Leg. Stud. 527 (2001).