Written in a breezy, informative style for non-lawyers, this 253 page book examines the single most challenging problem in the new era -- quality in managed care.
The impact of the law on this effort is central to the critical insights and elucidations offered. In nine chapters, this book addresses fundamental legal principles which pertain to relationships in managed care, caselaw on liability, state regulation of managed care quality, accreditation, typical provider contract provisions which affect quality, federal controls on managed care quality, and issues in performance measurement and data dissemination.
Finally, the book outlines the basic questions all of the health care players must address in the day-to-day world as well as in public policy as we grapple with this most vital problem for the American people.
The table of contents includes the following:
Chapter 1 The Quality of Health Care: Is It Strained?
A discussion of basic principles of quality and value purchasing juxtaposed against managed care techniques. The entities involved in providing managed care and new theories of managed care quality are presented. How the law influences quality is described.
Chapter 2 Who’s Responsible?: Liability in Managed Care Caselaw
Potentially the most contentious issue in health care today, this chapter looks at the caselaw on ERISA through 1995 which has led to today's patients' rights debate. Anybody who cares about patients' rights needs to understand the matters here.
Chapter 3 What Big Brother is Watching: Federal Controls on Managed Care Quality
(By Robert L. Roth)
Bob Roth, a veteran health law practitioner in Washington, D.C. wrote this chapter dealing with the role of the federal government generally and the quality control systems which were in place under federal law prior to Medicare+Choice.
Chapter 4 Carrots and Sticks: The Federal Fraud and Abuse Laws and Quality
It is not well understood that there has long been a concern for quality under federal law. This chapter looks at new theories of quality and false claims, and the government’s authority over exclusions, intermediate sanctions and civil money penalties as they relate to managed care. Anti-kickback laws and the Stark statute are also addressed as they were in effect as of 1995.
Chapter 5 The Wheat From the Chaff: Accreditation and Regulation
Accreditation entities have multiplied and the way they approach accreditation in managed care varies. This chapter looks at the link between accreditation and regulation and the activities of multiple accrediting bodies including NCQA, JCAHO, URAC and the now defunct TMQC (The Medical Quality Commission).
Chapter 6 The Little Red Hen Syndrome: States and "Anti-Managed Care" Laws
(By Robert L. Roth)
Bob Roth looks at the ERISA laws and how states launched into solving the problem of managed care reform before the federal government ever picked up the issue. The phenomena he identified continued throughout the country and remain in place.
Chapter 7 What’s the Deal?: Contractual Terms Aimed at Quality Control and Risk Management
Managed care contracts with physicians and providers include many provisions that go well beyond the payment system or compensation rates. This chapter elucidates those provisions in managed care contracts which are intended to motivate provider behavior with regard to quality.
Chapter 8 Numbers, Numbers, Who’s Got the Numbers?: Law and the Quantification of Quality
The advent of performance measurement and report cards found its basic iterations in the managed care world. The role of clinical practice guidelines and the implications of HEDIS date are considered along with beginning issues associated with data protection and confidentiality.
Chapter 9 Back to the Future: Millennial Speculations
This chapter draws together the themes in the book and speculates on the implications of developing trends in late 1995. That which was predicted has come true and one review compared this chapter with the prophecies of Nostradamus!