Liability issues in managed care

The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.     

Practical and ethical assessment issues in rural, impoverished, and managed care settings.

The rising costs of new psychological tests, increased frequency of test revisions, and difficulty receiving authorization and reimbursement from managed care companies make it increasingly difficult for practitioners to provide the best standard of care to clients when conducting psychological and neuropsychological assessments. Practitioners, especially those in low-income and rural areas, may struggle with handling these practical realities while maintaining ethical standards in conducting psychological assessment. Suggestions for how to manage practical challenges faced by practitioners who provide psychological assessments, such as selecting tests when authorization or reimbursement by a third-party payer is restricted or denied, purchasing psychological tests on a budget, and providing assessments with a limited number of qualified staff are discussed. The authors also provide recommendations for the future prevention of these challenges through work with test developers, test publishing corporations, third-party payers, political action groups, and the psychology profession itself. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Domestic violence: ethical issues in the health care system

Domestic violence is a highly prevalent event in the United States. Health providers frequently treat abused patients; however, many do not routinely assess for family violence or suspect it when the injuries seem fairly obvious. Because abused women feel stigmatized by the violence, they are hesitant to volunteer the abuse. In 1990, the Joint Commission on the Accreditation of Healthcare Organizations added requirements for emergency and ambulatory care services to develop and use protocols for the identification of violence among patients. This article addresses the ethical and legal dilemmas facing nurses that influence their assessment and intervention in family violence.     

Decisions about prostate cancer screening in managed care

The primary object of this research project was to establish the amount of incisor retraction to be expected during full fixed mechanotherapy and to generate regression models that could provide more accurate prediction of each of the three most popular combinations of symmetrical premolar extractions, where extraoral anchorage would not be used. Pretreatment and posttreatment records of 73 cases that had their four first premolars extracted (group 44), 74 cases with four second premolar extractions (group 55), and 59 cases with upper first and lower second premolar extractions (group 45) were selected. All these cases were treated by one orthodontist, who used the same edgewise technique throughout. The results indicate that, on average, maxillary retraction in relation to the facial plane (N Po) differed only slightly between group 55 (mean 4.2 +/- 2.4 mm) and group 44 (mean 4.7 +/- 2.3 mm), with relatively more retraction for group 45 (mean 6.6 +/- 2.5 mm; p < 0.05). In contrast, the mandibular incisors were retracted slightly more in group 44 than in the other two groups (p < 0.05). The regression models that were developed could be useful as an additional tool to assist the practitioner in the selection of which teeth to extract for a particular case.     

What ethicists talk about when they talk about managed care

Defining the values at stake as we move into managed care is an awesome--yet necessary--endeavor. To help sort things out, the Society for Health and Human Values brought together health care ethicists and medical humanists to discuss how human values are being incorporated into health care reform. Here's an excerpt from that conversation.     

Academic faculty practices: issues for viability in competitive managed care markets

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis-St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.     

Multicultural issues and ethical concerns in the delivery of nursing care interventions

Targeted mutagenesis was used to investigate the roles of the CsmA and CsmC proteins of the chlorosomes of the green bacteria Chlorobium tepidum and Chlorobium vibrioforme 8327. Under the photoautotrophic growth conditions employed, CsmA is required for the viability of the cells but CsmC is dispensable. The absence of CsmC caused a small red shift in the near-infrared absorption maximum of bacteriochlorophyll d in whole cells and chlorosomes, but chlorosomes were assembled in and could be isolated from the csmC mutant. The doubling time of the csmC mutant was approximately twice that of the wild-type strain. Fluorescence emission measurements suggested that energy transfer from the bulk bacteriochlorophyll d to another pigment, perhaps bacteriochlorophyll a, emitting at 800-804 nm, was less efficient in the csmC mutant cells than in wild-type cells. These studies establish that transformation and homologous recombination can be employed in targeted mutagenesis of Chlorobium sp. and further demonstrate that chlorosome proteins play important roles in the structure and function of these light-harvesting organelles.     

Key issues in managed competition

All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration's plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.     

Psychology's response to managed care.

Managed care has had a significant impact on the field of psychology. In this article, a former president of the American Psychological Association and an early career psychologist discuss how managed care has affected the practice of psychology, the training of psychologists, and the perception of psychotherapy. They also review how organized psychology has responded to managed care and provide some insights on the future of psychology as it relates to managed care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)