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October 1, 1997, Vol 278, No. 13 >
ARTICLE | October 1, 1997

Managed Care Regulation: Title and subTitle BreakIn the Laboratory of the States FREE

Tracy E. Miller, JD
[+] Author Affiliations

Reprints: Tracy E. Miller, JD, Box 1077, Department of Health Policy, The Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029 (e-mail: Tracy Miller@smptlink.mssm.edu).

Health Law and Ethics section editors: Lawrence O. Gostin, JD, the Georgetown/Johns Hopkins University Program on Law and Public Health, Washington, DC, and Baltimore, Md; Helene M. Cole, MD, Contributing Editor, JAMA.


JAMA. 1997;278(13):1102-1109. doi:10.1001/jama.1997.03550130076041
Text Size: A A A
Published online
Article
References

In the wake of failed national health care system reform, the responsibility of crafting public policy to respond to changes in the health care system has fallen largely to state governments. Beginning in 1995, state policymakers focused intensively on managed care regulation, adopting policies on a broad array of issues with important implications for patients, physicians, and the physician-patient relationship. To a surprising degree, the regulatory activity in diverse health care markets across the nation has reflected a shared set of concerns about managed care practices and trends. An evaluation of the impact of these state policies will provide essential information about the most effective role for government in promoting the physician-patient relationship and the rights of patients and health care professionals in the era of managed care.

REFERENCES

1 +
Miller RH, Luft HS.  Managed care plan performance since 1980: a literature analysis . JAMA . 1994;;271:1512-1519.
2 +
Emanuel EJ, Dubler NN.  Preserving the physician-patient relationship in the era of managed care . JAMA . 1995;;273:323-329.
3 +
Carey T, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: effects on preventive health care . J Clin Epidemiol . 1990;;43:1213-1220.
4 +
Epstein A.  Performance reports on quality: prototypes, problems and prospects . N Engl J Med . 1995;;333:57-61.
5 +
McGlynn EA.  Six challenges in measuring the quality of health care . Health Aff . 1997;;16:7-21.
6 +
Rodwin MA.  Consumer protection and managed care: issues, reform proposals and trade offs . Houston Law Rev . 1996;;32:1321-1381.
7 +
Rodwin MA.  Conflicts in managed care . N Engl J Med . 1995;;332:604-610.
8 +
Weston B, Lauria M.  Patient advocacy in the 1990s . N Engl J Med . 1996;;334:543-544.
9 +
Blumenthal D.  Effects of market reforms on doctors and their patients . Health Aff (Millwood) . 1996;;15:170-184.
10 +
Woolhandler S, Himmelstein DU.  Extreme risk: the new corporate proposition for physicians . N Engl J Med . 1995;;333:1706-1708.
11 +
Kassirer JP.  Managed care and the morality of the marketplace . N Engl J Med . 1995;;333:50-52.
12 +
Council on Ethical and Judicial Affairs, American Medical Association.  Ethical issues in managed care . JAMA . 1995;;273:330-335.
13 +
Mechanic D.  Changing medical organization and the erosion of trust . Milbank Q . 1996;:171-189.
14 +
Hellinger FJ.  The expanding scope of state legislation . JAMA . 1996;;276:1055-1060.
15 +
Families USA Foundation. HMO Consumers at Risk: States to the Rescue . Washington, DC: Families USA Foundation; July 1996;.
16 +
Dallek G, Jimenez C, Schwartz M. Consumer Protections in State HMO Laws: Analysis and Recommendations . Los Angeles, Calif: Center for Health Care Rights; 1995;.
17 +
Furrow BR, Greaney TL, Johnson SH, Jost TS, Schwartz RL. Health Law . St Paul, Minn: West Publishing Co; 1995;;2:53-64.
18 +
42 CFR §§417.100-417.180.
19 +
Joffe MS.  Current developments in state and federal regulation of managed care organizations . The Insider's Guide to Managed Care . Washington, DC: National Health Lawyers Association; 1990;:42-52.
20 +
29 USC §§1001-1461 (1974).
21 +
Shaw v Delta Airlines Inc, 463 US 85 (1983).
22 +
Corcoran v United Healthcare Inc, 965 F2d 1321 (1992).
23 +
Jordan KA.  Travelers insurance: new support for the argument to restrain ERISA preemption . Yale J Regul . 1996;;13:1-67.
24 +
115 SCt 1671 (1995).
25 +
Pacificare of Oklahoma Inc v Burrage, 59 F3d 151 (10th Cir 1995).
26 +
Mariner W.  State regulation of managed care and the employee retirement security act . N Engl J Med . 1996;;335:1986-1990.
27 +
Health Insurance Bill of Rights Act of 1997, S 353 (1997).
28 +
Hillman AL, Welch P, Pauly MV.  Contractual arrangements between HMOs and primary care physicians: three-tiered HMOs and risk pools . Med Care . 1992;;30:136-148.
29 +
Gold MR, Hurley R, Lake T, Ensor T, Berenson R.  A national survey of the arrangements managed care plans make with physicians . N Engl J Med . 1995;;333:1678-1683.
30 +
Ware JE, Bayliss MS, Rogers WH, et al.  Differences in 4-year health outcomes for elderly and poor chronically ill patients treated in HMO and fee-for-service systems . JAMA . 1996;;276:1039-1047.
31 +
Yelin E, Criswell A, Feigenbrum PG.  Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings . JAMA . 1996;;276:1048-1053.
32 +
Berwick DM.  Payment of capitation and the quality of care . N Engl J Med . 1996;;335:1227-1230.
33 +
Mechanic D.  Managed care: rhetoric and realities . Inquiry . 1994;;31:124-128.
34 +
General Accounting Office. Medicare: Physician Incentive Payments by Prepaid Health Plans Could Lower Quality of Care. Washington, DC: US Government Printing Office; 1988. Publication GAO/HRO-89-29.
35 +
Mechanic D, Schlesinger M.  The impact of managed care on patients' trust in medical care and their physicians . JAMA . 1996;;275:1693-1697.
36 +
Ga Ann Code §33-20A-6.
37 +
28 Tex Admin Code §11.1501 (1996).
38 +
RI Health and Safety Code §23-17-13.
39 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med . 1987;;317:1729-1731.
40 +
Council on Ethical and Judicial Affairs, American Medical Association.  Financial incentives to limit care: financial implications for HMOs and IPAs . In: Code of Medical Ethics: Reports of the Council on Ethical and Judicial Affairs of the American Medical Association . Chicago, Ill: American Medical Association; 1990;;1:130-135.
41 +
Pear R.  Laws won't let HMOs tell doctors what to say . New York Times . (September 19) ,1996;:A12.
42 +
Gray P.  Gagging the doctors . Time Magazine . (January 8) ,1996;:50.
43 +
Pear R.  Word for word HMO contracts: the tricky business of keeping doctors quiet . New York Times . (September 22) ,1996;;4:7.
44 +
Olmos D, Roan S.  HMO gag clauses on doctors spur protest . Los Angeles Times . (April 14) ,1996;:A1.
45 +
Rosenblatt R.  Doctors, HMOs clash at hearing on gag rules . Los Angeles Times . (May 31) ,1996;:A1.
46 +
Md Ann Code Article 48A, §490.
47 +
Harper v Healthsource New Hampshire Inc, 140 NH 770 (1996).
48 +
Katz J. The Silent World of Doctor and Patient . New York, NY: The Free Press; 1984;.
49 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. Washington, DC: US Government Printing Office; 1982.
50 +
Emanuel EJ, Brett AS.  Managed competition and the patient-physician relationship . N Engl J Med . 1993;;329:879-882.
51 +
Franks P, Clancy CM, Nutting PA.  Gatekeeping revisited: protecting patients from overtreatment . N Engl J Med . 1992;;327:424-429.
52 +
Shear CL, Gipe BT, Mattheis JK, Levy MR.  Provider continuity and quality of medical care: a retrospective analysis of prenatal and perinatal outcome . Med Care . 1983;;21:1204-1210.
53 +
Gordis L.  Effectiveness of comprehensive care programs in preventing rheumatic fever . N Engl J Med . 1973;;289:331-335.
54 +
Davis K, Collins KS, Schoen C, Morris C.  Choice matters: enrollees' views of their health plans . Health Aff (Millwood) . 1995;; (Summer) :99-112.
55 +
Taylor M.  Doctors choosing to give up choices: financial health of practices influenced increasingly by managed care group rules . Chicago Tribune . (November 19) ,1995;:C1.
56 +
Terry K.  When health plans don't want you anymore . Medical Economics . (May 23) ,1994;:138-149.
57 +
Jimenez R.  Court to hear insurers on right to drop MDs . Boston Globe . (January 28) ,1996;. New Hampshire Weekly:1.
58 +
Olmos DR.  Doctors lying lowregardingprops214,216: seemingly surprising response is indicative of HMOs' power . Los Angeles Times . (November 1) ,1996;: D1.
59 +
Kassirer JP.  The use and abuse of practice profiles . N Engl J Med . 1994;;330:634-636.
60 +
McNeil BJ, Pederson SH, Gatsonis C.  Current issues in profiles: potentials and limitations . In: Physician Payment Review Commission Conference on Profiling . Washington, DC: Physician Payment Review Commission; 1992;:46-70 Publication 92-2.
61 +
RI Gen Health and Safety Code, §23-17.13-3.
62 +
NY Pub Health Law §4406-D; NY Insur Law §4803.
63 +
Hutchcraft C.  Humana to modify doctors' contracts: AMA welcomes removal of a gag clause: other HMOs expected to follow suit . Chicago Tribune . (October 30) ,1996;:A1.
64 +
Wickline v State of California, 192 Cal App 3d 1630 (1986).
65 +
SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients . JAMA . 1995;;274:1591-1598.
66 +
Brunetti LL, Carperos SD, Westlund REW.  Physicians' attitudes towards living wills and cardiopulmonary resuscitation . J Gen Intern Med . 1991;;6:323-329.
67 +
Stolman CJ, Gregory JJ, Dunn D, Levine JL.  Evaluation of patient, physician, nurse, and family attitudes toward do not resuscitate orders . Arch Intern Med . 1990;;150:653-658.
68 +
Isaacs SL.  Consumers' information needs: results of a national survey . Health Aff (Millwood) . 1996;;15:31-41.
69 +
Hibbard JH, Sofaer S, Jewett JJ.  Approaches for communicating quality . Health Care Financing Rev . 1996;;18:95-109.
70 +
National Committee for Quality Assurance. Standards for Accreditation 27-31 . Washington, DC: National Committee for Quality Assurance; 1995;.
71 +
Blum JD.  The evolution of physician credentialing into managed care selective contracting . Am J Law Med . 1996;;22:173-204.
72 +
Ambrosino v Metropolitan Life Insurance Company, 899 F Supp 438 (1995).
73 +
Delta Dental Plan v Banasky, 27 Cal App 4th 1598 (1994).
74 +
Potvin v Metropolitan Life Insurance Company, Cal Ct App, No. B100170 (April 30, 1997).

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Miller RH, Luft HS.  Managed care plan performance since 1980: a literature analysis . JAMA . 1994;;271:1512-1519.
2 +
Emanuel EJ, Dubler NN.  Preserving the physician-patient relationship in the era of managed care . JAMA . 1995;;273:323-329.
3 +
Carey T, Weis K, Homer C.  Prepaid versus traditional Medicaid plans: effects on preventive health care . J Clin Epidemiol . 1990;;43:1213-1220.
4 +
Epstein A.  Performance reports on quality: prototypes, problems and prospects . N Engl J Med . 1995;;333:57-61.
5 +
McGlynn EA.  Six challenges in measuring the quality of health care . Health Aff . 1997;;16:7-21.
6 +
Rodwin MA.  Consumer protection and managed care: issues, reform proposals and trade offs . Houston Law Rev . 1996;;32:1321-1381.
7 +
Rodwin MA.  Conflicts in managed care . N Engl J Med . 1995;;332:604-610.
8 +
Weston B, Lauria M.  Patient advocacy in the 1990s . N Engl J Med . 1996;;334:543-544.
9 +
Blumenthal D.  Effects of market reforms on doctors and their patients . Health Aff (Millwood) . 1996;;15:170-184.
10 +
Woolhandler S, Himmelstein DU.  Extreme risk: the new corporate proposition for physicians . N Engl J Med . 1995;;333:1706-1708.
11 +
Kassirer JP.  Managed care and the morality of the marketplace . N Engl J Med . 1995;;333:50-52.
12 +
Council on Ethical and Judicial Affairs, American Medical Association.  Ethical issues in managed care . JAMA . 1995;;273:330-335.
13 +
Mechanic D.  Changing medical organization and the erosion of trust . Milbank Q . 1996;:171-189.
14 +
Hellinger FJ.  The expanding scope of state legislation . JAMA . 1996;;276:1055-1060.
15 +
Families USA Foundation. HMO Consumers at Risk: States to the Rescue . Washington, DC: Families USA Foundation; July 1996;.
16 +
Dallek G, Jimenez C, Schwartz M. Consumer Protections in State HMO Laws: Analysis and Recommendations . Los Angeles, Calif: Center for Health Care Rights; 1995;.
17 +
Furrow BR, Greaney TL, Johnson SH, Jost TS, Schwartz RL. Health Law . St Paul, Minn: West Publishing Co; 1995;;2:53-64.
18 +
42 CFR §§417.100-417.180.
19 +
Joffe MS.  Current developments in state and federal regulation of managed care organizations . The Insider's Guide to Managed Care . Washington, DC: National Health Lawyers Association; 1990;:42-52.
20 +
29 USC §§1001-1461 (1974).
21 +
Shaw v Delta Airlines Inc, 463 US 85 (1983).
22 +
Corcoran v United Healthcare Inc, 965 F2d 1321 (1992).
23 +
Jordan KA.  Travelers insurance: new support for the argument to restrain ERISA preemption . Yale J Regul . 1996;;13:1-67.
24 +
115 SCt 1671 (1995).
25 +
Pacificare of Oklahoma Inc v Burrage, 59 F3d 151 (10th Cir 1995).
26 +
Mariner W.  State regulation of managed care and the employee retirement security act . N Engl J Med . 1996;;335:1986-1990.
27 +
Health Insurance Bill of Rights Act of 1997, S 353 (1997).
28 +
Hillman AL, Welch P, Pauly MV.  Contractual arrangements between HMOs and primary care physicians: three-tiered HMOs and risk pools . Med Care . 1992;;30:136-148.
29 +
Gold MR, Hurley R, Lake T, Ensor T, Berenson R.  A national survey of the arrangements managed care plans make with physicians . N Engl J Med . 1995;;333:1678-1683.
30 +
Ware JE, Bayliss MS, Rogers WH, et al.  Differences in 4-year health outcomes for elderly and poor chronically ill patients treated in HMO and fee-for-service systems . JAMA . 1996;;276:1039-1047.
31 +
Yelin E, Criswell A, Feigenbrum PG.  Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings . JAMA . 1996;;276:1048-1053.
32 +
Berwick DM.  Payment of capitation and the quality of care . N Engl J Med . 1996;;335:1227-1230.
33 +
Mechanic D.  Managed care: rhetoric and realities . Inquiry . 1994;;31:124-128.
34 +
General Accounting Office. Medicare: Physician Incentive Payments by Prepaid Health Plans Could Lower Quality of Care. Washington, DC: US Government Printing Office; 1988. Publication GAO/HRO-89-29.
35 +
Mechanic D, Schlesinger M.  The impact of managed care on patients' trust in medical care and their physicians . JAMA . 1996;;275:1693-1697.
36 +
Ga Ann Code §33-20A-6.
37 +
28 Tex Admin Code §11.1501 (1996).
38 +
RI Health and Safety Code §23-17-13.
39 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med . 1987;;317:1729-1731.
40 +
Council on Ethical and Judicial Affairs, American Medical Association.  Financial incentives to limit care: financial implications for HMOs and IPAs . In: Code of Medical Ethics: Reports of the Council on Ethical and Judicial Affairs of the American Medical Association . Chicago, Ill: American Medical Association; 1990;;1:130-135.
41 +
Pear R.  Laws won't let HMOs tell doctors what to say . New York Times . (September 19) ,1996;:A12.
42 +
Gray P.  Gagging the doctors . Time Magazine . (January 8) ,1996;:50.
43 +
Pear R.  Word for word HMO contracts: the tricky business of keeping doctors quiet . New York Times . (September 22) ,1996;;4:7.
44 +
Olmos D, Roan S.  HMO gag clauses on doctors spur protest . Los Angeles Times . (April 14) ,1996;:A1.
45 +
Rosenblatt R.  Doctors, HMOs clash at hearing on gag rules . Los Angeles Times . (May 31) ,1996;:A1.
46 +
Md Ann Code Article 48A, §490.
47 +
Harper v Healthsource New Hampshire Inc, 140 NH 770 (1996).
48 +
Katz J. The Silent World of Doctor and Patient . New York, NY: The Free Press; 1984;.
49 +
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making Health Care Decisions. Washington, DC: US Government Printing Office; 1982.
50 +
Emanuel EJ, Brett AS.  Managed competition and the patient-physician relationship . N Engl J Med . 1993;;329:879-882.
51 +
Franks P, Clancy CM, Nutting PA.  Gatekeeping revisited: protecting patients from overtreatment . N Engl J Med . 1992;;327:424-429.
52 +
Shear CL, Gipe BT, Mattheis JK, Levy MR.  Provider continuity and quality of medical care: a retrospective analysis of prenatal and perinatal outcome . Med Care . 1983;;21:1204-1210.
53 +
Gordis L.  Effectiveness of comprehensive care programs in preventing rheumatic fever . N Engl J Med . 1973;;289:331-335.
54 +
Davis K, Collins KS, Schoen C, Morris C.  Choice matters: enrollees' views of their health plans . Health Aff (Millwood) . 1995;; (Summer) :99-112.
55 +
Taylor M.  Doctors choosing to give up choices: financial health of practices influenced increasingly by managed care group rules . Chicago Tribune . (November 19) ,1995;:C1.
56 +
Terry K.  When health plans don't want you anymore . Medical Economics . (May 23) ,1994;:138-149.
57 +
Jimenez R.  Court to hear insurers on right to drop MDs . Boston Globe . (January 28) ,1996;. New Hampshire Weekly:1.
58 +
Olmos DR.  Doctors lying lowregardingprops214,216: seemingly surprising response is indicative of HMOs' power . Los Angeles Times . (November 1) ,1996;: D1.
59 +
Kassirer JP.  The use and abuse of practice profiles . N Engl J Med . 1994;;330:634-636.
60 +
McNeil BJ, Pederson SH, Gatsonis C.  Current issues in profiles: potentials and limitations . In: Physician Payment Review Commission Conference on Profiling . Washington, DC: Physician Payment Review Commission; 1992;:46-70 Publication 92-2.
61 +
RI Gen Health and Safety Code, §23-17.13-3.
62 +
NY Pub Health Law §4406-D; NY Insur Law §4803.
63 +
Hutchcraft C.  Humana to modify doctors' contracts: AMA welcomes removal of a gag clause: other HMOs expected to follow suit . Chicago Tribune . (October 30) ,1996;:A1.
64 +
Wickline v State of California, 192 Cal App 3d 1630 (1986).
65 +
SUPPORT Principal Investigators.  A controlled trial to improve care for seriously ill hospitalized patients . JAMA . 1995;;274:1591-1598.
66 +
Brunetti LL, Carperos SD, Westlund REW.  Physicians' attitudes towards living wills and cardiopulmonary resuscitation . J Gen Intern Med . 1991;;6:323-329.
67 +
Stolman CJ, Gregory JJ, Dunn D, Levine JL.  Evaluation of patient, physician, nurse, and family attitudes toward do not resuscitate orders . Arch Intern Med . 1990;;150:653-658.
68 +
Isaacs SL.  Consumers' information needs: results of a national survey . Health Aff (Millwood) . 1996;;15:31-41.
69 +
Hibbard JH, Sofaer S, Jewett JJ.  Approaches for communicating quality . Health Care Financing Rev . 1996;;18:95-109.
70 +
National Committee for Quality Assurance. Standards for Accreditation 27-31 . Washington, DC: National Committee for Quality Assurance; 1995;.
71 +
Blum JD.  The evolution of physician credentialing into managed care selective contracting . Am J Law Med . 1996;;22:173-204.
72 +
Ambrosino v Metropolitan Life Insurance Company, 899 F Supp 438 (1995).
73 +
Delta Dental Plan v Banasky, 27 Cal App 4th 1598 (1994).
74 +
Potvin v Metropolitan Life Insurance Company, Cal Ct App, No. B100170 (April 30, 1997).

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