Chapter 9.B (or 3.B) -- Insurance Regulation and Managed Care

The American Association of Health Plans  web site has a variety of information about HMO quality and the debate over regulation.  For contrasting sources that collect HMO horror stories and negative news clippings, cartoons, etc. see:  http://www.nohmo.com/Archive.htmhttp://harp.org/ http://www.hmopage.org/  http://www.dranonymous.com/  On HMOs generally, see Alain C. Enthoven & Laura A. Tollen, Toward a 21st Century Health System: The Contributions and Promise of Prepaid Gorup Practice (Jossey-Bass, 2004).

The physician who Debra Moran sought out for treatment has the following website promoting her success with restorative microsurgery for treatment of peripheral nerve paralysisthis: http://jkterzis.com/

For additional analyses of managed care patient protection laws, see Linda C. Fentiman, Patient advocacy and termination from managed care organizations: Do state laws protecting health care professional advocacy make any difference?, 82 Neb. L. Rev. 508-574 (2003); Mark A. Hall, The "Death" of Managed Care: A Regulatory Autopsy, 30 J. Health Politics Policy & L. 427 (2005); Robert F. Rich and Christopher T. Erb, The two faces of managed care regulation & policymaking, 16 Stan. L. & Pol'y Rev. 233-276 (2005).

For more analysis of judicial reactions to managed care, see Robert F. Rich, et al., Judicial Interpretions of Managed Care Policy 13 Elder L. J. 85 (2005) (concluding that "our judicial institutions cannot make up their minds about whether to support or restrain managed care"). 

On insurance regulation of provider groups that bear risk, see Brant S. Mittler and Andre Hampton, The Princess and the Pea: the assurance of voluntary compliance between the Texas Attorney General and Aetna's Texas HMOs and its impact on financial risk shifting by managed care, 83 B.U. L. Rev. 553-590 (2003).

Another way to avoid insurance regulation is to market a network of providers who have negotiated discount prices, leaving the consumer to pay all the bills at the discounted rates.  This has led to problems of consumer confusion and fraud.  Gerard Britton, Discount Medical Plans the the Consumer: Health Care in a Regulatory Blind Spot, 16 Loy. Consumer L. Rev. 97 (2004).

Class action suits against managed care plans by physicians have been settled for substantial amounts.  Those by patients have been mostly dismissed, or settled for smaller amounts, based largely on the failure to obtain class certification or rejection of the primary theories of liability.  See In re Managed Care Litigation, 430 F.Supp.2d 1336  (2006). 

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