Ethically Important Distinctions among Managed Care Organizations

Rodwin Marc A. , Medicine, Money & Morals: Physicians' Conflicts of Interest (New York: Oxford, 1993): At 17; Fletcher John Engelhard Carolyn , “Ethical Issues in Managed Care,” Virginia Medicine Quarterly, 122, no. 3 (1995): 162–67; Quint Michael , “Health Plans Force Changes in the Way Doctors Are Paid,” New York Times, Feb. 9, 1995, at A1; Relman Arnold S. , “Medical Practice Under the Clinton Reforms—Avoiding Domination by Business,” N. Engl. J. Med., 329 (1993): 1574–76; and Mitka Mike , “HMOs See Steady Growth, Some Market Shifts,” American Medical News, May 1, 1995, at 9.

Freudenheim Milt , “Medicare, Jot This Down: Employers Offer Valuable Lessons on Saving Money with Managed Care,” New York Times, May 31, 1995, at C1; Johnsson Julie , “Medicare's Bumpy Ride into Private Sector,” American Medical News, June 12, 1995, at 1; Clymer Adam , “An Accidental Overhaul: Major Revamping of Health Care System Could be Byproduct of Steep Budget Cuts,” New York Times, June 26, 1995, at A1; and Freudenheim Milt , “Corporations Step up Efforts to Get Retirees into H.M.O.'s,” New York Times, June 13, 1995, at C1.

Relman Arnold S. , “The Impact of Marker Forces on the Physician-Patient Relationship,” Journal of the Royal Society of Medicine, 87 (supp. 22) (1994): 22–25; Relman Arnold S. , “Medical Insurance and Health: What about Managed Care?,” N. Engl. J. Med., 331 (1994): 471–72; and Pellegrino Edmund , “Ethics,” JAMA, 271 (1994): 1668–70.

Johnsson Julie , “Megamerger of Two Public Plans Spurs New Interest in Stock Offering,” American Medical News, Apr. 24, 1995, at 1; and Freudenheim Milt , “Penny-Pinching H.M.O.'s Showed Their Generosity in Executive Paychecks,” New York Times, Apr. 11, 1995, at C1.

Cal. Code Non-Profit Corp., § 5130-B (West 1980).

See Freudenheim , supra note 4; and Rodwin Marc , “Conflicts in Managed Care,” N. Engl. J. Med., 332 (1995): 604–07.

Thompson Steve Valentine Zabrae , “The Profiteering of HMOs,” California Physician, July 1994, at 28–32, based on a California Department of Corporations report for 1992.

Alameda–Contra Costa Medical Association, “Latest CMA Study Shows Rise in HMO Costs and Profits,” ACCMA Bulletin, Feb. 1995, at 14; and Freudenheim Milt , “A Bitter Pill for the HMO's,” New York Times, Apr. 28, 1995, at C1.

See Freudenheim , supra note 6; and Hiltzik Michael Olmos David , “Are Executives at HMOs Paid too Much Money?,” Los Angeles Times, Aug. 30, 1995, at A13.

See Fletcher Engelhard , supra note 1.

Eisenberg John M. , “Economics,” JAMA, 273 (1995): 1670–71.

Hillman Alan , “Financial Incentives for Physicians in HMOs: Is There a Conflict of Interest?,” N. Engl. J. Med., 317 (1987): 1743–48; see Rodwin , supra note 1, at 152–56.

Prager Linda , “State Licensing Boards Consider Curbing Financial Incentives,” American Medical News, Oct. 16, 1995, at 1, 74.

Emanuel Ezekiel Dubler Nancy N. , “Preserving the Physician-Patient Relationship in the Era of Managed Care,” JAMA, 273 (1995): 323–29; see Rodwin , supra note 1, at 98.

Krieger Lisa , “Family Doctors are Disappearing,” San Francisco Examiner, June 18, 1995, at A1.

Olmos David , “Some Doctors Head to Idaho, a State Without Managed Care,” Los Angeles Times, Aug. 29, 1995, at All.

Herschberg Seymour , “Potential Conflicts of Interest in the Delivery of Medical Services: An Analysis of the Situation and a Proposal,” Quality Assurance and Utilization Review, 7 (1992): 54–58.

Shenkin Budd , “The Independent Practice Association in Theory and Practice,” JAMA, 273 (1995): 1937–42.

Friedman Emily , “Changing the System: Implications for Physicians,” JAMA, 269 (1993): 2437–42.

Council on Ethical and Judicial Affairs, American Medical Association, “Ethical Issues in Managed Care,” JAMA, 273 (1995): 330–35.

See Rodwin , supra note 1, at 138–44.

See Relman , supra note 1; and Cangello Vincent , “The Real Issue,” ACCMA Bulletin, Jan. 1995, at 18.

Hiltzik Michael , “Emergency Rooms, HMOs Clash over Treatments and Payments,” Los Angeles Times, Aug. 30, at A12.

Phillips William , letter: “Hassle Hypertension: A Risk of Managed Care,” JAMA, 274 (1995): 795–96.

See Rodwin , supra note 1, at 135.

One study of IPAs and physician groups with capitated contracts shows that physicians tend to employ the same type of barriers to care, such as pre-authorization requirements, as health plans. The study did not include the largest group practice HMO in California, Kaiser Permanente, which does not use pre-authorization requirements to control costs. Kerr Eve , “Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?,” Annals of Internal Medicine, 123 (1995): 500–04.

Crosson Francis J. , “Why Outcomes Measurement Must be the Basis for the Development of Clinical Guidelines,” Managed Care Quarterly, 3, no. 2 (1995): 6–11; Eddy David , “Broadening the Responsibilities of Practitioners: The Team Approach,” JAMA, 268 (1993): 1849–55; and Zendle Les , “Controlling Costs: The Case of Kaiser,” JAMA, 274 (1995): 1135.

See Friedman , supra note 19.

See Crosson , supra note 27.

Hillman Alan , “Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments,” Annals of Internal Medicine, 112 (1990): 891–93.

Rodwin , supra note 1, at 139–41.

Jecker Nancy S. , “Managed Competition and Managed Care,” Clinics in Geriatric Medicine, 10 (1994): 527–40; see Emanuel Dubler , supra note 14; and Council on Ethical and Judicial Affairs, supra note 20.

Clement Dolores , “Access and Outcomes for Elderly Patients Enrolled in Managed Care,” JAMA, 271 (1994): 1487–92.

See Council on Ethical and Judicial Affairs, supra note 20; Sulmasy Daniel , “Managed Care and Managed Death,” Archives of Internal Medicine, 155 (1995): 133–36; and Hiltzik Michael Olmos David , “A Mixed Diagnosis for HMO's,” Los Angeles Times, Aug. 27, 1995, at A1.

Richmond Julius , “The Health Care Mess,” JAMA, 273 (1995): 69–71.

Miles Steven , “End-of-Life Treatment in Managed Care: The Potential and the Peril,” Western Journal of Medicine, 163 (1995): 302–05.

See Eisenberg , supra note 11; and “Study: Managed Care Lowers Hospital Costs, Improves Quality,” American Medical News, June 19, 1995, at 6.

Meisel Joan , Quality of Care in HMOs: A Review of the Literature (Sacramento: CAHMO, Sept. 1994); California Cooperative HEDIS Reporting Initiative, Report on Quality of Care Measures (San Francisco: CCHRI, Feb. 1995); and National Committee for Quality Assurance, Report Card Pilot Project/Technical Report (New York: NCQA, 1994).

Somerville Janice , “CMA Study: High HMO Administrative Costs for Medicaid,” American Medical News, May 15, 1995, at 12.

See Hillman , supra note 12.

Woodstock Theological Center, Ethical Considerations in the Business Aspects of Health Care (Washington, D.C.: Georgetown University Press, 1995): At 9–14.

Id. at 20–22.

Board of Directors of Kaiser Foundation Hospitals and Kaiser Foundation Health Plan, “Principles of Responsibility” (1984): In-house circular.

Forces external to managed care are exerting a growing pressure against undertreatment. For example, the 1990 Medicare amendment restricts prepaid plans contracting with the Health Care Financing Administration from creating an “incentive plan as an inducement to reduce or limit medically necessary services to a specific individual.” See Medicare law in 42 U.S.C. § 1395mm(i)(8)(A) (1990). Legislation pending in several states would put limits on the type of cost-control measures that MCOs can employ. See Ogrod Eugene , “The Many Faces of Managed Care,” California Physician, Aug. 1995, at 10; and Johnsson Julie , “State Laws on Managed Care Spur New Battles,” American Medical News, July 24, 1995, at 3, 51.

Biblo Joan D. , Ethical Issues in Managed Care: Guidelines for Clinicians and Recommendations to Accrediting Organizations (Kansas City: Midwest Bioethics Center, 1995); Wolf Susan M. , “Health Care Reform and the Future of Physician Ethics,” Hastings Center Report, 24, no. 2 (1994): 28–41; see Council on Ethical and Judicial Affairs, supra note 20; and Tristram Engelhardt H. Rie Michael A. , “Morality for Medical-Industrial Complex: A Code of Ethics for the Mass Marketing of Health Care,” N. Engl. J. Med., 319 (1988): 1086–89.

Barr Donald , “The Effects of Organizational Structure on Primary Care Outcomes under Managed Care,” Annals of Internal Medicine, 122 (1995): 353–59.

See Relman , supra note 1; Angell Marcia , “The Beginning of Health Care Reform: The Clinton Plan,” N. Engl. J. Med., 329 (1993): 1569–70; and Bernadin Cardinal Joseph , “Making the Case for Not-for-Profit Healthcare,” speech by Bernadin Cardinal Joseph , Harvard Business School Club of Chicago, Jan. 12, 1995.

See Rodwin , supra note 1, at 136.

See Council on Ethical and Judicial Affairs, supra note 20.

Emanuel Ezekiel , “Managed Competition and the Patient-Physician Relationship,” N. Engl. J. Med., 329 (1993): 879–82.

Harding Jonathan , “The Role of Organizational Ethics Committees,” Physician Executive, 20, no. 2 (1994): 19–24; see Emanuel Dubler , supra note 14.

Azevedo David , “Can the World's Largest Integrated Health System Learn to Feel Small?,” Medical Economics, 72, no. 2 (1995): 82–103.

Azevedo David , “What You Can Bargain for When HMO's Compete,” Business & Health, June (1995): 44–56.

Quint Michael , “Merger to Create Largest Company for Health Plans,” New York Times, June 27, 1995, at A1.