Biomaterial Database

Liability issues in managed care. 1997

M S Ellis

Otolaryngology-Head & Neck Surgery at LSU School of Medicine in New Orleans, USA.

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.

UI	MeSH Term	Description	Entries
D007351	Insurance, Liability	Insurance against loss resulting from liability for injury or damage to the persons or property of others.	No-Fault Insurance,Insurance, No-Fault,Liability Insurance,No Fault Insurance
D008329	Managed Care Programs	Health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as HEALTH MAINTENANCE ORGANIZATIONS and PREFERRED PROVIDER ORGANIZATIONS.	Case Management, Insurance,Insurance Case Management,Managed Health Care Insurance Plans,Managed Care,Care, Managed,Managed Care Program,Management, Insurance Case,Program, Managed Care,Programs, Managed Care
D010344	Patient Advocacy	Promotion and protection of the rights of patients, frequently through a legal process.	Patient Ombudsmen,Patient Representatives,Clinical Ombudsman,Patient Ombudsman,Advocacy, Patient,Ombudsman, Clinical,Ombudsman, Patient,Ombudsmen, Patient,Patient Representative,Representative, Patient,Representatives, Patient
D010817	Physician-Patient Relations	The interactions between physician and patient.	Doctor-Patient Relations,Doctor Patient Relations,Physician Patient Relations,Physician Patient Relationship,Doctor Patient Relation,Doctor-Patient Relation,Physician Patient Relation,Physician Patient Relationships,Physician-Patient Relation,Relation, Doctor Patient,Relation, Doctor-Patient,Relation, Physician Patient,Relation, Physician-Patient,Relations, Doctor Patient,Relations, Doctor-Patient,Relations, Physician Patient,Relations, Physician-Patient,Relationship, Physician Patient,Relationships, Physician Patient
D012017	Referral and Consultation	The practice of sending a patient to another program or practitioner for services or advice which the referring source is not prepared to provide.	Consultation,Gatekeepers, Health Service,Hospital Referral,Second Opinion,Consultation and Referral,Health Service Gatekeepers,Hospital Referrals,Referral,Referral, Hospital,Referrals, Hospital,Consultations,Gatekeeper, Health Service,Health Service Gatekeeper,Opinion, Second,Opinions, Second,Referrals,Second Opinions
D003219	Confidentiality	The privacy of information and its protection against unauthorized disclosure.	Patient Data Privacy,Privacy of Patient Data,Privileged Communication,Confidential Information,Secrecy,Communication, Privileged,Communications, Privileged,Data Privacy, Patient,Information, Confidential,Privacy, Patient Data,Privileged Communications
D003254	Consumer Advocacy	The promotion and support of consumers' rights and interests.	Public Advocacy,Advocacies, Consumer,Advocacies, Public,Advocacy, Consumer,Advocacy, Public,Consumer Advocacies,Public Advocacies
D004992	Ethics, Medical	The principles of professional conduct concerning the rights and duties of the physician, relations with patients and fellow practitioners, as well as actions of the physician in patient care and interpersonal relations with patient families.	Medical Ethics
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.
D014600	Utilization Review	An organized procedure carried out through committees to review admissions, duration of stay, professional services furnished, and to evaluate the medical necessity of those services and promote their most efficient use.	Review, Utilization,Reviews, Utilization,Utilization Reviews