Managed Care’s Crimea: Medical Necessity, Therapeutic Benefit, and the Goals of Administrative Process in Health Insurance

This Essay explores the concept of medical necessity as it has evolved in the judicial and administrative oversight of managed care. The goals of the Essay are to illustrate the range of plausible rationales for establishing administrative procedures to govern medical necessity disputes, and to demonstrate the difficulty of incorporating into those procedures the most important professional and social responsibilities of managed care in today’s health care system. Part I of the Essay explains the ideological and practical significance of medical necessity as managed care has evolved. Part II examines medical necessity as a legal problem, and questions whether current independent review programs match social needs. Part III offers an alternative perspective on oversight of decisionmaking in managed care that emphasizes therapeutic effect rather than contractual enforcement. Part IV describes improvements in both independent review and overall medical necessity policy that would better serve therapeutic objectives. Among other things, the Essay suggests that independent review procedures should be different for insured individuals who are severely or chronically ill than for those who are only occasional users of health care services

Managed Care’s Crimea: Medical Necessity, Therapeutic Benefit, and the Goals of Administrative Process in Health Insurance

En brotyp som är vanlig bland brokonstruktioner är plattrambron. Denna brotyp byggs både med slak- och spännarmering. Det är dock vanligare att bygga med slakarmering än spännarmering, vilket övervägs särskilt då spännvidderna är ungefär 25- 30 meter eller mer. Inledningsvis har en noggrann litteraturstudie genomförts tillsammans med en intervju av en kunnig brokonstruktör för att säkerställa en interaktion mellan teori och aktuell praxis. Detta arbete har haft ett huvudmål, vilket är att ur ett struktur- och kostnadsperspektiv jämföra och utvärdera hur behovet av slakarmering varierar i en plattrambros farbana då spännvidder varieras och betongtvärsnitt ändras. Arbetet har utförts med hjälp av finita elementprogrammet ”Brigade Standard”, vilket erbjuder en tre-dimensionell strukturanalys. Fyra olika tvärsnitt för spännvidder mellan 10-20 meter analyseras. Dimensioner på brodelar bestäms med hjälp av tumregler samt generella råd från intervjuperson; höjd i fält enligt L/20, L/25, L/30 samt L/35, där L är spännvidden. Resultatet visar främst att för ökade spännvidder mot 20 meter ökar lasteffekten på grund av egentyngd drastiskt och då särskilt det tvärsnitt som är störst, det vill säga L/20. Vidare visas även att slankare tvärsnitt resulterar i aningen högre armeringsmängd. Dock påverkas betongkostnaden i större utsträckning av slankare tvärsnitt och särskilt större spännvidder. Även om större spännvidd och slankare tvärsnitt föranleder ett större armeringsbehov, fås en lägre totalkostnad. Det bör noteras att priset på betong och stål är starkt beroende av konjunktur och tillgång till material. Denna studie kan bli ännu intressantare då priset varierar kraftigt för stål och föranleder att betongpriset blir mindre dominerande än vad det är idag. Huvudprodukten från detta arbete är att med hjälp av tabeller och nya priser kunna beräkna en preliminär totalkostnad för plattrambrons farbana för olika spännvidder och hur olika tvärsnittsalternativ påverkar denna kostnad

Executive Authority to Reform Health: Options and Limitations

Presidential power has provoked increasingly vigorous debate since the turn of this century. In recent years, scholars and lawyers have been grappling with how Congress\u27s dictates may limit the President\u27s Commander-in-Chief power to detain enemy combatants at Guantanamo Bay, to fight wars abroad, and to conduct intelligence activities at home. But policymakers have not yet explored the many possibilities for invoking the President\u27s Take Care power to change health care policy. This paper explores the scope and limits of President Barack Obama\u27s ability to invoke his executive authority to reform health care. Specifically, it identifies ways the Obama Administration can use directives to: (1) expand Medicaid and SCHIP coverage through section 1115 waivers; (2) test quality initiatives through Medicare demonstration authority; (3) expand health information technology; (4) allow drug reimportation and experiment with contracting power under Medicare; (5) enhance patient protections and private coverage requirements; (6) lift coverage restrictions on Medicaid and SCHIP; and (7) build on the health insurance program for federal employees. Consistent with the mission of the Legal Solutions in Health Reform project, this paper does not endorse a particular policy. Instead of recommending what, it explains how

Identifying Health Facilities outside the Enterprise: Challenges and Strategies for Supporting Health Reform and Meaningful Use

Objective: To support collation of data for disability determination, we sought to accurately identify facilities where care was delivered across multiple, independent hospitals and clinics. Methods: Data from various institutions' electronic health records were merged and delivered as continuity of care documents to the United States Social Security Administration (SSA). Results: Electronic records for nearly 8000 disability claimants were exchanged with SSA. Due to the lack of standard nomenclature for identifying the facilities in which patients received the care documented in the electronic records, SSA could not match the information received with information provided by disability claimants. Facility identifiers were generated arbitrarily by health care systems and therefore could not be mapped to the existing international standards. Discussion: We propose strategies for improving facility identification in electronic health records to support improved tracking of a patient's care between providers to better serve clinical care delivery, disability determination, health reform and meaningful use. Conclusion: Accurately identifying the facilities where health care is delivered to patients is important to a number of major health reform and improvement efforts underway in many nations. A standardized nomenclature for identifying health care facilities is needed to improve tracking of care and linking of electronic health records

Health Insurance Exchanges in Health Care Reform: Legal and Policy Issues

Examines the role of health insurance exchanges in a reformed healthcare system, reviews past experiences with exchanges, compares the House and Senate bills' approaches to the exchanges' design and function, and discusses the policy issues they raise

Home and Community-based Services: Quality Management Roles and Responsibilities

Early in the development of this first working paper on QM roles and responsibilities, QA/QI grantees contributed to a preliminary outline of the issues to be addressed. A subset of grantee states agreed to more fully discuss their perceptions of the issues and to guide the exploratory efforts of Muskie School staff. While the initial list of issues was quite lengthy, it was subsequently reduced to four essential questions: How is quality defined for HCBS? What is meant by quality management? How do states develop quality management expertise? How do states organize their quality management strategies? This paper attempts to answer these questions from the perspectives of the grantees and available federal guidance. The topic is limited to quality management strategies focused on the quality of services and supports for HCBS consumers and is not intended to represent the quality management field as a whole