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

Enterprise Liability and the Emerging Managed Health Care System

“Enterprise medical liability” is a term used to describe a system in which health care organizations bear responsibility for medical malpractice in addition to or instead of individual health professionals. Enterprise liability is in many senses a natural outgrowth of the increasing dependence of medical practice on institutional resources and expertise. Proposals for enterprise liability surfaced briefly from the academic literature into the political spotlight during the 1993-94 health care reform debate. At that time, objections to the concept as a basis for medical malpractice liability, even in a restructured health care system, were nearly universal. Just five years later, many of the groups vehemently opposing the Clinton malpractice reform have become vigorous supporters of managed care liability. Moreover, courts and legislatures are holding managed care organizations accountable for malpractice in ways superficially compatible with the Clinton proposal. In the process, however, enterprise liability has been transformed from a theory without a movement to a movement without a theory. This article explores why this happened, whether it is likely to be a transitory phase or a sustained trend, and what it portends for the public policy objectives of medical tort law. Part II of this article describes the theoretical justifications for imposing liability for medical malpractice on managed care organizations, emphasizing proposals that were made in connection with the national health care reform debate. Part III explains why enterprise liability failed to attract support in 1993-94. Part IV discusses the very different attitudes that prevail in 1998, and details the legal manifestations of the current movement to expand malpractice liability in managed care. Parts V and VI of the article analyze the relationship among theoretical constructs of enterprise liability, the reality of today’s managed care marketplace, and the legal response managed care has provoked. Specifically, Part V outlines several respects in which the market and the legal system have moved away from characteristics that previously made enterprise liability desirable, and Part VI identifies potentially significant trends that could lead to a rapprochement between our health care system and the public policy justifications for extending malpractice liability to managed care organizations. Finally, Part VII suggests that federal legislation is necessary for malpractice liability to serve socially constructive purposes in managed care, and identifies a set of principles that should guide future legislative action

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

A Copernican View of Health Care Antitrust

Sage and Hammer use the analogy of Copernican astronomy to suggest that understanding the dramatic change wrought by managed care requires a conceptual reorientation regarding the meaning of competition in health care and its appropriate legal and regulatory oversight. Both share the belief that misperceiving the world limits potential for technical and social progress

Assembled Products: The Key to More Effective Competition and Antitrust Oversight in Health Care

This Article argues that recent calls for antitrust enforcement to protect health insurers from hospital and physician consolidation are incomplete. The principal obstacle to effective competition in health care is not that one or the other party has too much bargaining power, but that they have been buying and selling the wrong things. Vigorous antitrust enforcement will benefit health care consumers only if it accounts for the competitive distortions caused by the sector’s long history of government regulation. Because of regulation, what pass for products in health care are typically small process steps and isolated components that can be assigned a billing code, even if they do little to help patients. Instead of further entrenching weakly competitive parties engaged in artificial commerce, antitrust enforcers and regulators should work together to promote the sale of fully assembled products and services that can be warranted to consumers for performance and safety. As better products emerge through innovation and market entry, competition may finally succeed at lowering medical costs, increasing access to treatment, and improving quality of care

Brand New Law! The Need to Market Health Care Reform

The most serious problem with the Patient Protection and Affordable Care Act (ACA) is not its contents but its packaging. Because it requires significant departures from business as usual in health insurance, health care delivery, and health behavior, the ACA is unlikely to succeed unless Americans feel a shared stake in its success. Unfortunately, the new law has been branded only by its opponents. Neither the Obama administration nor its congressional allies have effectively communicated the law’s key elements to the public. Most surprisingly, the groundbreaking program of near-universal health coverage the ACA creates does not even have a name. This essay explores the process of branding major American social legislation such as the ACA, and suggests a strategy for improving public understanding and building loyalty. Legal brand equity, like its commercial counterpart, implies a functional, emotional, and expressive relationship between the law and its intended beneficiaries. Accordingly, an effective marketing strategy for the ACA means creating consistent expectations regarding the law’s goals and performance, and ensuring that those expectations are met

Minding Ps and Qs: The Political and Policy Questions Framing Health Care Spending

Tracing the evolution of political conversations about health care spending and their relationship to the formation of policy is a valuable exercise. Health care spending is about science and ethics, markets and government, freedom and community. By the late 1980s the unique upward trajectory of post-Medicare U.S. health care spending had been established, recessions and tax cuts were eroding federal and state budgets, and efforts to harness market forces to serve policy goals were accelerating. From the initial writings on “managed competition,” through the failed Clinton health reform effort in the early 1990s, to the passage of the Affordable Care Act in 2010, the policy narrative of health spending acquired a superficial consistency. On closer examination, however, it becomes apparent that the cost problem has been repeatedly reframed in political discourse even during this relatively brief period. The clearest transition has been from a narrative centered on rationing necessary care to one committed to reducing wasteful care – although the role of accumulated law and regulation in perpetuating waste remains largely unrecognized and the recently articulated commitment to population health seems an imperfect proxy for explicitly developing social solidarity with respect to health and health care in the United States

Our \u27Patchwork\u27 Health Care System: Melodic Variations, Counterpoint, and the Future Role of Physicians

This Foreword to a forthcoming symposium on the patchwork health care system to be published in the Houston Journal of Health Law & Policy considers whether current reactions to fragmentation in health care represent minor variations on a longstanding theme in US health policy or offer a more substantial counterpoint to that theme. The theme is this: that perfect physicians should be allowed to control health care even if safeguards are needed in practice because real physicians are not perfect. The Foreword previews four scholarly articles featured in the published symposium. It concludes that, while all the articles present original and valuable insights, the future health care system they describe is more variation than counterpoint on the theme of physician control

Over Under or Through: Physicians, Law, and Health Care Reform

My purpose in this commentary is twofold. First, I want to offer a few thoughts on why the American medical profession sometimes has a hard time accepting law on its own terms. Second, I want to suggest that even “good law” from the perspective of the medical profession—should it overcome its habits of resistance—may still be bad health policy for the United States

Drug Product Liability and Health Care Delivery Systems

This note will use the principles of law and economics to examine the interaction of market structures and product liability rules in a world of imperfect information. The goals of the analysis are to create incentives for optimal care by producers and consumers, induce the socially appropriate amount of consumption of each product (often referred to as the activity level ), and minimize the costs of bearing the risk of injury. The note will conclude that the existence of health maintenance organizations ( HMOs ) and similar prepaid providers with superior information capacity and total patient care responsibility may create a context in which current standards of drug liability should be revised