The Shift toward Managed Care and Emerging Liability Claims Arising from Utilization Management and Financial Incentive Arrangements between Health Care Providers and Payers
![handle is hein.journals/ualr19 and id is 171 raw text is: THE SHIFT TOWARD MANAGED CARE AND EMERGING
LIABILITY CLAIMS ARISING FROM UTILIZATION MANAGEMENT
AND FINANCIL INCENTIVE ARRANGEMENTS BETWEEN
HEALTH CARE PROVIDERS AND PAYERS
Brian P. Battaglia
All these years, [providers] have been concerned
with fighting socialized medicine, and now they've
been blind-sided by capitalism.'
I. INTRODUCTION
The entire system of managed care (managed care or managed
competition) has again come under attack due to recently publicized lawsuits
and incidents focusing on injuries and deaths resulting from decisions that
limited or denied medical care to patients. In light of these events, consumers
of health care and the media have questioned whether such decisions were
undertaken with the patient's best interests in mind or merely for the purpose
of saving another health care dollar.
As a result of these concerns, it is imperative that consumers, the media,
and health care professionals understand the factors which necessitated the
transformation of health care delivery and provider reimbursement toward
managed care and competition. The courts, deciding cost containment liability
claims, must well understand events leading up to the present metamorphosis
in the delivery of health care, and the critical part cost containment and
financial risk shifting play in the managed care formula. With such knowledge,
courts will be better suited to render legal decisions that can chart a course for
providers, utilization managers, and legal professionals, who must navigate the
newly discovered managed care liability waters. Such decisions will provide
much needed guidance as to when and under what circumstances, cost
containment mechanisms become instruments simply to enhance the provider's
bottom line to the detriment of the consumer.
Managed care and managed competition are relatively new terms in health
care terminology. Therefore, much of the confusion and doubt as to what these
systems entail is the result of the health care industry's failure to skillfully
explain to the public terms relating to cost containment delivery systems, such
as health maintenance organization (HMO), preferred provider organization
(PPO), physician-hospital organization (PHO) or integrated delivery systems
* J.D., Drake University Law School; LL.M., Institute for Health Law, Loyola
University Chicago School of Law; Chair, Health Law Practice Group, The Law Firm of
Battaglia, Ross, Dicus & Wein, P.A., Tampa/St. Petersburg, Florida.
1. BETTY LEYERLE, THE PRIVATE REGULATION OF AMERICAN HEALTH CARE 3 (1994).](ViewImageLocal?handle=hein.journals/ualr19&div=16&collection=&method=preview&ext=.png&size=3)
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