The effective management of appropriate health care should be able to contain medical care costs and improve accessibility while addressing rationing concerns. However, managed care in the United States has not lived up to the expectations set for it.Managed care quickly gained popularity among employers and public policy makers as a mechanism for curbing the excessive growth of health care insurance costs. Nonetheless, since its introduction, the system of largely for-profit managed care has been the subject of much public and political debate. The change from a fee-for-service system toward a system in which the health care insurance component is combined with the delivery of a broad range of integrated health care services for populations of plan enrollees that are financed prospectively from a limited budget has been widely criticized and has even been called repugnant. Instead of placing the blame on managed care organizations, however, we need to keep in mind that such organizations operate without societal agreement on critical issues such as a workable definition of health, an authoritative standard for defining the scope of entitlements, and on the distribution of labor between public and private sector entities. The health care system in the United States is also characterized by decentralization as well as the absence of a comprehensive health care planning or budgeting system, substantive access rules, and agreed-upon minimum health care benefit package. Therefore, managed care organizations only have limited responsibilities. The nonexistence of a shared, unifying paradigm of responsibility has been called the leading cause of the inability to manage health care appropriately. The stakeholders in health care operate on a set of widely varying interpretations of the notion of responsibility. The concept of genuine responsibility, recognizing the complexity of health care and the need for stakeholder-specific interpretations of responsibility, proposes as the underlying premise of responsibility (at least in regard to health care) the social agreement that distributive choices should be made on the basis of the premise of deliberate reciprocity. When all parties share the same foundation on which the notion of responsibility is built the resulting trust and cooperation among stakeholders enables them to find morally appropriate solutions in reforming health care.
Part 1. Health care costs and scarcity. 1. Introduction. 2. Development of Managed Care. 2.1 The concepts of "costs". 2.2 Economic restraints. 3. Rationing: A dilemma for ethicists. 3.1 Scarcity is an economic reality. 3.2 Ethics and rationing. 3.3 Medical necessity. 3.4 Cost effectiveness and cost benefit analysis. 3.5 Affordability. 3.5 A comprehensive approach. 3.6 Talking about responsibility. 4. Responsibility. 4.1 What is the distribution claim made by agency theories? 4.2 Normative weakness. 4.3 Responsibility: the key notion. 4.4 "Genuine responsibility" as a proposal for a unifying paradigm. Part 2. The concept of managed care and its practical implications. 1. Introduction. 2. Quality of Care in Managed Care. 2.1 F airness in managed care. 2.2 Public distrust. 3. History of Managed Care. 3.1 Economic Pressure. 3.2 Medical Waste as a Contributor to Cost. 4.Where does managed care find its market. 5. Definition of managed care. 5.1 Different forms of managed care. 5.2 Implications of managed care. 5.3 Characteristics of managed care. 5.4 Expectations and disappointments. 6. Managed care as unknown territory. 6.1 Distribution by managing outcomes. 6.2 Utilization versus best practice data. 6.3 What ought to be versus what is. 7. Methodological concerns regarding data collection. 7.1 Normative concerns about data. 8. Population-based distribution and individual autonomy. 8.1 Reconsidering medical paternalism. 8.2 F oundation of a rights-orientated health care. 9. Balancing responsibilities. 9.1 Denial of liability and accountability. 9.2 Responsibility of MCOs to members. 10. Changes in managed care. 10.1 The obvious question. Part 3. Ideology: the silent partner. 1. Introduction. 2. The concept of ideology. 3. Ideology in medicine. 3.1 Ideological components in the definition of health. 3.2 Models of causation of disease and their ideological relevance. 4. The context of scarcity and its ideological impact on health care. 4.1 The ideological context of the model of rationing and its symbolicy forms. 5. Conclusion. Part 4. Concept of Genuine Responsibility. 1. Introduction. 2. Changing the focus in health care distrisbution. 2.1 Unlimited access versus cost containment. 2.2 An analogy. 2.3 An ethics approach. 2.4 Rationality and Empathy. 3. The notion of responsibility. 3.1 An ethics of genuine responsibility. 3.2 The definition of "Genuine Responsibility". 3.3 Implications on the notion of personal responsibility. 4. Justice and health care. 4.1 Just health care. 4.2 The odds of just health care. 4.3 Impediment to justice. 5. Key presumptions. 5.1 Challenging the notion of responsibility in managed care. 5.2 Health care distribution in a free-market economy. 5.3 Justice as appropriation. Part 5: Revising the template for modeling health care. 1. Introduction. 2. Necessity for change. 2.1 Recapitulating the applied theoretical framework. 2.2 The ideological argument in the health care debate. 3. Defining health and health care. 4. The main parties involved. 4.1 Society. 4.1.1 Justice and public policy making. 4.1.2 The contribution of justice as appropriation. 4.1.3 The contribution of genuine responsibility to the debate. 4.1.4 Defining entitlement to healthcare. 4.2 Government. 4.2.1 Privatization and cost containment. 4.2.2 Empirical observations. 4.3 Recapitulation. 4.3.1 Genuine responsibility and health care business. 4.4 Managed care organizations. 4.4.1 Business as moral agent. 4.4.2 Corporate citizenship in the market place. 4.4.3 Corporate responsibility and the healthcare business. 4.4.4 Prioritization of interests. 4.4.5 The nature and the scope of responsibility. 4.4.6 Solidarity and the notion of universal access. 4.4.7 The implications for managed care organizations. 4.4.8 Two alternatives for control. 4.4.9 How genuine responsibility would guide managed care distribution. 4.4.10 Compliance or integrity behavior. 4.4.11 Accounting for the focus on for-profit managed care organizations. 4.4.12 Effects o
Traces the growth of managed care as a mechanism for curbing excessive growth in health costs, and the controversies that have risen around for-profit health care. This title examines decentralization in US health care, and the absence of comprehensive health care planning, access rules, and minimum health care benefit standards.
Summary of the challenges of the managed care system
Offers a theoretical framework to improve access to quality but affordable health care provided in a competitive market environment
Calls for cooperation and a shared responsibility by all parties involved in health care