Private Policy Making and American Health Care
Eleanor D. Kinney
Indiana University Robert H. McKinney School of Law
Administrative Law Review, Health Law Symposium Issue, Vol. 51, No. 1, 1999
Journalistic reports and widely publicized court decisions have fueled consumer concerns about the availability of high quality health care in prepaid managed care plans. Most consumer concerns about health care services pertain to coverage of services and quality of care. This article analyzes the private processes for developing coverage and quality policy for public and private health plans in the United States. First, this article explores the nature and importance of coverage and quality policy in health plans today and how such policy relates to the current problems consumers face with health plans generally and prepaid health plans in particular. Second, the article reviews the development of coverage and quality policy since the advent of widespread health insurance coverage in the mid-Twentieth Century. Third, this article explores how sponsors of public and private health plans make decisions about coverage and quality policy. As coverage and quality policy is informed predominantly by standards of care developed by private medical organizations and private accrediting bodies, this article also examines the procedures by which these entities develop standards of care. Finally, this article concludes with recommendations for sound policy making procedures for private coverage and quality policy and the standards of care used to develop this policy. Specifically, policy making procedures can do much to ensure that plan coverage and quality policy exhibits three core values of validity, credibility and democratic legitimacy. Proposed here are three principles of policy making procedures that promote these values, with respect to all types of standards of care. First, designated process, however informal must exist, for adopting any coverage and quality policy or any standard of care used in the formulation of a coverage or quality policy. Second, procedural methods must assure that the relevant scientific and clinical information is marshaled, made available and expertly considered by the decision makers formulating the policy. Third, all policy must be publicized and made available easily to affected parties, especially physicians, health professionals and consumers.
Accepted Paper Series
Date posted: December 2, 1998
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