Tough Love: The Emergence of Criminal Statutes and Disciplinary Actions against Managed Care Plans for Inadequate Care
Journal of Contemporary Health Law & Policy, Vol. 18, p. 53, 2001
56 Pages Posted: 20 Mar 2012 Last revised: 5 Oct 2012
Date Written: Winter 2001
The ascent of managed care organizations (MCO) since the enactment of the Employment Retirement Income Security Act (ERISA) of 1974 is well documented. Critics of managed care assert that MCOs are corrupt, greedy and provide dangerously unsafe health care. However, supporters contend that criticism of managed care is misplaced and marvel at the ability of MCOs to provide comprehensive health care to millions despite increasing medical costs. MCOs deny physician-recommended treatment based on vague definitions of medical necessity but frequently fail to disclose the basis of these standards to the attending physician. Regardless of posturing, the current system needs to change.
Based on FDA, elder care and environmental prosecutions, this article contends the enactment of health care criminal statutes that establish a standard of medically necessary care and accompanying MCO obligations will not only survive legal challenges, but is the socially, legally and morally correct path to take.
Keywords: Managed Care, health care, hospitals, doctors, patients, ERISA, Employment Retirement Income Security Act, HMO, criminal, medical, medical necessity, inadequate care
JEL Classification: I18, K14
Suggested Citation: Suggested Citation