New management techniques and complex organizational structures allow the health care industry to continue placing costs above care and profits over patients.
On one side of my office, piles of articles tout the transformation, even death, of managed care. Even the media seem to have lost interest in the tragic stories that continue to emerge from our profit-driven health care system. According to the health industry, we have entered into a "kinder and gentler" era of health insurance, one in which health plans claim they are moving away from medical gatekeepers and denials of care.
The other side of my office tells a different story. Piles of e-mail messages and letters from patients, as well as mounds of evidence on how health plans really work, bring to mind a new twist on the famous words of Mark Twain: News of managed care's death may be greatly exaggerated. In fact, evidence from my files indicates that managed care is alive and thriving, so much so that one health care executive claims we are in the middle of its "second coming."
Twenty-first century managed care is best defined as the organizational practices of any health care entity using business strategies to influence or control access to and availability of medical services for economic gain. Patients can become victims of systems that lead to too much care as well as too little, and they now risk danger from corporations as much as from individual agents.
This should not surprise anyone, since the provision of health care, from for-profit insurance companies to nonprofit government organizations, still works on a simple principle: Financial success and "savings" depend on maximizing the gap between money taken in and money paid out. Its face may change, but managed care is not going away. New companies, strategies, and profits continue to mushroom, with HMOs reporting $5.5 billion in profits for 2002, an 81 percent increase since 2001. At the same time, more Americans are uninsured or underinsured, and patients face mounting bureaucratic nightmares and diminishing protections.
The Health Maintenance Organization Act of 1973 launched the explosion of new forms of health delivery and finance. HMOs began as prepaid health plans, organized to provide "basic and supplemental health services to [their] members . . . without limitation as to time and cost." They were intended to reduce the spiraling costs of medical care through a focus on prevention, early intervention, and health maintenance.
However, it soon became obvious that this type of cost-control required lengthy business cycles, so insurers would not reap profits for many years. The companies began to focus on what would produce immediate profits.
The earliest forms of managed care focused on what the industry calls "low-hanging fruit," or areas that generated the quickest and highest "savings." Primitive forms of managed care relied heavily on "cherry-picking", that is, enrolling only healthy people and not accepting those with health problems, as well as network limitation, discounts, risk-sharing, and blunt utilization review that targeted-denial of expensive tests and treatments, specialty referrals, and hospitalizations. Managed care represented an unprecedented opportunity for organizations to control medical care before it was delivered.
Physicians no longer practice medicine alone. Severe limitations, denials, and alterations of care led to great profitability in the early to mid-1990s, but these savings proved to be one-time phenomena. High-profile effects, like 24-hour maternity stays and 48-hour mastectomy stays, caused a consumer "backlash." By the new millennium, decreased profits, poor public relations, and demands for better "patient protection" sent the health insurance industry back to its drawing board.
Although earlier forms of managed care still exist, insurers' practices are increasingly subtle, refined, and disguised. Instead of one company doctor sitting in corporate headquarters making decisions about treatments and hospitalizations, several different people in many different locations manage patient care.
In addition to health plans and insurance companies, care can be managed by external utilization-management companies; third-party administrators; benefit-management, disease-management, pharmacy-management, and mental-health-management companies; hospitals; employers; and government payers, to name just a few.
I have reviewed documents in which a single patient's care was managed through the health plan's gatekeeper, a disease-management company for congestive heart failure, a case manager for diabetes-related complications, a pharmacy-benefits manager, and a managed mental-health care company. Each of these entities had a different definition of "medical necessity" and different policies and structures, with little or no coordination among them.
"Disease management" represents the newest managed care trend, as the health industry concentrates its resources on wringing out savings from a trillion-dollar health-care coffer. Also, with the current focus on drug costs and new Medicare legislation, pharmacy-management companies will have increased effects on decisions related to patient care. For example, the merger of two giant pharmaceutical-benefits managers , Caremark RX, Inc., and AdvancePCS, will give a new company the opportunity to manage prescriptions for about 70 million members.
Other businesses specialize in the management of networks, doctor "scorecards," credentialing, special populations (like Medicaid recipients and prisoners), and specific care areas (such as rehabilitation, home-health care, and "complementary", or alternative, medicine).
Managed care systems depend on the manipulation of patients, physicians, benefits, and medical management to achieve cost-savings and profits. Early forms of managed care relied more on blunt denials of treatment that often harmed patients. Newer forms of managed care are marked by sophisticated systems that distribute management and change care in ways that still harm patients, but are less obvious. The emerging trends include the following.
Health insurance companies continue to limit benefits in ways that are rarely disclosed and are seldom understood by potential enrollees. Often patients do not understand the implications of certain restrictions until they need services that they expected their plan to cover.
In other situations, some contracts indicate that certain benefits will be available, but when patients need the specific benefit, they discover that tightened authorization procedures limit the benefit. Some health care organizations continue to use misrepresentation and deception to gain financial or market advantage, with potential serious consequences for patients.
Medical necessity. The term "medical necessity" can have hundreds of different meanings, interpretations, and applications, even within the same company. And as health plans fragment and outsource more of their management functions, different companies may use and apply varied definitions of "medical necessity," including some that are more restrictive than the one contractually disclosed to members.
Health plans can also delegate decision-making about medical necessity to medical groups and other vendors who are under risk-sharing arrangements, such as capitation, that is, set fees an HMO agrees to pay a physician per patient, regardless of the frequency or cost of the medical care provided. These providers have financial incentives to limit or deny care, or substitute less costly alternatives. In some cases, even reinsurance companies enter into medical decision-making prospectively, requiring health plans to seek their approval first. In these situations, the reinsurer's definition of "medical necessity" may be more restrictive than the plan's.
Furthermore, nothing about this additional layer of medical management is ever disclosed to plan members. I have examined a case in which a health plan would have approved an expensive treatment but eventually denied it after the reinsurance company determined that the treatment did not meet its criteria for "medical necessity."
Despite claims that denials have decreased, a study of two California health plans reported that between 8 percent and 10 percent of requests for medical treatment and coverage were explicitly denied, an increase of 3 percent over previous reports. And even though medical-necessity determinations remain critical to cost control, we know little about how they are made, and each decision must be examined carefully to determine its validity.
Medical guidelines. Medical management depends on having codified criteria that provide the rules for evaluating medical necessity and making other medical determinations. For example, in the early days of managed care, authorization requests for hysterectomies were evaluated by medical directors who relied primarily on their understanding of the prevailing clinical standards of care, which would come predominantly from research and academic literature. However, when company doctors began to review requests for medical treatment, these standards allowed too much variation in medical judgment.
Many companies sprang up to fill the gaps, so that now almost every medical treatment or service is so systematized that little independent medical judgment enters into the review for many managed care organizations. In one case, a company made the conditions for approval of a hysterectomy so narrow that they would have required conservative treatments to fail and the patient to have suffered a recurrence of invasive carcinoma before she could have the surgery. In other situations, managed care organizations applied outdated or wrong criteria and manipulated criteria inappropriately to justify a denial.
Although "evidence-based medicine" is the new buzz phrase, there is a difference between legitimate clinical criteria that have been developed through research and peer review, and proprietary protocols developed by commercial companies using pseudo-scientific processes.
Exclusions for "experimental and investigational" treatments. When managed care was first established, health plans often relied on prevailing clinical and government standards to determine whether a requested treatment was experimental. With advancements in technology and research, the exclusion grew to include investigational procedures. Now, definitions that used to be only a couple of sentences long extend for pages. Some plans try to exclude standard therapies simply because they are part of a researcher's data collection and study.
As with "medical necessity," patients may find that health plans apply different definitions of these terms. In one case I examined, a plan member's medical needs were not excluded under the contract's broad, two-line definition of "experimental." However, when the health plan sent the case to an outside consultant, it requested that he use a detailed definition and criteria that were nearly two pages long, giving the physician more technicalities on which to justify a denial.
Traditional HMO membership is decreasing, and more members are choosing preferred provider organizations (PPOs) and other managed care hybrids. Although PPOs are generally viewed as less restrictive, they continue to use many of the managed care practices associated with HMOs, such as hospital precertification and authorizations for certain tests, treatments, referrals, and drugs.
Although many PPOs do not use gatekeeping, that is, they don't use physicians to control patients' access to treatments, tests, and specialists, they have other ways to control patients and their physicians. Some PPOs delegate utilization management to physician groups such as individual practice organizations, which in turn use contracts, payments, and even peer pressure to influence and control treating physicians' decisions. PPOs also use disease management, pharmacy management, selected networks, and medical criteria in making "medical necessity" decisions that can emphasize cost rather than care.
Managed-indemnity plans. Many people buy "indemnity" health insurance that they believe is closer to traditional coverage, without managed care. However, these insureds often discover that when they need medical treatment, they face managed care practices that are often associated with more restrictive health plans.
For example, I reviewed a case in which a health insurance company used a medical-necessity requirement as a basis for a denial, even though the insured's contract did not contain such a provision. Further investigation revealed that the company was channeling all its medical management through a utilization-review department designed for its HMO business. Even though some consumers were paying more for a less-managed health plan, they were essentially treated as if they were HMO members.
Tiered plans. Health care companies continue to rely on network restrictions as a means to control costs and care, although new health plans appear to be less managed, with their various "tiers" of providers and benefits. Many patients in these tiered plans discover that to receive medically necessary, high-quality care, they must choose the most expensive tiers, if they can afford to do so.
For example, a plan's lowest tier will restrict the network of doctors and require HMO-type restrictions for referrals and specialty care. If a patient chooses this tier, out-of-pocket costs will be minimal and care might be limited. The highest tier will allow more open access to doctors and hospitals with fewer restrictions, at increased patient expense.
In tiered plans, patients assume their own health care management and might find that they will have to deny themselves quality care for financial reasons. If patients remain in the lowest-cost tier, they will be in an HMO-type plan, with most of the more restrictive managed care practices. These tiered plans have the potential to affect quality of care: "More efficient" physicians and other providers who provide the least expensive treatment are placed in lower-cost tiers, putting sicker patients and the physicians who care for them at serious economic disadvantage. The physicians in the lowest tiers are the most "cost effective," so they provide the least amount of care and will not want to treat sicker patients. Patients, both well-off and poor, who need more care may need to go to other tiers.
The sheer complexity of these arrangements may result in significant savings and profits to health plans. The administrative complexity makes it hard for patients and physicians to get access and payment, so delays and payment hassles multiply, and plans benefit from anything that allows them to keep the money longer.
Illusory choice and cost-shifting. The managed care backlash and decreasing profitability have driven insurance companies to develop new plans that capitalize on consumers' demands for choice and freedom in treatment and the doctors they can choose. Some consumers can put together their own networks and choose levels of benefits according to how much they want to pay.
Few consumers understand the implications of these new plans, especially the amount of cost-shifting that occurs when patients require medical treatment. This shifting of the economic burden becomes the most sophisticated cost-management tool yet. In one case, a couple discovered after they had a child that they had chosen a network that did not include the specialized neonatal care their child needed. They had to assume greater out-of-pocket costs so their child could receive appropriate medical treatment.
These new arrangements also engage in their own forms of stealth managed care. Companies that offer these new plans have their own networks and even pay providers under capitation arrangements. Consumers will have to be clairvoyant about which benefit levels and networks they will need to design their plans. They now design their plans by making choices about how much they want to pay in premiums, deductibles, and copayments; what type of pharmacy benefits they want; and what network they want.
Although the structures of these new plans vary widely, most arrangements have a threshold at which some care management occurs. In such situations, patients will have the illusion of choice and freedom for medical needs like acupuncture, laser eye surgery, and other discretionary medical expenses, but will be surprised to find themselves at the mercy of a company that will decide the medical necessity of critical hospitalizations, surgeries, and expensive medical treatments.
Through sophisticated information-management systems, a managed care organization can identify particular codes, patterns, profiles, cost thresholds, or other identifiers of medical conditions and treatments for focused review and adjust its management strategies to fit current trends.
For example, as more care shifts to outpatient services, utilization management can target office-based surgeries, home health care, new diagnostic tests, high-cost injectable drugs, and durable medical equipment. Specific diseases, conditions, treatments, and even particular patients can be targeted, identified, and selectively managed. I have examined documents in which cost accounts were kept for particular members, and certain levels of review kicked in at different cost thresholds or when preset cost triggers were reached.
Disease management. This is the most rapidly growing medical-management industry, with over 150 companies now vying for the managed care of specific patient populations and medical conditions, such as congestive heart failure and renal disease. Many of these companies enter into risk-sharing arrangements with health plans that create financial benefits from shorter hospitalizations, decreased emergency room visits, cheaper drugs, and provisions of fewer medical services.
Although new forms of managed care are often portrayed as patient-friendly, there is no clear data showing that "disease management" reduces the cost of health care while improving its quality. In fact, I have reviewed many files that suggest that disease management adds to patient risk in dangerous ways. For example, in one case, a renal-care company discouraged treatment for medical complications because approving the treatment would cut into its profits.
Pharmacy management. Changes in Medicare drug benefits and the rising costs of pharmaceuticals suggest that prescription-drug management will be critical for the future of managed care. I receive calls frequently from patients who are unable to obtain necessary medications or who are forced to accept substitutes that are often less effective. In some cases, serious harm and death result from a managed care organization's interference with drug treatments.
Many health care plans include new "incentive-based formularies," in which patients choose among tiers of drugs grouped by cost and copayments. For example, a patient might need a specific drug that places him or her in a tier that requires higher copayments or cost-sharing, forcing him or her to use another less costly drug that might be less effective or even dangerous. Health plans reap significant savings with these arrangements, but patients' lives are endangered when these plans are misrepresented or poorly disclosed. Patients, especially those with chronic illnesses, can suffer and die needlessly if they are unable to afford necessary drugs that should be covered.
Pharmacy management will continue to evolve, with new and refined attempts to increase restrictions by using pharmacy networks, limiting the availability of certain drugs, tightening precertification requirements, and expanding drug-specific utilization management.
Hospital and other institutional management. Precertification for facility care, including acute hospitalization, skilled nursing care, inpatient rehabilitation, psychiatric treatment, and other forms of institutional care, remains a critical focus for medical management. Controlling admissions and lengths of stays in these facilities provides immediate, lucrative economic returns for managed care organizations.
Many companies use software programs with detailed medical protocols for their assessments. The so-called guidelines used by these programs often become rigid rules that are applied without regard for a patient's age and sex or the presence of other medical problems. A "reviewer," who may not even be a nurse, can apply rules that assign the number of days that a patient with a particular medical condition will be allowed to be treated in a hospital or other facility.
In addition to tighter precertification, managed care organizations use "concurrent review", meaning health plan nurses directly monitor a patient's care in a medical facility through daily phone calls or on-site visits. This kind of micromanagement gives a managed care organization the means to control the entire course of inpatient treatment, especially decisions about transfer, discharge, and follow-up care.
Predictive modeling and "prospective" care. The health industry understands that a small percentage of patients incur the largest percentage of costs. Traditional managed care depends on identifying high-cost patients through diagnosis or "cost triggers," but cost management may occur too late.
New models depend on making predictions about particular patients who are likely to be costly. Through methods of data analysis, pattern recognition, and new techniques like "time-series analysis" and "neural networking," managed care organizations can target specific individuals, and even physicians, to proactively "manage" healthy patients long before they need care. For example, a plan can use data patterns to identify patients who might be at risk for heart disease, and then it can concentrate on limiting the future costs of these patients before they have even developed any signs of the disease.
Even prevention is giving way to new strategies of "prospective" medicine, with the development of "health coaches" and earlier intrusion by health plans into lifestyle choices.
Health plans have also discovered that scouring claims for the "worried well", patients who seek frequent health care, convinced that they are ill even though they are physically well, enables them to control the potential costs of another population of patients before the patients need care. Health plans might use this kind of data for aggressive underwriting and marketing as well as for management, providing increased opportunities to avoid patients whose care might be costly. The next phase of this kind of management will no doubt include genetic testing.
The development of ways to influence physician behavior and practice patterns continues to be critical to managed care.
Physician profiling. As information management and technology become more sophisticated, managed care organizations can use physician profiling to identify specific providers according to costs and quality, and use this information to influence practice patterns. This area of physician control is likely to grow more extensive and effective.
Studies show that physicians who have been subject to profiling linked to financial incentives, meaning that managed care organizations have detailed reports on the physicians' hospital admissions, test orders, and referrals to specialists, and they link payment to those numbers, giving higher payments and bonuses to physicians who stay within those numbers and penalizing those who exceed them, reported difficulties with making appropriate medical decisions for their patients. These physicians said they were often torn about doing what is best for the patient while working under a health plan that rewards physicians who control costs by limiting treatment.
Physician profiling has already succeeded as a means to do economic credentialing, in which plans choose physicians based on economic performance and cost-effectiveness. Plans award the most economical physicians by placing them in networks and plans that will bring the physicians the most financial return. In some cases, economic credentialing has been coupled with targeted reviews to remove noncompliant, difficult, or costly physicians.
Expanded capitation. Although some reports claim that capitation is waning, it still remains an effective method to control costs by shifting the financial risk of loss for medical treatments to many different providers. Initially, health plans used capitation for primary care physicians (PCPs) or physician groups in an attempt to fix the amount of money available to pay for the medical care of a panel of members.
A panel is a group of patients who use the same primary care physician. If 500 members have Dr. A as their PCP, for example, Dr. A has a panel of 500, for which he will be paid a fixed amount. The panel members do not even have to be patients that Dr. A has seen. This is the idea behind capitation: Get your panel number up as high as possible, then do as little as possible for members. The ideal would be for none of the 500 panel members ever to visit the doctor.
Now health plans have expanded capitation to specialists, especially in fields that have high frequency and costs of surgery like gynecology, orthopedics, and otolaryngology. Under these arrangements, specialists are induced to behave more like gatekeepers.
Health care companies also use capitation for outsourced management firms, such as disease- management companies. Like traditional HMOs, these companies profit to the degree that they can control the costs of medical treatments, services, hospitalizations, drugs, and equipment.
Organizational incentives and disincentives. In addition to financial arrangements with providers, managed care organizations set up cultural, administrative, and economic controls to influence their employees' work. Some health plans have used cash bonuses to reward doctors and nurses for decreased costs. Other incentives are less blatant. Various methods can be used, from bonuses tied to overall company profitability or performance, to cultural and employment pressures such as audits and evaluations designed to meet cost-management objectives.
I have examined many situations in which employees who work for health plans and other health care organizations were directly and indirectly influenced to make decisions that adversely affected patients' health.
For example, in one case, when a medical director told a patient that he had been hospitalized for as long as the plan would allow, the patient's treating physician released him, putting the patient's health at risk but saving him the cost of paying out of-pocket for a hospital stay that the plan wouldn't cover. In another instance, company nurses and doctors ignored indications that a patient's condition was too serious to discharge him from the hospital. They denied continued hospitalization, and they received bonuses for doing so.
Payment for quality. The newest trend in physician payment is providing incentives for quality. Under some arrangements, physicians receive additional payments or bonuses for meeting certain goals like high immunization rates or increased patient satisfaction. But several quality-based plans have significant utilization or financial incentives that result in high-quality care for some, not all, patients.
For example, physicians under plans in which quality bonuses are paid for meeting certain goals, like ordering more mammograms, may feel pressured to give special attention to patients from whom they will benefit the most, leaving other patients at rink of different standards of care. So a plan might emphasize screening for breast cancer but not treating it.
Health plans and insurance companies create streams of disputes that result in hassles, delays, and denials of care. Although many disputes involve less than life-and-death decisions, an analysis by the Center for Health and Public Policy Studies, a research and policy-analysis group at the University of California, Berkeley, revealed that significant numbers of patients whose treatment was delayed or denied reported that their health worsened and that they suffered permanent disabilities as a result.
The appeal process serves as an effective management tool. Health care companies benefit financially from anything that produces delays or obstacles, from patients who are too ill to fight for their treatment to personnel who are too overworked to care. Often little is known about the outcome of an appeal until a particular patient's experience unravels in litigation.
Internal correspondence, medical case files, and other documents in patients' legal cases reveal that reviews are sometimes poorly investigated and performed. I have evaluated cases in which health plans based decisions on wrong protocols, or ignored or even hid reports from outside consultants that were favorable to patients. Even external companies that consider patient appeals do not ensure accessible, unbiased, high-quality reviews.
In addition to continued delays and denials of care, the new consumer-directed and tiered plans will introduce layers of complexity that can result in a bureaucratic nightmare of unimaginable proportions. Countless patients have faced complicated claim problems after they were treated for serious illnesses, and these problems affected their future medical care. When patients and their families exhaust their energy and finances struggling through administrative mazes, medical treatment may be compromised.
If these new strategies do not support continued profitability, health plans may return to older, more stringent forms of managed care. Already, there is evidence that earlier forms of managed care are re-emerging, as medical directors and physician advisers report that they are pressured to review more "tightly."
Medical, legal, academic, business, and political professionals have duties to ensure that individuals and organizations are accountable, not only for specific decisions but also for the systems they create and set in motion. Until we create a health care system based on effective administrative, clinical, ethical, and legal accountability, managed care will move toward its "third coming." In this phase, the privileged will experience management by excess as they seek boutique care and enhancement medicine, and the disadvantaged will suffer management by the brutal rationing that will be necessary to keep the health industry ever more profitable.
It is not enough to focus on medical errors and malpractice without a careful examination of the underlying systems in which unsafe or negligent acts occur. It is not enough to focus on institutional safety or individual professional negligence without also addressing issues of organizational and corporate responsibility. Until we have substantive ethical, legal, and political change to our health care system, managed care will continue to endanger patients.
1. See, e.g., Dennis Connaughton, Managed Care Is Dead, Says Assembly Keynote Speaker, FP REPORT, Oct. 4, 2001, available at http://www.aafp.org/ (search for "managed care is dead") (last visited Apr. 2, 2004).
2. See Bradley C. Strunk & James D. Reschovsky, Center for Studying Health System Change, Kinder and Gentler: Physicians and Managed Care, 1997-2001, Tracking Rep. No. 5 (2002), available at http://www.hschange.com/ (last visited Mar. 29, 2004).
3. Jeff Margolis, The Health Care Consumer's Unlikely Ally: Managed Care, MANAGED CARE MAG., Feb. 2003, available at www.managedcaremag.com/archives/0302/0302.viewpoint_margolis.html (last visited Mar. 29, 2004).
4. Joan R. Rose, HMO Coffers Overflow, MED. ECON., Feb. 6, 2004, at 19.
5. 42 U.S.C. Â§300e (b) (2002).
6. See generally Linda Peeno, Managed Care and the Corporate Practice of Medicine, TRIAL, Feb. 2000, at 18.
7. Eli Ginzberg & Miriam Ostow, Managed Care, A Look Back and a Look Ahead, 336 NEW ENG. J. MED. 1018 (1997).
8. Robert J. Blendon et al., Understanding the Managed Care Backlash, 17 HEALTH AFF. 80 (July/Aug. 1998).
9. Suzanne Felt-Lisk & Glen P. Mays, Back to the Drawing Board: New Directions in Health Plans' Care Management Strategies, 21 HEALTH AFF. 210 (Sept./Oct. 2002).
10. Press Release, Centers for Medicare & Medicaid Services, Health Care Spending Reaches $1.6 Trillion in 2002 (Jan. 8, 2004) (at www.cms.hhs.gov/media/press/release.asp?Counter=935) (last visited Mar. 29, 2004).
11. Roger Yu, AdvancePCS-Caremark Merger Is Approved, DALLAS MORNING NEWS, Feb. 11, 2004, at 3D.
12. Laura Landro, Doctor "Scorecards" Are Proposed in a Health-Care Quality Drive, WALL ST. J., Mar. 25, 2004, at A1.
13. See generally Bob Carlson, Reinsurers Offer Services to Keep Client Costs Down, MANAGED CARE MAG., Jan. 2004, available at www.managedcaremag.com/archives/0401/0401.reinsurance.html (last visited Mar. 29, 2004).
14. Kanika Kapur et al., Managing Care: Utilization Review in Action at Two Capitated Medical Groups, HEALTH AFF., June 18, 2003, available at content.healthaffairs.org/cgi/reprint/hlthaff.w3.275v1.pdf?ck=nck (last visited Mar. 29, 2004).
15. Sara J. Singer & Linda A. Bergthold, Prospect for Improved Decision-Making About Medical Necessity, 20 HEALTH AFF. 200 (Jan./Feb. 2001) available at content.healthaffairs.org/cgi/reprint/20/1/200.pdf (last visited Mar. 29 2004).
16. See Douglas J. Peters, Evidence-Based Medicine in Court, TRIAL, July 2002, at 74.
17. See generally Alan M. Garber, Evidence-Based Coverage Policy, 20 HEALTH AFFS. 62 (Sept./Oct. 2001).
18. Some Worry Quality Suffers in Move to Tier Physicians, MANAGED CARE MAG., Apr. 2003 available at www.managedcaremag.com/archives/0304/0304.news_qualitysuffers.html (last visited Mar. 29, 2004).
19. See generally James C. Robinson, Hospital Tiers in Health Insurance: Balancing Consumer Choice with Financial Incentives, HEALTH AFF., Mar. 19, 2003, available at content.healthaffairs.org/cgi/reprint/hlthaff.w3.135v1.pdf (last visited Mar. 29, 2004).
20. See Jon B. Christianson et al., Defined-Contribution Health Insurance Products: Development and Prospects, 21 HEALTH AFF. 49 (Jan./Feb. 2002).
21. See generally Margaretann Cross, Will New Benefit Design Harm Some Patients?, MANAGED CARE MAG., Dec. 2003, available at www.managedcaremag.com/archives/0312/0312.outcomes.html (last visited Mar. 29, 2004).
22. Alison Johnson, Measuring DM's Net Effect Is Harder Than You Might Think, MANAGED CARE MAG., June 2003, at 28, available at www.managedcaremag.com/index.html (search for title) (last visited Mar. 29, 2004).
23. Cindy Parks Thomas, Incentive-Based Formularies, 349 NEW ENG. J. MED. 2186 (2003).
24. Bob Carlson, Predictive Modeling, Sharp Lens on Near Future, MANAGED CARE MAG., July 2003, available at www.managedcaremag.com/archives/0307/0307.predictive.html (last visited March 29, 2004).
25. Laura Landro, Preventive Medicine Gets More Aggressive: The â€˜Health Coach', WALL ST. J., Feb. 12, 2004, at D1.
26. Frank Diamond, How to Manage the Worried Well, MANAGED CARE MAG., June 2003, available at www.managedcaremag.com/archives/0306/0306.worriedwell.html (last visited March 29, 2004).
27. Carl Pearson, Genomics and Managed Care: Preparing for the Revolution, 41 HEALTHPLAN 14 (2000).
28. Landro, supra note 12.
29. Jeffrey Stoddard et al., Financial Incentives and Physicians' Perceptions of Conflict of Interest and Ability to Arrange Medically Necessary Services, 26 J. AMBULATORY CARE MGMT. 39 (2003).
30. HELEN H. SCHAUFFLER ET AL., CTR. FOR HEALTH & PUB. POLICY STUDIES, FIRST DO NO HARM: ACCOUNTABILITY AND HEALTH PLAN DECISIONS, POLICY ALERT (Feb. 1999) available at chpps.berkeley.edu/publications/Policy_Alert_Feb_99.pdf (last visited Mar. 29, 2004).
31. See Carole Roan Gresenz et al., Patients in Conflict with Managed Care: A Profile of Appeals in Two HMOs, 21 HEALTH AFF. 189 (July/Aug. 2002).
32. GERALDINE DALLEK & KAREN POLLITZ, INST. FOR HEALTH CARE RESEARCH & POLICY, EXTERNAL REVIEW OF HEALTH PLAN DECISIONS: AN UPDATE (May 2000), available at www.nysenior.org/News/reports/external%20review%20study%2000.pdf (last visited Mar. 29, 2004).
33. Frank Diamond, Dr. Do-Good and Mr. Bottom-Line, MANAGED CARE MAG., Dec. 2003, available at www.managedcaremag.com/archives/0312/0312.meddir.html (last visited Mar 29, 2004).
Linda Peeno is a Louisville, Kentucky, physician and consultant on corporate health care practices, managed care, and health care ethics.