Legal implications of managed care arrangements

Prior to the 1980s, managed care was virtually nonexistent as a force in health care. Presently, 64 percent of employees in America are covered by managed care plans, including health maintenance organizations (20 percent) and preferred provider organizations (44 percent). In contrast, only 29 percent of employees were enrolled in managed care plans in 1988 and only 47 percent in 1991. To date, the primary reason for this incredible growth in managed care has been economic-market pressure to reduce health care costs. For the foreseeable future, political pressures are likely to fuel this growth, as managed care is at the center of President Clinton's national health care plan. Although there are numerous legal issues surrounding managed care, this article focuses primarily on antitrust implications when forming managed care entities. In addition, the corporate practice of medicine doctrine, certain tax issues, and the fraud and abuse laws are discussed.     

Community rating--an approach that works

How our current system works and what changes need to be made are the subjects of intense scrutiny by policy makers today. One of the primary areas of concern with our present health care system is its accessibility to the average American, in terms of both price and ability to obtain insurance. With an estimated 37 million Americans without health care insurance, and countless others severely underinsured, this issue will lie at the core of any health care reform that results from the current debate. One possible approach to the uninsured problem that might alleviate the situation is community rating.     

Employment-based health benefits: analysis of the April 1993 Current Population Survey

The April 1993 CPS differs from the March 1993 CPS in a number of respects. The April 1993 CPS supplement surveys only workers, whereas the March CPS examines the noncash benefits received by all Americans. The April CPS asks workers about health coverage in the week in which the questions were fielded, whereas the March CPS asks about coverage in the preceding year. In April 1993, there were 112.5 million civilian American workers between the ages of 18 and 64 with jobs. Eighty-two million (73 percent) of them worked for an employer that sponsored a health insurance plan, and 65 million (58 percent of all workers) participated in their employer's health plan. About one-third of workers at firms with fewer than 10 employees had employers who offer health benefits; about one-quarter of all of the workers in these firms participated in their employer's plan. Conversely, 94 percent of workers at firms with more than 1,000 employees had an employer who sponsored health benefits, and over 77 percent of these workers participated in their employer's plan. There are 16.5 million American workers whose employers sponsored health benefits but who did not participate in these benefits. Over one-half of these workers (8.5 million) chose not to be covered. Another 36 percent of these workers (5.9 million) did not participate because they were ineligible or denied coverage. Over 66 percent of the ineligible workers did not participate because they were part-time, contract, or temporary workers. Another 26 percent had not yet completed a probationary period. Among the reasons that those who chose not to participate in their employer's coverage, the vast majority (75 percent) stated they were covered by another health care plan. Twenty-nine percent stated that they chose not to purchase coverage because it was too costly or that they did not need or want the coverage. In 1993, there were 16.7 million workers with no health insurance coverage. The vast majority of these workers (95 percent) were employed by private employers. Sixty-six percent of the workers with no health insurance coverage were self-employed or worked for firms with fewer than 100 employees.     

Interrupted stories, interrupted lives

In attempting to manage their practices efficiently, doctors may not allow seriously ill patients enough time to sort out their feelings and raise important questions. What is at stake here is not information about prognosis and treatments but the very survival of the soul.     

The model of place utility revisited

"The purpose of this paper...is twofold: first, to specify a way of calculating place utility so that potential migrants could move to the place where overall place utility is maximized; and second, which is more important, to reveal how decision-makers in the real world, who are acting within 'bounded rationalities'...,make their decisions on where to migrate. This study is supported by an empirical survey of recent Chinese immigrants to Edmonton [Canada].... The findings reveal that when people evaluate different places, they do not necessarily look for the one that generates the highest overall value or utility across all properties.... The study further indicates that the assumption underlying most microeconomic models (that maximizing utility or benefit is the ultimate rule for choosing one location out of several) has not been verified." (SUMMARY IN FRE AND SPA)     

DO RESPONDENTS REALLY "MARK ALL THAT APPLY" ON SELF-ADMINISTERED QUESTIONS?

An experiment was conducted to assess the effect of using "markall that apply" question instructions on survey reporting aspart of the field test for the Second Follow-up of the NationalEducation Longitudinal Study of 1988 Eighth Graders (NELS:88).Mark-all-that-apply instructions were compared with instructionsasking respondents to indicate "yes" or "no" to each responseoption on responses to three items dispersed throughout thequestionnaire and consisting of different topics and numbersof response options. For the three items, significantly fewerresponse options were selected with the mark-all-that-applyinstructions than with the yes/no instructions, but becauseexternal validity criteria were not available, overreportingto the yes/no instructions cannot be ruled out. Instructiondependentprimacy effects, predicted under the hypothesis that respondentswould engage in more superficial processing when given the mark-all-that-applyinstructions, were not found.     

The impact of migration on gender roles: findings of field research in Turkey

Findings are based on a sample of four types of Turkish women affected by migration: 1) pioneer women who emigrated on their own (33 persons); 2) followers with wage work experience, who joined or left with husbands (44 persons); 3) followers without wage work experience (39 persons); and 4) women left behind when husbands migrated (45 persons). These women are compared to a non-migrant control group (54 persons). Sample surveys were conducted in three sites, which varied in levels of industrial development, economic diversification, and urbanization (Ankara, Kisehir, and eight rural villages in the province of Kisehir). The sample includes returnees registered with the Social Insurance Institute and persons located by the chain inquiry method. Prior research supports the importance of including typologies based on family types, marriage types, levels of education, and experience with wage work. This study confirms that pioneer women were more likely to have romantic marriages, to have nuclear families, to have higher educational levels, and to have prior wage work. Analysis of the 116 women with migration experience shows that 75% migrated during 1968-74. 22% migrated after 1980. 51% were returnees during 1983-85, and many received retirement benefits. Almost 65% spent 10 or more years abroad. 56% were aged under 24 years. 85% were married at the time of emigration. 61% viewed their migration experiences as improving their maturity and ability to handle affairs compared to nonmigrant women. 88% became housewives after returning. 27% of return migrants and 82% of nonmigrants had never had their own bank accounts. 69% of return migrants and only 22% of nonmigrants reported movement outside the home without permission. 63% of migrants and 39% of nonmigrants would cast political votes independently of their husbands. Migrating women exercised more independent behavior but retained traditional responsibility for housework. The greatest differences were between women with wage work and women without or with migrating husbands. Followers without wage work were the most disadvantaged. Migration is viewed as a significant factor in determining gender roles among Turkish women.     

Gambling and the Law®: Endless fields of dreams

This article examines the current trends of proliferation of commercial gaming, especially in the United States, in the context of the third wave of legalization of gambling that has been experienced since the founding of the nation. The author looks at the historic foundations of the spread of casino-style gambling, and notes the types of casino gaming that have led the way in the current expansion. He also points out why it is reasonable to expect that this wave too may come crashing down, as general acceptance of wide-spread casino gaming in America may indeed be short-lived.Gambling and the Law^® is a registered trademark of I. Nelson Rose.     

Corporate compliance programs: risk management for the future

The Department of Justice has estimated that the government loses $100 billion annually in health care fraud. Consequently, the government's health care fraud enforcement activities with respect to all health care providers and suppliers continue to grow. Last year alone, the government collected more than $8 billion in settlements, fines, and penalties involving health care fraud. Recent settlements with the government have begun to include corporate compliance programs that require continued government oversight of the health care organization as an essential part of the settlement. The first section of this article describes the legal significance of health care companies' having corporate compliance programs. The second section provides a sample list of topics that should be included in any corporate compliance program. Finally, we describe various issues related to the creation and implementation of corporate compliance programs.