Managed Care, Quality of Care, and Patient Rights Edward L. Fitzsimmons

Beverly J. Kracher Katie Woods

Creighton University Abstract The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no per- suasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.

Q �9 O

T he increasing business or market orientation of the system of health care delivery in the United States has been seen as a threat to the rights of indi- viduals for access to quality health care. The increasing market orientation

of the health care system is the result of government policies designed to control costs and promote competition among health care providers, and the increasing prominence of for-profit organizations in the health care system. These develop- ments have led to the replacement of a fee-for-service system of health care deliv- ery with managed care.

Folland, Goodman, and Stano have outlined the role of the federal government in the transition from a fee-for-service system of health care delivery to a system dominated by managed care.1 Prior to 1973 the policy of the federal government could be described as permissive. In this mode the courts and the Federal Trade Commission struck down various restrictions imposed by organized medical groups on physicians who might have otherwise participated in the prepaid group practice plans operating during those times. But concern about the rising costs of care associated with the fee-for-service delivery systems favored by organized medicine led to the passage of the Health Maintenance Organization (HMO) Act of 1973 which promoted the growth of federally qualified prepaid plans by offer- ing loan guarantees or grants to assist with startup costs, and required large firms operating in an HMO's service area to offer the HMO as a health benefit option.

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Public acceptance came slowly, but accelerated in the 1980s with the emergence of for-profit HMOs, preferred provider organizations, and other forms of man- aged care. As a result almost 85 percent of persons covered by employer spon- sored health plans are currently covered by some type of managed care plan. 2

The transformation of a fee-for-service health care system into a managed care system has brought changes in responsibilities, menus of choices, and incentives which have forced changes in behavior that have been a source of dissatisfaction among medical professionals and health care consumers. Under a fee-for-service system physicians had clinical responsibility for care but no fiscal responsibility. Patients had limited fiscal responsibility and almost unlimited choice. These responsibilities, combined with almost unlimited choice, created incentives for maximal if not excessive patient care and considerable protection of patient rights, but resulted in unacceptable rates of increase in the cost of care. Under managed care physicians have clinical responsibility subjected to fiscal con- straints. Fiscal responsibility of patients has increased and patient choices are limited by health plans. These changes in responsibilities and limitations on choice have limited health care cost increases in recent years but have also result- ed in plan-member dissatisfaction and pleas from the medical profession and con- sumer advocates that the federal government rein in the monster it helped create and protect the rights of patients enrolled in managed care plans.

It is the purpose of this paper to examine the nature of fight to health care and the nature of the rights claimed by health care consumers with a view to offering guidance to public policy. This purpose will be accomplished in the following order. First, a theory of health care rights will be proposed. Second, complaints voiced by health care consumers will be outlined and evaluated in light of the the- ory proposed and some of the factual data available on quality and access to care. Third, this evaluation will conclude with a recommendation for the general direc- tion of public policy for health care.

Theory of Patient Rights

Charles Dougherty provides a moral theory that can be employed to assess recent claims about patient rights. 3 He invites us to explore the question, "is there a fight to health care in a just society?" His answer includes a moral justification of the position that all persons have a right to health care and a description of a health care right as a core element of a bundle of four specific rights.

Defining the Question "Is There a Right to Health Care?" If there is a moral right to health care, it is an entitlement to health care. Dougherty explains that an entitlement is a way of securing equal moral standing for each person in a soci-

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ety. 4 A right to health care thus guarantees that a person gets moral health care equal to other persons. A moral right to health care can be interpreted as a nega- tive or positive right, respectively, a freedom against interference in living what- ever health style one sees fit or equal access to health care. Since every right has a corresponding duty, if a person has a right to health care then someone has a duty to provide the health care. Since no one can expect that others should pay for any and all of their health care costs, a right to health care must be a limited right. If a health care entitlement exists, Dougherty says, it is prima facie, that is, can be overridden by other moral considerations.

The Justification for a Right to Health Care Dougherty offers a pluralistic jus- tification for the right to health care. He convincingly combines the insights and arguments from four influential theories of justice; namely, utilitarianism, egali- tarianism, libertarianism and contractarianism to create a reasonable foundation for a moral right to health care.

Utilitarianism, Dougherty argues, focuses on maximizing good consequences. 5 Utilitarians use a cost/benefit analysis to demonstrate which alternative in a situ- ation maximizes good consequences. In the case of health care, a cost/benefit analysis determines the optimal health coverage arrangement for a society. Dougherty argues that establishing a right to health care is part of the optimal health care arrangement in a just society. It has the best chance of producing the greatest social good since it inevitably raises health standards and the happiness and pleasures of people.

Whereas utilitarianism focuses on the utility of an act or rule to create happi- ness, egalitarianism focuses on treating persons equally. 6 Since each person has intrinsic value, each person has basic rights equal to every other person; namely, the fight to respect as a person, the right to opportunity and liberty, and the right to basic goods necessary for life. In a just society, these rights can not be given up or set aside for utility. Dougherty shows how egalitarianism implies a right to health care. A right to health care expresses respect for persons and guarantees the equal opportunities and freedoms that come with good health. A right t o health care ensures that basic health needs are equally met for all. These health needs are defined negatively as those necessary for the relief of pain and suffer- ing, prevention of disabilities, and premature death.

Libertarianism opposes the notion that either happiness or human needs create moral rights. 7 Libertarianism focuses on personal freedom. The most important moral right is that persons must be free to reason things out on their own and make their own choices--the right to noninterference. Negative rights, that is, rights to be free from interference, are the only true rights. For the libertarian, a just society guarantees negative rights including the right to private property and

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its just acquisition. Owners should use private property as the owners see fit and not as redistributed by government according to some social plan. Since positive rights impose duties to do something or provide something, they violate the right to be free from interference. Libertarians do not acknowledge positive rights.

Dougherty shows that libertarianism is the only one of the four theories ofjus- rice that is typically understood to imply that there is no right to health care. Simply put, a right to health care violates basic rights to noninterference. A right to health care violates health-care professionals' freedom by taking away their choice to use the skills that are rightfully theirs in whatever way they see fit. A right to health care violates the liberty of citizens by requiring a public investment in health care.

But when we understand the complexity of libertarianism, Dougherty argues, we see that libertarianism can be used to defend a right to health care. Though libertarians claim that government should have a minimal role in our lives, they do contend that government should rectify past injustices. Since it is a fact that the general distribution of health care resources in the American society has been unjust, Dougherty argues that an appropriate government response to this injus- tice is to establish a right to health care for all.

Finally, Dougherty uses contractarianism to defend a right to health care. 8 According to this theory the principles of a just society are not derived from the concepts of utility, equality or freedom. Rawls, a contractarian, grounds morali- ty in the agreements made by rational, social persons. 9 A hypothetical decision- model called the original position is the tool used by contractarians to show how principles of justice would be agreed to by a group of rational, impartial and self- interested people. In the original position, people recognize that it is rational to maximize one's own minimum share of social goods--this makes their decision rational. They do not know particular things about who they will be once they get out into the world they are creating, e.g., race, gender, religion, etc.--this makes their decision impartial. They decide on principles of justice that they will actu- ally have to live by--this makes their decision self-interested. People in the orig- inal position know that there are natural differences among people; and they understand that it is possible that any one could be the least well off in society. Contractarians contend that any group of rational, impartial and self-interested individuals in the original position would agree to three principles. First, like the egalitarians and libertarians, they would agree to equal liberty for all. (Though unlike the libertarians they would not include private property rights in these lib- erties since anyone could end up the least advantaged, without property and with- out recourse against those better off.) Second, like the egalitarians, people in the original position would agree to equal opportunity for all. And finally, like the libertarians, they would agree to a difference principle, an unequal distribution of

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goods and services, in a just society. But unlike the libertarians the distribution must advantage the least well-off in the society. These principles of liberty, equal opportunity and difference are ordered in priority, as any rational person would agree.

Dougherty shows that a right to health care is implied by contractarianism. Rational, impartial, self-interested people would agree to a right to health care. Since they do not know whether they will be strong, disabled, have a heart con- dition, diabetes, etc., it is rational to assume that they could be the most unhealthy person in their society. Out of self-interest, any rational person would agree to guarantee a right to health care for everyone.

One possible contractarian interpretation of this fight to health care is a right to fair equal opportunity based on Rawls' second principle of justice. According to this interpretation, Dougherty explains, a right to health care is a positive moral right, that is, a fight to access health care for medical needs, just as the right to education is a positive moral right to access educational systems for educational needs. Medical needs are defined by Dougherty as those needs that ensure nor- real health functions, that is, the ability to formulate and pursue life plans typical of normal persons in society. Rational, impartial, self-interested people would agree to guarantee equal rights to health care necessary for attaining normal health functioning.

In summary, Dougherty shows that utilitafianism, egalitarianism, libertarian- ism, and contractarianism together create a reasonable foundation for a moral fight to health care. A right to health care has social utility, treats persons with equal worth, is a way of compensating for past health care system injustices, and would be agreed to by any group of rational, impartial, self-interested persons. The next question is, in what does the right to health care consist?

The Description of a Right to Health Care According to Dougherty, the right to health care is the core element of a bundle of four ordered rights. 10 He uses a modified contractarianism to articulate the right to health care, yet he includes the strengths from libertarianism, egalitarianism and utilitarianism to detail the specifics of the bundle. Dougherty modifies contractarianism to include a fourth principle, namely, a right to access a decent minimum share of the necessities of life. This right to minimum security is ordered after the liberty principle and before the opportunity and difference principles. Dougheny argues that any ratio- nal person would agree to it. No one would accept a difference in income and sta- tus unless by being made better off they are at least above a certain minimum stan- dard.

With this modification Dougherty contends that the fight to health care is com- posed of a group of four ordered rights consistent with the ordering implicit in the

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contractarian theory of justice. The first and most important principle of contrac- tarianism is equal liberty (noninterference) for all, which implies a negative right of health non-interference. This right, compatible with libertarianism, assures that all moral agents be given full information before they accept or reject the administration of offered medical procedures. Second in importance in this mod- ified contractarian scheme is the principle of minimum security which guarantees a universal right of equal access to a decent minimum level of health care. This right, reflecting elements of egalitarianism, would guarantee preventive and other types of basic care which society deems to be necessary and which society decides it can afford to provide to all its members. This positive right to basic care would extend to both those seen as curable and those seen as incurable. The type of care this right envisions would be described as less-technology intensive for the curable and for the incurable, palliative, thus reducing the problem of expense associated with universal care. Ranked third in importance is the princi- ple of fair equal opportunity. This principles guarantees a right to access health care designed to maintain or restore normal health functions when normalcy is a possibility, that is, the ability to formulate and pursue life plans typical of normal persons in society. But the principle of fair equal opportunity applies not only to health care but also to other processes contributing to the development of the human person for all members of a society. Thus, claims of resources for cura- tive health care might have to be limited if allocation of resources to curative health care interferes with a reasonable allocation of resources to meet other human needs for all members of a society. Such a limitation might be applied in strict utilitarian fashion so that the right to care would be operative only if treat- ment was assuredly effective and the individual's prognosis for return to, or main- tenance of, normalcy was very likely. Or the limitation could be applied using egalitarian principles to restrict treatment to certain types of illnesses or employ a lottery to select those treated. Sin taxes or higher deductibles or co-payments might also be employed, not to deny treatment, but to defer the costs of care required by those who voluntarily put their health at risk. Last in importance in a modified contractarianism, an application of the difference principle would allow those with greater wealth to purchase health care in addition to that provid- ed by right. Dougherty argues that this component violates strict egalitarianism but that all would gain if allowing the open market purchase of additional health care would facilitate the acceptance by society of the three previous components of the right to health care.

Dougherty's description of the right to health care was written in the context of a discussion of a society-wide guarantee of the right to care; so applying Dougherty's theory to evaluate the extent to which managed care plans respect the fight to health care requires some adaptation. Managed care plans can be evalu- ated according to the extent they respect the negative right of health non-interfer-

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ence. Likewise plans can be evaluated according to the extent they guarantee a minimum level of care to all members. However, apart from concerns that HMO's have withheld full information about treatment options, health care con- sumers generally have not complained about violations of these components of the right to health care by managed care plans. Nor have they complained about the plans' application of the difference principle. The major source of complaint has been the plans' application of Dougherty's third component of the fight to health care, the principle of fair equal opportunity; the principle which suggests that access to certain types of care may be limited without violating patient rights. Health care consumers have been most vocal in their complaints about the limi- tations imposed by managed care plans on relationships with physicians and the limitations on types of treatment judged medically necessary. These complaints have been revealed in public opinion polls and proposed congressional legisla- tion.

Health Care Consumer Complaints

A recent poll conducted by Wall Street Journal / NBC News is offered as a rep- resentative sampling of the opinion of health care consumers on managed care. 11 Pollsters randomly selected 2006 adults without regard to health plan participa- tion for telephone interviews about managed care. 12 Selected responses are shown in Table 1. With respect to the issues shown in the Table, respondents were asked, "Of the following issues, do you think HMOs have helped, hurt or have not made a difference?" In one way or another each of the items in the table can be associated with perceptions about the extent to which HMOs facilitate or limit access to care relative to fee-for-service health insurance, the dominant health plan prior to managed care. The responses can be classified into two groups: those expressing satisfaction with HMOs, and those expressing dissatisfaction.

A preponderance of respondents reported satisfaction with HMOs with respect to costs and coverage of preventive care and prescriptions. For example, 47 per- cent reported that HMOs have helped in keeping out-of-pocket expenses reason- able; whereas only 15 percent reported that HMOs have hurt health care users in this regard. Somewhat smaller proportions of respondents found HMOs helpful in the reduction of insurance premiums (37 percent), the control of health care costs in the aggregate (35 percent), and reducing paperwork (36 percent). HMOs were also seen as helpful in the provision of preventive care and prescriptions, by percentages of 45 and 44 percent, respectively.

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Issue

Table 1

Patient Opinion of Access to Health Care Provided By HMOs

Percentage of Respondents Who Reported HMOs:

Helped Made No Difference

Responses Suggesting Satisfaction

Keeping out-of-pocket expenses reasonable 47 20

Reducing insurance premiums 37 22

Keeping total U.S. health-care costs reasonable 35 28

Reducing paperwork patients must file 36 19

Providing preventive-care services 45 25

Coveting prescriptions 44 18

Hurt

15

19

23

25

16

19

Responses Suggesting Dissatisfaction

Informing patients about medical options 1 16

Patients having enough time with doctors 2 13

Access to specialists 2 22

Patient-doctor long-term relationship 2 14

Access to all available medical treatment 3 24

Doctors (not insurance administrators) 14 controlling treatment decisions 3

24

27

18

22

20

19

47

47

50

54

45

54

Wall Street Journal, June 24, 1998, AI4. 1Restrictions on information. 2Restrictions on relationships with physicians. 3Restrictions on treatments judged medically necessary.

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However, HMOs were criticized for limiting access to care in three ways: by restrictions on information, by restrictions on relationships with physicians, and by restrictions on treatments judged medically necessary. Forty-seven percent of respondents complained that HMOs restricted information about all medical options. Forty-seven percent felt that patients were allowed too little time with doctors; 50 percent complained about access to specialists, and 54 percent expressed concerns about patient-doctor relationships. Forty-five percent of respondents reported that HMOs had hurt access to all medical treatment avail- able, and 54 percent expressed concerns about restrictions on physician control of treatment decisions.

Consumer complaints about limitations on access to care like those just described have led to calls tbr government regulation to protect patient rights. Politicians have responded. No legislation passed the 105th Congress, but a Republican measure to strengthen consumer protections in managed care passed the House. This bill, summarized by Carey, responded to concerns about physi- cian-patient relationships by requiring plans to allow access to specialists not on approved lists of providers and to allow women and children to see gynecologists and pediatricians, respectively, as their primary care physicians. 13 The bill responded to concerns about informing patients of all medical options by pro- hibiting restrictions on physicians providing information to patients. The bill also addressed concerns about restrictions on treatment judged medically necessary by setting financial penalties for withholding medical care and mandating processes for appeals that increase patients' powers to challenge plan decisions about cov- erage.

Polling and proposed legislation strongly suggest that concern for patient rights is concern about patient access to information, limitations on doctor-patient rela- tionships, and restrictive medical-necessity determinations. The theory of patient rights proposed here would question restrictions on information made available to patients if it violated the negative right of health non-interference. But limitations on doctor-patient relationships and restrictive medical-necessity determinations are consistent with limitations on patients rights implied by the principle of fair equal opportunity which suggests that treatment may be withheld if not likely to be effective or that some types of treatment may be uniformly denied to all. The principle of fair equal opportunity permits a balance between health care needs and other human needs. Public opinion currently judges the balance struck by managed care plans to be biased in favor of other human needs. The public believes that managed care places too much emphasis on cost containment, and it is cost containment that conserves the resources of those paying health plan pre- miums-individuals, private employers and governments--tor allocation to other human needs. Indeed, Duff reported that 86 percent of those surveyed in the pre-

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viously reported Wall Street Journal/NBC News poll expressed the belief that HMO's and other forms of managed care are more concerned with controlling costs than with providing quality care. 14 Thus the source of concern about man- aged care and patient rights appears to be concern about the quality of care pro- vided. But what can be said about managed care quality'?

Quality of Managed Care

Evaluating managed care quality requires a base of comparison. Since public opinion generally objects to restrictions not present in fee-for-service health plans, the quality of care provided by fee-for-service plans is a convenient basis tbr comparison. Two papers written by Miller and Luft (1994, 1997), provide a review of clinical studies comparing the quality of care provided by both types of plans.

In their first paper they analyzed the findings of 54 studies which compared managed care and fee-for-service plans with respect to health care utilization, expenditure, level of premiums, use of preventive tests, procedures, quality of care, and patient satisfaction. Studies analyzed met the following criteria: 1) Data with ending dates of 1980 or later; 2) Private insurance or Medicare plan enrollees; 3) Control groups were used; 4) Reasonable attempt at statistical adjustment for non comparable managed care and fee-for-service enrollees; 5) Peer reviewed findings.15

Of these 54 studies 16 compared the quality of care received by patients. These 16 studies made 17 observations of the quality of care administered in treating a wide range of conditions or diseases, including congestive heart failure, colorec- tal cancer, diabetes, hypertension, cerebrovascular accident, and chronic problems like joint pain, chest pain, and urinary incontinence. In these studies 14 of 17 observations indicated either better or equivalent quality of care for managed-care enrollees relative to fee-for-service enrollees. Only two observations, both of which involved patients with mental problems, indicated results clearly unfavor- able for managed-care patients.

A more recent paper by the same authors reviewed 37 more recent studies not included in the first. 16 Once again the authors only analyzed those studies which compared results of treatment for enrollees in managed care and fee-for-service plans. All studies analyzed were peer reviewed and employed research designs that met requirements similar to those analyzed in the first study. Fifteen studies focused on quality of care. Findings painted a somewhat less favorable picture of the quality of care provided by managed care plans. Five of the studies found that the care provided by managed care plans was significantly worse than the care provided by fee-for-service plans. But the majority of the studies found that man- aged care was either significantly better or equivalent to the care provided by fee-

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for-service plans. As before, managed care provided better care in a wide range of conditions and diseases, including acute apendicitis, intensive care units, can- cer patients, and medicaid elderly.

The authors urge caution in interpreting their findings. They point out the need for more comprehensive studies. They note that studies in their more recent paper rely on data collected before 1993 and, thus, the need for more current analyses. But they unequivocally state that their findings do not support those who argue that the transition from fee-tbr-service to managed care has resulted in a general deterioration in the quality of care.

One analyst exercising the caution recommended by Miller and Luft is Sullivan. Noting that Miller and Luft's articles are the only two comprehensive reviews of the literature on managed care that have appeared in peer reviewed journals, he takes exception to their findings. Iv Re-examining Miller and Luft's work, he argues that eight of the studies of care quality reviewed by them should be excluded primarily because they did not control for differenccs in insurance coverage. 18 Since Miller and Luft found managed care quality either better than or equivalent to lee-for-service care quality in seven of the eight studies he excluded, Sullivan's assessment of managed care quality is less favorable than Miller and Luft's. He concludes that the quality of care provided by managed care is equivalent or interior to the quality of care provided by fee-for service health- care delivery systems.19

While Sullivan's critique raises questions about the quality of care provided by managed carc, it certainly does not provide conclusive evidence of a general dete- rioration in the quality of care. Blendon et al. agree and offer an explanation tbr the apparent contradiction between lack of evidence of a general deterioration in the quality of care and the public backlash against managed care. 2~ Relying on an analysis of twenty-one nation-wide public opinion surveys conducted between 1995 and 1997, Blendon et al. found that most Americans with managed care insurance coverage were satisfied with their own managed care plan. Yet they were more likely than those insured by a fee-for-service plan to be afraid that their managed care plan would fail to provide adequate coverage when they were seri- ously ill. Blendon et al. attribute this lear to two sources. First, a significant pro- portion of respondents insured by managed care plans report lack of satisfaction with aspects of care like waiting times and access to specialists and diagnostic tests. Second, continued media attention to the relatively few but dramatic fail- ures of managed care gives rise to fears of respondents that their plans will fail them when they really need medical care. Thus, it appears that the public back- lash against managed care is not based on a general deterioration in the quality of care unless one equates quality with consumer satisfaction with the processes whereby carc is delivered.

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But even though they have different views of managed care quality, both Miller and Luft and Sullivan agree consumer satisfaction is an aspect of health care dif- ferent from clinical quality, and both agree that consumer satisfaction and clinical quality should be analyzed separately. 21 When they are analyzed separately, even Davidson, who has developed a framework for analyzing the problems associat- ed with managed care plans, writes that there is little persuasive evidence demon- strating that managed care has been accompanied by a general deterioration in the quality of care. He notes that officials of managed care plans have made bad deci- sions. But he reminds us that "... errors and insensitivity to patients were part of the indemnity [fee-for-service] landscape as well, and in spite of the publicity, there is no evidence that either has increased substantially. ''22

Public Policy Recommendations

If there has been no general deterioration in the quality of care, it becomes more difficult to argue that government should intervene to redress the balance between the health care needs of plan members and other human needs for all members of society that have a claim on resources which might be allocated to health care. Perhaps managed care is operating within the pale of the principle of fair equal opportunity. If reforms of our health care system are to be justified by claims of violation of patient rights, it is difficult to claim that the principle of fair equal opportunity has been violated; and thus it is difficult to claim that restrictions on doctor-patient relationships and restrictive medical-necessity determination have violated patient rights. We must look for violations of other components of the right to health care.

Recalling the priority of rights within the right to health care proposed in this paper, we remember that the negative right of health non-interference has prima- cy. We had put aside discussion of this right since the major source of complaint about managed care is a violation of the principle of equal opportunity. However, a second type of complaint noted in the Wall Street Journal/NBC poll is restric- tion on information about all medical options. Public policy makers should inves- tigate these managed care plan restrictions and fashion appropriate regulation because restrictions on patient access to information violate the right of non-inter- ference. Patients must have full information so they can freely accept or reject the administration of medical procedures offered. Though a discussion of "full infor- mation" is outside the scope of this paper, it may be possible to frame a definition based on Holley's theory of acceptable market exchange where knowledge, non- complusion and rationality are conditions of voluntary choice. 23

Second in priority is the universal right of access to a decent minimum level of care. This right has been largely ignored in the current debate over patient rights,

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and in doing so the debate has largely ignored the rights of 43.4 million people in the United States who lack health insurance. 24

Absent changes in public policy, continued growth in the number of uninsured is expected in the future. 25 If anything, government mandated easing of restric- tions on doctor-patient relationships and medical-necessity determination prac- ticed by managed care plans will increase health plan premiums and thereby accelerate the growth in the numbers of the uninsured. Given the theory of health care fights presented here, justice requires that public policy makers address the right of the uninsured to a decent minimum level of care before they attempt to fine tune managed care plan restrictions on doctor-patient relationships and med- ical-necessity determinations.

Summary and Conclusions

It has been the purpose of this paper to examine the nature of right to health care and the nature of the rights claimed by health care consumers with a view to offer- ing guidance to public policy. This purpose was accomplished in three steps. First, a theory of health care fights was proposed. Second, the rights claimed by consumers of health care were outlined and evaluated in the light of the theory proposed and some of the factual data available on quality and access to care. Third, this evaluation led to the conclusion that health policy reforms should address rights to information and universal access to some minimum level of care before attempting to regulate doctor-patient relationships and medical-necessity determination. Priofitizing public policy goals in this way may not be politically expedient but would more fully respect patient rights.

Notes

1. Folland, et al., 274-275.

2. Smith et al., 138.

3. Dougherty, 115-132. Here, Dougherty pulls together his framing of the ques- tion and discussion of utilitarianism, equalitarianism, libertarianism, and contrac- tarianism developed in previous chapters to produce a description of the right to health care.

4. Ibid, 23-34.

5. lbid, 35-50.

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6. lbid, 51-68.

7. lbid, 69-91.

8. lbid, 92-114.

9. Rawls, 11-22.

10. Dougherty, 125-127.

11. Anonymous, Wall Street Journal, Data were extracted from graph titled "The hnpact of HMOs," AI4. Commentary on data was written by authors of this paper.

12. The poll was conducted June 18 through June 21, 1998 by the polling orga- nization of Peter D. Hart and Robert Teeter. The sample was taken from 520 regions selected at random from the continental United States. The number of households selected in each region was proportionate to the region's share of the population. Households with either listed or unlisted telephone numbers had an equal chance of selection. One adult in each household was selected for inter- viewing in a way that insured that genders were represented proportionally. A I2.

13. Carey (1998), 1754. Writing a year later Carey (1999) noted that in thel06 th Congress both House passed HR 2990 and Senate passed S 1344 address the same concerns. For example HR 2990 responds to concerns about physician-patient relationships by mandating that women in plans covering obstetrical and gyneco- logical care be allowed to visit those specialists without a referral from their pri- mary care physician. Parents would also be allowed to designate a pediatrician as their child's primary care physician. Concerns about withholding information are addressed by prohibitions of health plan restrictions on doctors discussing all treatment options, even those not covered by the plan. Finally, concerns about medical necessity determinations are addressed in four ways. The bill requires that doctors, not health plan officials, determine what treatments are medically necessary. This requirement is reinforced by mandated processes for internal and external appeal and by allowing plan members harmed by denial of care to sue for damages in state courts.

14. Duff, A9.

15. Miller and Luft (1994), 1512-1519.

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Managed Care, Quality of Care, and Patient Rights

16. Miller and Luft (1997), 7-25.

17. Sullivan, 1003.

18. Ibid, 1005�9

19. lbid, 1007.

20. Blendon et al., 90-92.

21. Sullivan, 1004.

22. Davidson, 1051.

23. Holley, 508-514.

24. U.S. Department of Commerce, 1.

25. Smith et al., 133.

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