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Vernellia R. Randall, Managed Care, Utilization Review, and Financial Risk Shifting: Compensating Patients for Health Care Cost Containment Injuries , 17 University of Puget Sound Law Review 1 (Fall, 1993) (Footnotes) (Full Document)


Table of Contents

Prelude, p.3

I. Introduction. p. 6

II. Historical Background. P. 9
A. Overview of Historical Development. p. 10

  1. From Home to Hospital. P. 10
  2. The Coming of the Blues. P. 11
  3. World War II and Beyond. P. 12
  4. Medicare and Medicaid. P. 13

B. Impact of Third-Party Payers on Health Care. P. 14

C. The Development of Managed Care Products. P. 19

  1. Health Maintenance Organizations. P. 20
  2. Preferred Provider Organizations. P. 22

D. Summary. P. 24

III. Third-Party Cost Containment Measures, p. 26

A. Utilization Review. P. 27

  1. Utilization Review Defined. P. 27
  2. Utilization Review Structure. P. 28

B. Strict Enforcement Through Financial Risk Shifting. P. 30

C. Effects of Cost Containment Measures on Health Care. P. 32

  1. Assuring Quality Care in the Managed Care Product. P. 33
  2. Maintaining the Ethical Basis of Health Care. P. 36
  3. Maintaining Access to Health Care. P. 38

D. Summary. P. 40


IV. Traditional Theories of Liability. P. 41
A. Negligence (or Direct Liability) for Injuries Caused by Cost Containment Measures. P. 42
B. Corporate Negligence Doctrine. P. 48
C. Respondent Superior Doctrine. P. 53
D. Ostensible Agency Doctrine. P. 55

  1. Boyd v. Albert Einstein Medical Center. P. 58
  2. Williams v. Good Health Plus. P. 60
  3. Analysis of Boyd and Williams. P. 62

E. Summary. P. 65


V. ERISA as a Barrier to Compensation for Injuries. P. 65
A. Background. P. 66
B. Corcoran v. United HealthCare. P. 68

VI. The Medical Injury Compensation Fund-A Proposal. P. 73
A. Problems with the Tort System. P. 73
B. Elements of a Medical Injury Compensation Fund. P. 76

  1. Defining Compensable Medical Injuries. P. 77
  2. Compensation. P. 78
  3. Financing the Fund. P. 78
  4. Duty of Public Notice. P. 79
  5. Exemptions. P. 79
  6. Attorney's Fees. P. 79

C. Problems of a Medical Injury Compensation Fund. P. 80

  1. Fiscal Stability. P. 80
  2. Fraud, Abuse, and Malingering. P. 81
  3. Constitutionality. P. 81
  4. Political Feasibility. P. 82

D. Benefits and Consequences of a Medical Injury Compensation Fund. P. 82

  1. Reduced Administrative Costs. P. 82
  2. Increased Participation. P. 83
  3. Reduced Monetary Recovery. P. 83
  4. Greater Spread of the Cost of Managed Care Injuries. P. 84

E. Summary. P. 84

VII. Conclusion. P. 84