Managed Care Quality: Hearing Before the Subcommittee on Health and Environment of the Committee on Commerce, House of Representatives, One Hundred Fifth Congress, First Session, October 28, 1997, Volume 4

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Page 35 - NCQA's mission is to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health care purchasing decisions.
Page 189 - While on the one hand, this serves the valid goal of ensuring that the plans' resources are not depleted by flurries of litigation, on the other, it leaves mistreated members with little or no recourse. The Corcoran court suggested that change might be in order: [T]he world of employee benefit plans has hardly remained static since 1974. Fundamental changes such as the widespread institution of utilization review would seem to warrant a reevaluation of ERISA so that it can continue to serve its noble...
Page 173 - Third party payers of health care services can be held legally accountable when medically inappropriate decisions result from defects in the design or implementation of cost containment mechanisms, as, for example, when appeals made on a patient's behalf for medical or hospital care are arbitrarily ignored or unreasonably disregarded or overridden.
Page 171 - ERISA's statutory scheme compelled the conclusion that the parents have no remedy, state or federal, for what may have been a serious mistake." For this reason, the court urged Congress to reevaluate the scope of ERISA preemption in order to protect the interests of employees. The PARCA amendment would serve this purpose and ensure that the unjust result in Corcoran is not repeated.
Page 136 - Its promise is to save money and provide more effective care through better coordination of services and a strong emphasis on preventive and primary care. Managed care plans are also uniquely positioned to educate millions of women and men about how to get and stay healthy. Women, especially, stand to benefit from managed care done right. A quality managed care plan can make it easier for women to learn about and obtain services such as mammograms, Pap smears, and prenatal care, as well as health-promoting...
Page 173 - The patient who requires treatment and who is harmed when care which should have been provided is not provided should recover for the injuries suffered from all those responsible for the deprivation of such care, including, when appropriate, health care payers.
Page 96 - Act; or upon the express consent of the enrollee or applicant; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of claim or litigation between such person and the health maintenance organization wherein such data or information is pertinent.
Page 39 - Committee believes that an important objective of a good managed care plan should be to help members become active partners in their health care decisions. To do so means that the health plan must equip members to make informed choices about their care. The Committee's objective in defining this domain was to develop measures that would assess how effectively health plans accomplished that result. • Use of services: How a health plan uses its resources is a signal of how efficiently care is managed...
Page 37 - A set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma, and diabetes. HEDIS also includes a standardized survey of consumers...
Page 189 - The result ERISA compels us to reach means that the Corcorans have no remedy, state or federal, for what may have been a serious mistake. This is troubling for several reasons. First, it eliminates an important check on the thousands of medical decisions routinely made in the burgeoning utilization review system.

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