Managed Care Patient Protection or Provider Protection? A Qualitative Assessment

American Journal of Medicine--December 2004
Vol. 117, No. 12
December 2004
Hall, M.A.
pp. 932-7

Opponents of managed care regulation allege that a patient’s bill of rights, in reality, represents provider protections motivated by the desire to curtail the economic onslaught of managed care. This claim is assessed through a large qualitative study of state managed care patient protection laws.

State laws were reviewed and categorized, and regulators in each state were surveyed, to determine the pattern and content of relevant enactments as of the end of 2001. In 2002, six states were selected for in-depth case studies to reflect a range of market, demographic, and legal characteristics. In each state, 16 to 24 key informants were interviewed, including provider advocates, physician practices, health plan managers, regulators, patient advocates, and various industry observers. Additional interviews were conducted from a national perspective, for a total of 138 interviews. Interviews were semistructured, and interview notes were analyzed using qualitative techniques.

These laws are directed primarily to patients’ rights and only secondarily to providers’ interests. Enactment of these laws was rarely attributed primarily to provider advocacy. Instead, providers aligned with consumers, or the impetus came from legislators or regulators. There was little evidence that these laws, collectively or individually, have had much effect on providers’ economic concerns. Health plans are still free to form and shape networks as they see fit, subject to competitive constraints. Provider due process laws might suppress deselection to some extent, but most subjects thought these laws only marginally restrain health insurers from removing providers who they no longer want.

Managed care patient protection laws do not advance a self-interested provider agenda that disables features of managed care that are beneficial to consumers. Instead, these laws appear to embody a convenient alignment of interests among providers, patients, and lawmakers.

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