9781587781803

Law and the American Health Care System

by ; ;
  • ISBN13:

    9781587781803

  • ISBN10:

    1587781808

  • Format: Paperback
  • Copyright: 2001-06-01
  • Publisher: Foundation Pr

Note: Supplemental materials are not guaranteed with Rental or Used book purchases.

Purchase Benefits

  • Free Shipping Icon Free Shipping On Orders Over $35!
    Your order must be $35 or more to qualify for free economy shipping. Bulk sales, PO's, Marketplace items, eBooks and apparel do not qualify for this offer.
  • eCampus.com Logo Get Rewarded for Ordering Your Textbooks! Enroll Now
List Price: $37.00 Save up to $9.25
  • Buy Used
    $27.75

    USUALLY SHIPS IN 2-4 BUSINESS DAYS

Supplemental Materials

What is included with this book?

Summary

This title updates the original health care law casebook with new material on managed care, ERISA, and other judicial and legislative developments in the field. The complete set covers all major aspects of law and the American health care system.

Table of Contents

Preface iii
Roadmap xvii
Table of Cases
xix
Introduction: Law and American Health Care Delivery 1(1)
The Rise and Crisis of Provider-Dominated Health Care
1(2)
The Impact of the Market on Professional Authority: The Case of Drug Testing
1(1)
The Predicted Sharp Rise in Health Care Costs, 1998--2007
2(1)
Conflicting Values in American Health Care
3(3)
Health and Social Inequality
3(1)
The Market Competition Model
4(1)
The Nature and Future of American Health Care Policy
4(1)
Conclusion
5(1)
Access to Health Services
6(79)
Introduction
6(5)
Barriers to Access
6(1)
Lack of Health Insurance
6(4)
The Consequences of Being Uninsured
10(1)
Other Barriers to Access
10(1)
The Ambivalent Tradition of the Common Law
11(1)
The Impact of EMTALA on Childbirth as an Emergency
11(1)
Examination and Treatment for Emergency Medical Conditions and Women in Labor (``EMTALA'')
11(37)
The Hill Burton Act
12(2)
The Text of EMTALA (42 U.S.C. § 1395dd)
14(5)
Not Only the Poor and Uninsured
19(1)
Defining Duties under EMTALA
20(1)
The Duty to Screen
20(3)
Notes and Questions
23(1)
The Duty to Stabilize
24(1)
Howe v. Hull
24(3)
Roberts v. Galen of Virginia
27(1)
Notes and Questions
28(2)
Must the Patient Come to the Emergency Room?
30(4)
State Malpractice Limitations
34(8)
Notes and Questions
42(1)
Federal Administrative Enforcement of EMTALA
43(1)
EMTALA, Health Care Reform and Managed Care
44(1)
Medicare+Choice and Coverage of Emergency Care
44(2)
OIG/HCFA Special Advisory Bulletin on the Patient Anti-Dumping Statute
46(2)
Notes and Questions
48(1)
Tax Exemption and Access to Care
48(1)
Antidiscrimination Law and Access to Medical Care
48(37)
Racial Discrimination
48(6)
Discrimination Against People with Disabilities
54(2)
Defining ``Disability'' and ``Direct Threat to the Health and Safety of Others''
56(1)
Bragdon v. Abbott
56(15)
Notes and Questions
71(3)
Sutton v. United Air Lines, Inc.
74(5)
Institutional and Physician Liability Under the ADA and Federal Rehabilitation Act
79(1)
Howe v. Hull
79(3)
Notes and Questions
82(3)
The Financing and Organization of Health Care
85(547)
Private Insurance Coverage and State Law
85(7)
Introduction to Coverage
85(1)
State Regulation of Private Health Insurance
85(1)
State Tort Law: Bad Faith Breach of Contract
85(1)
Wohlers v. Bartgis
85(5)
Notes and Questions
90(2)
Private Health Plan Coverage and Federal Law: The Origins and Development of Erisa Preemption
92(63)
Introduction to ERISA: Background, Mandated Benefits, and Legislative History
92(1)
ERISA: An Analytic Overview
92(10)
The Statutory Text of ERISA Preemption
102(1)
ERISA § 502(a), 29 U.S.C. § 1132(a) (Civil Enforcement)
102(1)
Judicial Interpretation of Preemption and the ERISA Regulatory Vacuum
103(1)
State Common Law Remedies, The Insurance Savings Clause, and the Preemptive Force of the Civil Remedies Provision, ERISA § 502
103(1)
Pilot Life Insurance Co. v. Dedeaux
104(8)
Notes and Questions
112(1)
Problem
112(1)
Reinsurance or ``Stop-Loss Insurance,'' the Insurance Savings Clause, and the Deemer Clause
113(1)
``Relate to Any Employee Benefit Plan''
113(1)
New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Insurance Company
113(9)
Notes
122(2)
California Division of Labor Standards Enforcement v. Dillingham Construction
124(3)
De Buono v. NYSA-ILA Medical and Clinical Services Fund
127(4)
Boggs v. Boggs
131(4)
Reinsurance or ``Stop-Loss Insurance,'' the Insurance Savings Clause, and the Deemer Clause
135(2)
American Medical Security, Inc. v. Bartlett
137(6)
Notes and Questions
143(2)
Michigan Affiliated Healthcare System, Inc. F/k/a Lansing General Hospital v. CC Systems Corp. of Michigan
145(1)
The Insurance Savings Clause and § 502 Revisited
146(1)
UNUM Life Insurance Company of America v. Ward
146(6)
Notes and Questions
152(3)
Private Health Plan Coverage and Federal Law: Process Rights, Fiduciary Duties, and Plan Amendments Under Erisa
155(14)
ERISA Provisions: Plan Duties and Individual Rights
155(1)
Fiduciary Duties
155(1)
The Fiduciary Duty of Disclosure and the Debate Over ``Equitable Relief'' to Individuals
156(1)
Eddy v. Colonial Life Insurance Company of America [Eddy I]
156(3)
Notes
159(5)
The Uncertainty of Attorney's Fees under ERISA
164(1)
Eddy v. Colonial Life Insurance Company of America [Eddy II]
164(3)
Notes and Questions
167(2)
Plan Amendment and Reduction of Benefits
169(1)
AIDS, Health Insurance, and ``Fair Discrimination''
169(1)
Private Health Plan Coverage and Benefit Denials: Determining Health Plan Obligations under Federal and State Law
169(44)
Benefit Determination: The Standard of Judicial Review under ERISA
169(1)
The Jurisprudence of Claiming Benefits Under ERISA
169(4)
The Ambivalence of Firestone Tire & Rubber Co. v. Bruch
173(1)
Cutting v. Jerome Foods, Inc.
174(3)
Ascertaining Whether an ERISA Plan Grants Discretion to the Fiduciary
177(1)
Martin v. Blue Cross & Blue Shield of Virginia, Inc.
177(2)
Doe v. Travelers Insurance Company
179(1)
Insurer or Administrator Conflict of Interest and the ERISA Standard of Review
180(1)
Armstrong v. Aetna Life Insur. Co.
181(1)
Killian v. Healthsource Provident Administrators, Inc.
182(5)
``Full and Fair Review,'' ERISA Procedural Rights, and the ERISA Standard of Review
187(1)
Crocco v. Xerox Corp.
187(7)
Notes and Questions
194(2)
Exclusions of ``Experimental'' and ``Not Medically Necessary'' Treatments: High Dose Chemotherapy and Bone Marrow Transplants for Advanced--Stage Breast and Other Cancers
196(1)
The Dangers of ``Unilateral Discretion'' and ``Science'' Conflict of Interest, Objectivity, and Consistency
196(1)
``Clinical Trials,'' ``Medical Research,'' and Specific Exclusions
196(1)
The Role of Payers/Insurers/Health Plans
196(1)
The Impact of Deferential Review on Litigation About Coverage Exclusion of HDCT for Breast Cancer
197(1)
Healthcare America Plans, Inc., v. Bossemeyer
197(7)
Notes and Questions
204(4)
New Scientific and Legislative Developments Regarding Coverage Exclusions on Grounds of Experimental Care and Medical Necessity, Particularly with Respect to Breast Cancer
208(1)
Study Results Released in April 1999
208(2)
Legislation and Consensus-Building About Insurance Coverage of Clinical Trials
210(1)
Legislation, Fierce Struggle, and the Hope of Consensus Around the Definition of ``Medical Necessity'' in Private Health Insurance
211(2)
Federal Regulation of Employee Health Benefit Plans
213(33)
Continuation Coverage: COBRA
213(1)
COBRA Continuation in the Courts
213(1)
Access to Group and Individual Insurance Coverage for Persons with Preexisting Conditions: The Health Insurance Portability and Accountability Act of 1996
214(1)
The Structure and Impact of HIPAA
214(3)
HIPAA Privacy Rules and the Bush Administration Agency Directive on Regulations
217(3)
Notes
220(1)
Federal Antidiscrimination Law and Health Insurance: the Americans with Disabilities Act (ADA)
221(1)
What Is a ``Disability''?
221(1)
Who is a ``qualified individual with a disability''?
221(1)
Ford v. Schering-Plough Corporation
221(2)
Cleveland v. Policy Management Systems Corp.
223(2)
Notes and Questions
225(1)
What Kinds of Entities Can Be Sued Under the ADA?
226(1)
Carparts Distribution Center, Inc. v. Automotive Wholesaler's Ass'n of New England, Inc.
226(1)
Lee v. California Butchers' Pension Trust Fund
227(2)
Does ADA Title III Reach the Content of Insurance Policies, or Only Guarantee Physical Access to ``Insurance Offices''?
229(3)
Parker v. Metropolitan Life Insur. Co.
232(1)
Note
232(1)
What is ``Discrimination'' under the ADA in Health Insurance Coverage?
232(1)
What constitutes ``disability-based discrimination'' in health insurance under Titles I and III of the ADA, in the light of the ``insurance safe harbor'' provisions, ADA § 501, 42 U.S.C. § 12201?
232(1)
Carparts Distribution Center, Inc. v. Automotive Wholesaler's Ass'n of New England, Inc.
233(2)
Krauel v. Iowa Methodist Medical Center
235(1)
Public Employees Retirement System v. Betts
236(1)
Modderno v. King
236(1)
Doe v. Mutual of Omaha Insurance Company
237(9)
Notes and Questions
246(1)
Medicare
246(4)
National Coverage Decisions and Local Medical Review Policies Regarding New Technologies or Procedures
246(1)
Judicial Review of National Coverage Decisions
246(1)
Bosko v. Shalala
247(2)
Note
249(1)
Medicaid
250(22)
Eligibility for Medicaid: Who Should Be Excused From the Full Risk of the Market?
250(1)
Impact of the Balanced Budget Act of 1997
251(1)
Medicaid Coverage Limitations: The Paradoxes of ``Non-Discriminatory'' Rationing
251(1)
Rodriguez v. City of New York
251(7)
Notes and Questions
258(2)
The Entitlement Debate Revisited: The Meaning of Mandatory Requirements for State Plans
260(1)
Wilder v. Virginia Hospital Association
260(1)
The Repeal of the Boren Amendment by the Balanced Budget Act of 1997
261(1)
When Should Federal Statutes Create Enforceable ``Rights''?
261(1)
Blessing v. Freestone
262(2)
Notes and Questions
264(2)
Medicaid Reforms Through Legislative and Agency Action: A Dated Statute and Competing Visions of Change
266(1)
National Governors Association: Health Reform Proposals (February 2001)
267(5)
Notes and Questions
272(1)
Reimbursement of Health Care Providers
272(8)
Paying Hospitals
272(1)
State Efforts to Regulate Hospital Reimbursement
272(1)
Federal Attempts to Regulate Hospital Reimbursement
273(1)
Nothing Succeeds as Planned: The Shortcomings of Medicare Hospital Payment Controls
273(1)
Reimbursement and Uncompensated Care
274(1)
Payment to Physicians
274(1)
Medicare and Private Insurance
274(1)
Assignment and Balance Billing Rules Governing Physician Services
274(3)
Medicaid Reimbursement of Physician Services
277(1)
Graduate Medical Education Financing: The Role of Provider Reimbursement
278(1)
Patient Care Reimbursement in a Teaching Context
278(1)
Graduate Medical Education Payment and Congressional Reform
279(1)
Reimbursement for Care Furnished by Foreign Medical Graduates
279(1)
The Continuing Transformation of Managed Care
280(249)
Introduction
280(1)
The Transformation of Medicaid to Managed Care
281(2)
Medicaid Managed Care: The Early Years (1965-1976)
283(3)
Medicaid Managed Care: 1976-present
286(5)
The Transformation of Medicare to Managed Care
291(1)
Medicare Managed Care: The 1970s and the TEFRA Amendments
292(1)
Reforming Medicare Managed Care and its Consequences
293(2)
The Structure and Limits of State Regulation of Managed Care
295(5)
Managed Care Financial Incentives: Disclosure and Regulation
300(1)
The Shift in Financial Incentives from Overtreatment to Undertreatment
300(1)
The Legal Contexts of Financial Incentives in Health Care
301(2)
Disclosure of Managed Care Financial Incentives
303(1)
Does ERISA preempt state statutes and doctrinal law that might require health plans, HMOs or other entities to disclose managed care financial incentives?
303(1)
Anderson v. Humana, Inc.
303(2)
Notes and Questions
305(1)
Does ERISA's fiduciary duty require health plan or HMO disclosure of managed care financial incentives?
306(1)
Shea v. Esensten (Shea I)
306(2)
Notes
308(1)
Weiss v. Cigna Healthcare, Inc.
309(2)
Notes
311(1)
Drolet v. Healthsource, Inc.
311(2)
Peterson v. Connecticut General Life Insurance Company
313(1)
Does the ERISA statute or regulations require ERISA Plans, or HMOs and other managed care entities, to disclose managed care financial incentives?
314(1)
Does ERISA preempt a state law action against a physician for failing to disclose managed care financial incentives?
314(1)
Shea v. Esensten (Shea II)
314(4)
Does state law provide a cause of action against (a) a physician and/or (b) an HMO or other managed care entity for failure to disclose managed care financial incentives?
318(1)
Shea v. Esensten (Shea III)
318(2)
Does state law otherwise require a HMOs or other entities or physicians to disclose managed care financial incentives?
320(1)
The Use of Managed Care Financial Incentives
320(1)
Does ERISA's fiduciary duty prohibit or regulate the use of managed care financial incentives?
320(1)
Pegram v. Herdrich
320(14)
Notes and Questions
334(3)
Does state law prohibit or regulate the use of managed care financial incentives?
337(1)
Texas Insurance Code Article 20A.14 (2000)
337(1)
Texas v. Aetna U.S. Healthcare, Inc.
338(4)
Neade v. Portes
342(6)
Does the ADA regulate the use of managed care financial incentives?
348(1)
Zamora-Quezada v. Health Texas Medical Group of San Antonio
348(9)
Note
357(1)
Utilization Review, Practice Guidelines, and Medical Necessity: The Fairness of Internal Process
358(1)
Introduction
358(1)
Disclosure of Medical Necessity or Practice Guidelines Under ERISA
359(1)
Doe v. Travelers Insurance Company (Doe I)
359(4)
Doe v. Travelers Insurance Company (Doe II)
363(3)
Notes and Questions
366(1)
Department of Labor (DOL) Pension and Welfare Benefits Administration (PWBA)29 CFR Part 2560
367(5)
Notes and Questions
372(1)
The Medical Reviewer's Fiduciary Role Under ERISA
372(1)
Bedrick v. Travelers Insurance Company
372(6)
McGraw v. Prudential Insurance Company of America
378(5)
Notes and Questions
383(1)
Can Practice Guidelines Themselves be Reviewed under ERISA and the Federal Medicaid Statute?
383(1)
Jones v. Kodak Medical Assistance Plan
383(3)
Notes and Questions
386(1)
Dukes v. U.S. Healthcare
387(1)
Massachusetts Eye and Ear Infirmary v. Commissioner of the Division of Medical Assistance
388(3)
State Regulation of and Litigation about Utilization Review
391(1)
Question
391(1)
New York Public Health Law Article 49. Utilization Review
391(4)
Batas v. Prudential Insurance Company of America
395(7)
Notes
402(1)
Network Formation, Composition, and Internal Governance
402(1)
Network Formation and Composition: ``Any Willing Provider'' Laws
403(1)
Stuart Circle v. Aetna Health Management
403(5)
Cigna Healthplan of Louisiana, Inc. v. State of La. ex rel. Ieyoub
408(3)
Washington Physicians Service Association v. Gregoire
411(6)
Notes and Questions
417(3)
Provider ``Deselection'': Contract-at-Will, Non-Renewal, and Provider Due Process
420(1)
Harper v. Healthsource New Hampshire, Inc.
420(3)
Notes and Questions
423(1)
New York Public Health Law § 4406-d
423(2)
Notes and Questions
425(1)
Potvin v. Metropolitan Life Insurance Co.
426(13)
Notes and Questions
439(1)
Prohibition of ``Gag Clauses'' and Other Means to Protect Professional Speech
440(1)
Corporate Health Insurance, Inc. v. Texas Department of Insurance (Corporate Health I)
440(3)
Notes and Questions
443(1)
Independent External Review of Coverage-Related Treatment Decisions by Managed Care Organizations
443(1)
Introduction
443(1)
Access to external independent review under ERISA
444(1)
Corporate Health Insurance, Inc. v. Texas Department of Insurance (Corporate Health I)
445(4)
Corporate Health Insurance, Inc. v. Texas Department of Insurance (Corporate Health II)
449(2)
Moran v. Rush Prudential HMO, Inc.
451(8)
Notes and Questions
459(3)
Department of Labor, 29 CFR Part 2560
462(3)
Independent External Reviews and Medicaid Managed Care
465(1)
J.K. v. Dillenberg
465(5)
Notes
470(1)
Independent External Reviews and Medicare Managed Care
471(1)
Notes and Questions
472(1)
Federal Reform: Toward A Broader Regulatory Framework for Managed Care
472(1)
Medicare and Medicaid Managed Care
473(1)
Employer-Sponsored Health Benefit Plans and Other Privately Insured Managed Care Arrangements
473(4)
Tax Exemption in the Modern Health Care System
477(3)
The Nature of Community Benefit
480(1)
Geisinger Health Plan v. Commissioner of Internal Revenue (Geisinger I)
480(9)
Notes and Questions
489(2)
The Integral Part Doctrine
491(1)
Geisinger Health Plan v. Commissioner of Internal Revenue (Geisinger III)
491(9)
Notes and Questions
500(4)
Joint Ventures With Nonexempt Entities
504(2)
Redlands Surgical Services v. Commissioner of Internal Revenue
506(17)
Notes and Questions
523(6)
The Application of Antitrust Principles to Health Care Financing and Organization
529(25)
Traditional Impediments to Applying Antitrust Law to Health Care
529(1)
The ``Learned Profession'' Exemption
529(1)
The ``State Action'' Doctrine
530(1)
Surgical Care Center of Hammond, L.C. v. Hospital Services District No. 1 of Tangipahoa Parish
530(1)
Price Fixing
531(1)
Horizontal Arrangements
531(3)
Market Power and Attempts at Monopolization
534(2)
Market Division
536(1)
Acquisitions and Mergers
537(3)
Note on Hospital Joint Ventures
540(14)
Health Care Fraud and Abuse
554(65)
False Claims
554(1)
Federal Prosecutions Under the Civil and Criminal False Claims Acts
554(1)
``Qui tam Actions''
555(1)
Vermont Agency of Natural Resources v. United States ex rel. Stevens
555(11)
Notes and Questions
566(1)
Riley v. St. Luke's Episcopal Hospital
567(19)
United States ex rel. Kelly v. Boling Co.
586(2)
Notes and Questions
588(1)
Actions Brought under the Racketeer Influenced and Corrupt Organizations Act (RICO)
588(1)
Preemption of RICO Actions by State Laws Regulating the Business of Insurance
589(1)
Humana, Inc. v. Forsyth
589(6)
Notes and Questions
595(2)
RICO Standing
597(1)
Maio v. Aetna, Inc.
597(21)
Notes and Questions
618(1)
Health Reform
619(13)
State Health Reform
619(1)
Update on Tenn Care
619(4)
Health Reform incrementation: The State Children's Health Insurance Program (SCHIP)
623(9)
Quality of Care And The Law Defining Standards and Structuring Enforcement
632(110)
From Physician Autonomy to Modestly Egalitarian Social Contract: Medical Malpractice Law and Standards of Care
632(3)
From the Locality Rule to a ``National Standard''
632(1)
Customary vs. Accepted Practice
632(1)
Blood Transfusions and the Standard of Care
632(1)
Osborn v. Irwin Mem. Blood Bank
633(1)
Advincula v. United Blood Services
633(2)
Informed Consent: Professional or Patient-Based Standard?
635(1)
Apologizing for the Tuskegee Study
635(1)
Hospitals as Monitors of Quality of Care: The Impact of Medical Malpractice Law
636(3)
The Collapse of Charitable Immunity and the Rise of Respondeat Superior
636(1)
The Corporate Practice of Medicine Doctrine
636(1)
Berlin v. Sarah Bush Lincoln Health Center
636(2)
Non-Employee Physicians and the Expanding Concepts of Agency and Nondelegable Duty
638(1)
Managed Care and Quality of Care
639(82)
ERISA Preemption of State Remedies for Harms Caused by Private Payers
639(1)
Why ERISA Matters: The Problem of Damages
639(1)
The Problem of Damages Revisited
639(1)
Durham v. Health Net
639(1)
Cracks in the ERISA Wall: Removal, Preemption, and Claims About the Quality of Benefits Received
639(1)
The Impact of Current ERISA Preemption Doctrine on Preemption of State Damages Claims Connected with Medicare and FEHBA
639(1)
Wartenberg v. Aetna U.S. Healthcare, Inc
640(1)
Post-Dukes Litigation Regarding ERISA Preemption of State Law Damages Actions
640(2)
Ouellette v. Christ Hospital
642(2)
Notes and Questions
644(1)
Lancaster v. Kaiser Foundation Health Plan
645(5)
Notes and Questions
650(1)
In re U.S. Healthcare, Inc.
651(6)
Notes and Questions
657(1)
Lazorko v. Pennsylvania Hospital
658(1)
Pryzbowski v. Pennsylvania Hospital
658(12)
Notes and Questions
670(2)
State Court Decisions on ERISA Preemption of State Law Claims
672(1)
Pappas v. Asbel
672(11)
Notes and Question
683(1)
Apparent Agency and Managed Care
684(1)
Petrovich v. Share Health Plan of Illinois, Inc.
684(1)
Williams v. Good Health Plus, Inc.
685(1)
Corporate Liability and Managed Care
685(1)
Nealy v. US Healthcare HMO
686(1)
Shannon v. McNulty
686(1)
Jones v. Chicago HMO Ltd. of Illinois
687(12)
Notes and Questions
699(2)
McEvoy v. Group Health Cooperative of Eau Claire
701(7)
Notes
708(1)
1997 Tex. Sess. Law Serv. Ch. 163 (S.B. 386) (VERNON'S) Health Care---Review of and Liability for Treatment
708(5)
Corporate Health Insurance, Inc. v. Texas Department of Insurance (Corporate Health I)
713(2)
Notes and Questions
715(1)
Other Sources of State Law, Managed Care, and ERISA Preemption
716(1)
Murphy v. Board of Medical Examiners of the State of Arizona
716(4)
Morris v. District of Columbia Board of Medicine
720(1)
Questions
721(1)
Ending Medical Treatment
721(21)
The Right to Assistance in Dying
721(1)
Washington v. Glucksberg
721(19)
Vacco v. Quill
740(2)
Long Term Care
742(29)
Defining and Paying for Long Term Care
742(10)
Private Insurance
742(1)
Long Term Care Insurance: The Impact of HIPAA
742(2)
Interim guidance on long term care services and insurance
744(3)
Medicaid
747(1)
Medicaid Long Term Care Benefit Issues
747(1)
Skubel v. Fuoroli
747(5)
The Americans with Disabilities Act and the Rights of Persons with Disabilities in the Provision of Long Term Care
752(19)
Introduction
752(1)
Olmstead v. L.C.: Implications for Public Funding of Health Services for Persons with Disabilities
752(1)
Olmstead v. L. C.
752(16)
Notes
768(3)
Managing Long Term Care: The Integration of Acute Care and Long Term Care into Managed Care Programs
771(1)
Program of All Inclusive Care for the Elderly (PACE) 771

Rewards Program

Reviews for Law and the American Health Care System (9781587781803)