Principles and managed care: Not mutually exclusive

The latest version of the AMA's compendium of managed care policies is now available and shows how to make managed care fair and equitable.

Editorial. Jan. 17, 2005.

The AMA has released an updated version of its Principles of Managed Care, and the new edition is available at the Association's Web site. That should make it easy to find for doctors, patients and, perhaps most importantly, for health plans.

This is the fifth version of the Principles -- a compendium of AMA polices and ethical opinions, first published in 1993. Its goal is to "promote effective managed care techniques that are fair and equitable to physicians in ensuring high quality health care services to patients."

The latest version contains 16 sections on key topics such as disclosure provisions, credentialing and recredentialing, selective contracting, disease management, and Medicare and Medicaid managed care.

One section of the Principles sure to get some renewed attention is the section on independent and external reviews.

In June 2004, the U.S. Supreme Court struck down a Texas law allowing patients to sue their health plans in state court. The ruling effectively closes that avenue of redress for treatment denials to the millions of patients covered by employer-sponsored health plans that fall under the federal Employee Retirement Income Security Act of 1974. As a result, patients covered by and physicians contracting with those plans who want to challenge managed care decisions have only the independent and external review process.