The National Center on Elder Abuse (NCEA) serves as a national resource for elder rights advocate... more The National Center on Elder Abuse (NCEA) serves as a national resource for elder rights advocates, law enforcement and legal professionals, public policy leaders, researchers, and citizens. It is the mission of the NCEA to promote understanding, knowledge sharing, and action on elder abuse, neglect, and exploitation.
/Guardians-of-the-Elderly-An-Ailing-System-Part-I-Declared-Legally-Dead-by-a-Troubled-System/id-1... more /Guardians-of-the-Elderly-An-Ailing-System-Part-I-Declared-Legally-Dead-by-a-Troubled-System/id-1198f64bb05d9c1ec690035983c02f9f .
Managed care disputes can have an urgency often lacking in the fee-forservice system. Conflicts f... more Managed care disputes can have an urgency often lacking in the fee-forservice system. Conflicts frequently occur before treatment rather than after. Enrollee health and wellbeing may be at stake-and justice delayed truly may be justice denied. Moreover, conflicts may arise out of intemal HMO decisions riddled by tension between the health needs of consumers and the cost constraints of the plan. And consumers-often traumatized by health concernsmay sometimes be in the dark about who made the decision, on what grounds and with what evidence, and where to turn next. Finally, processes for resolving disputes in managed care vary depending on the payer-with Medicare, Medicaid, state laws, and Employee Retirement Income Security Act procedures differing dramatically. To make matters more difficult, there is not even a common language on managed care dispute resolution. Words like complaint, grievance, and appeal often are used interchangeably with little agreed-upon definition. We know that consumers are experiencing a variety of difficulties in obtaining care from managed care organizations. A survey of consumer experiences in managed care conducted by the Lewin Group last summer revealed that 27 percent of managed care households surveyed had experienced a difficulty with their health plan in the previous twelve months. A fair number of those consumers with problems (29 percent) had taken no action to resolve them; among those who sought resolution of their difficulties, 54 percent were dissatisfied with the resolution or had not yet resolved the problem. Clearly, if managed care is going to work, procedures for addressing consumer conflicts must be timely, fair, consistent, accessible-and readily understood by enrollees. What should such procedures look like? The question is a compelling one that raises a host of knotty issues: How can the enrollee really have an opportunity to be heard? What kinds of processes would engender careful and fair review of enrollee healthcare needs? What are reasonable time frames for the resolution of consumer disputes? Of urgent care disputes? What kinds of help should consumers have in navigating managed care problems and cutting through bureaucratic delays and impediments? Should plan decisions be reviewable by external independent entities, as now occurs in Medicare? Should services slated to be reduced or terminated be continued pending appeal? How can dispute resolution processes be most accessible to older people and people with disabilities? How much do dispute resolution processes cost? These issues have been in the forefront recently in several arenas. One is Medicare. The Balanced Budget Act of I997 (BBA) creates a new program, Medicare + Choice (Medicare Part C), of which HMOs and other managed care plans for Medicare beneficiaries will be a part. The new statute contains language on appeals and grievance procedures that is similar to existing law and regulations. The BBA required the Health Care Financing Administration to publish regulations establishing standards for the Medicare+Choice program by June 1, 1998. As of this writing, HCFA plans to include regulations on grievance and appeal procedures in its June 1 "mega-regulation" and has solicited comments on beneficiary protections. HCFA is likely to stick with its current regulation on expedited appeal procedures for certain urgent cases, but it may change time frames for other appeals and may create other new policies affecting resolution of disputes. Meanwhile, a key presidential commission also has been debating dispute resolution concerns. In March 1997, President Clinton appointed the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, composed of representatives of all major stakeholders in today's healthcare arena. The president recognized the importance of dispute resolution by mandating that the commission develop a consumer bill of rights ensuring that "consumers have access to simple and fair procedures for resolving health care coverage disputes with plans. …
Guardianship is a relationship created by state law in which a court gives one person or entity (... more Guardianship is a relationship created by state law in which a court gives one person or entity (the guardian) the duty and power to make personal and/or property decisions for another (the ward or incapacitated person). A judge appoints a guardian upon finding that an adult individual lacks capacity to make decisions for him or herself. Guardianship is a powerful legal tool that can bring good or ill for an increasing number of vulnerable people with cognitive impairments, affording needed protections, yet drastically reducing fundamental rights. Court monitoring of guardians is required to ensure the welfare of incapacitated persons, identify abuses, and sanction guardians who demonstrate malfeasance. In 2005 the AARP Public Policy Institute, in conjunction with the American Bar Association (ABA) Commission on Law and Aging, conducted a survey to examine current court practices for guardian oversight. In 2006 the two organizations are continuing to study guardianship monitoring through site visits and telephone interviews, and a second report will follow with recommendations on promising practices.
WooD, AMERICAN BAR ASSOCIATION COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY, UNDERSTANDING HEALTH ... more WooD, AMERICAN BAR ASSOCIATION COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY, UNDERSTANDING HEALTH PLAN DISPUTE RESOLUTION PRACTICES (2000). JOURNAL OF HEALTH CARE LAW & POLICY disputes in the private commercial arena, as well as in Medicare and Medicaid, and to identify workable options for improving the process. A. Overview and Study Rationale Health maintenance organizations (HMOs)' and other managed health care plans continue to capture a growing share of the health care delivery market. Between 1994 and 1998, the number of HMO plans climbed 62.2%, from 556 to 902; and between 1994 and 1999 HMO market penetration increased nearly 17% to reach 37.9%.4 At the same time, the number of government beneficiaries enrolling in managed care continues to grow. 5 The growth of managed care has brought advantages in cost control, preventive care and the potential of coordinating treatmenta feature especially critical for members who are elderly, chronically ill or who have disabilities. 6 However, the rise of managed care also raises compelling questions concerning the scope of coverage, authorization for services and the "gatekeeper" concept, physician/patient/ plan communications, physician payment rates, quality of careand how best to resolve plan-enrollee differences about care and payment. 3. A "health maintenance organization" (HMO) is "a type of managed-care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Benefits are typically financed through capitation with limited copayments, and services are furnished through a system of affiliated providers." PHYSICIAN PAY
Purpose-This study investigates the impact of statutory reform in adult guardianship on court pra... more Purpose-This study investigates the impact of statutory reform in adult guardianship on court practice. Methods-Case files for 298 cases of adult guardianship were reviewed in three states with varying degrees of statutory reform: MA (no reform), PA (major amendments in 1992), and CO (full re-enactment of statute per UGPPA in 2000). Five court practices associated with progressive statutory reform were studied: (1) diversion to less restrictive alternatives; (2) minimal and appropriate use of emergency procedures; (3) presence of the alleged incapacitated person at the hearing; (4) use of functional evaluation; (5) use of limited orders. Results-CO more frequently utilized all five practices, whereas PA used diversion to less restrictive alternatives and less frequent emergency procedures, but not other practices. MA files rarely showed evidence for use of any of these reforms. Implications-Statutory reform may improve court practice. More study of the effects of reform on court practices, and the vulnerable adults served by these courts, is needed.
Institute informs and stimulates public debate on the issues we face as we age. Through research,... more Institute informs and stimulates public debate on the issues we face as we age. Through research, analysis and dialogue with the nation's leading experts, PPI promotes development of sound, creative policies to address our common need for economic security, health care, and quality of life. The views expressed herein are for information, debate, and discussion, and do not necessarily represent official policies of AARP. The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association and should not be construed as representing the policy of the American Bar Association.
The National Center on Elder Abuse (NCEA) serves as a national resource for elder rights advocate... more The National Center on Elder Abuse (NCEA) serves as a national resource for elder rights advocates, law enforcement and legal professionals, public policy leaders, researchers, and citizens. It is the mission of the NCEA to promote understanding, knowledge sharing, and action on elder abuse, neglect, and exploitation.
/Guardians-of-the-Elderly-An-Ailing-System-Part-I-Declared-Legally-Dead-by-a-Troubled-System/id-1... more /Guardians-of-the-Elderly-An-Ailing-System-Part-I-Declared-Legally-Dead-by-a-Troubled-System/id-1198f64bb05d9c1ec690035983c02f9f .
Managed care disputes can have an urgency often lacking in the fee-forservice system. Conflicts f... more Managed care disputes can have an urgency often lacking in the fee-forservice system. Conflicts frequently occur before treatment rather than after. Enrollee health and wellbeing may be at stake-and justice delayed truly may be justice denied. Moreover, conflicts may arise out of intemal HMO decisions riddled by tension between the health needs of consumers and the cost constraints of the plan. And consumers-often traumatized by health concernsmay sometimes be in the dark about who made the decision, on what grounds and with what evidence, and where to turn next. Finally, processes for resolving disputes in managed care vary depending on the payer-with Medicare, Medicaid, state laws, and Employee Retirement Income Security Act procedures differing dramatically. To make matters more difficult, there is not even a common language on managed care dispute resolution. Words like complaint, grievance, and appeal often are used interchangeably with little agreed-upon definition. We know that consumers are experiencing a variety of difficulties in obtaining care from managed care organizations. A survey of consumer experiences in managed care conducted by the Lewin Group last summer revealed that 27 percent of managed care households surveyed had experienced a difficulty with their health plan in the previous twelve months. A fair number of those consumers with problems (29 percent) had taken no action to resolve them; among those who sought resolution of their difficulties, 54 percent were dissatisfied with the resolution or had not yet resolved the problem. Clearly, if managed care is going to work, procedures for addressing consumer conflicts must be timely, fair, consistent, accessible-and readily understood by enrollees. What should such procedures look like? The question is a compelling one that raises a host of knotty issues: How can the enrollee really have an opportunity to be heard? What kinds of processes would engender careful and fair review of enrollee healthcare needs? What are reasonable time frames for the resolution of consumer disputes? Of urgent care disputes? What kinds of help should consumers have in navigating managed care problems and cutting through bureaucratic delays and impediments? Should plan decisions be reviewable by external independent entities, as now occurs in Medicare? Should services slated to be reduced or terminated be continued pending appeal? How can dispute resolution processes be most accessible to older people and people with disabilities? How much do dispute resolution processes cost? These issues have been in the forefront recently in several arenas. One is Medicare. The Balanced Budget Act of I997 (BBA) creates a new program, Medicare + Choice (Medicare Part C), of which HMOs and other managed care plans for Medicare beneficiaries will be a part. The new statute contains language on appeals and grievance procedures that is similar to existing law and regulations. The BBA required the Health Care Financing Administration to publish regulations establishing standards for the Medicare+Choice program by June 1, 1998. As of this writing, HCFA plans to include regulations on grievance and appeal procedures in its June 1 "mega-regulation" and has solicited comments on beneficiary protections. HCFA is likely to stick with its current regulation on expedited appeal procedures for certain urgent cases, but it may change time frames for other appeals and may create other new policies affecting resolution of disputes. Meanwhile, a key presidential commission also has been debating dispute resolution concerns. In March 1997, President Clinton appointed the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, composed of representatives of all major stakeholders in today's healthcare arena. The president recognized the importance of dispute resolution by mandating that the commission develop a consumer bill of rights ensuring that "consumers have access to simple and fair procedures for resolving health care coverage disputes with plans. …
Guardianship is a relationship created by state law in which a court gives one person or entity (... more Guardianship is a relationship created by state law in which a court gives one person or entity (the guardian) the duty and power to make personal and/or property decisions for another (the ward or incapacitated person). A judge appoints a guardian upon finding that an adult individual lacks capacity to make decisions for him or herself. Guardianship is a powerful legal tool that can bring good or ill for an increasing number of vulnerable people with cognitive impairments, affording needed protections, yet drastically reducing fundamental rights. Court monitoring of guardians is required to ensure the welfare of incapacitated persons, identify abuses, and sanction guardians who demonstrate malfeasance. In 2005 the AARP Public Policy Institute, in conjunction with the American Bar Association (ABA) Commission on Law and Aging, conducted a survey to examine current court practices for guardian oversight. In 2006 the two organizations are continuing to study guardianship monitoring through site visits and telephone interviews, and a second report will follow with recommendations on promising practices.
WooD, AMERICAN BAR ASSOCIATION COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY, UNDERSTANDING HEALTH ... more WooD, AMERICAN BAR ASSOCIATION COMMISSION ON LEGAL PROBLEMS OF THE ELDERLY, UNDERSTANDING HEALTH PLAN DISPUTE RESOLUTION PRACTICES (2000). JOURNAL OF HEALTH CARE LAW & POLICY disputes in the private commercial arena, as well as in Medicare and Medicaid, and to identify workable options for improving the process. A. Overview and Study Rationale Health maintenance organizations (HMOs)' and other managed health care plans continue to capture a growing share of the health care delivery market. Between 1994 and 1998, the number of HMO plans climbed 62.2%, from 556 to 902; and between 1994 and 1999 HMO market penetration increased nearly 17% to reach 37.9%.4 At the same time, the number of government beneficiaries enrolling in managed care continues to grow. 5 The growth of managed care has brought advantages in cost control, preventive care and the potential of coordinating treatmenta feature especially critical for members who are elderly, chronically ill or who have disabilities. 6 However, the rise of managed care also raises compelling questions concerning the scope of coverage, authorization for services and the "gatekeeper" concept, physician/patient/ plan communications, physician payment rates, quality of careand how best to resolve plan-enrollee differences about care and payment. 3. A "health maintenance organization" (HMO) is "a type of managed-care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Benefits are typically financed through capitation with limited copayments, and services are furnished through a system of affiliated providers." PHYSICIAN PAY
Purpose-This study investigates the impact of statutory reform in adult guardianship on court pra... more Purpose-This study investigates the impact of statutory reform in adult guardianship on court practice. Methods-Case files for 298 cases of adult guardianship were reviewed in three states with varying degrees of statutory reform: MA (no reform), PA (major amendments in 1992), and CO (full re-enactment of statute per UGPPA in 2000). Five court practices associated with progressive statutory reform were studied: (1) diversion to less restrictive alternatives; (2) minimal and appropriate use of emergency procedures; (3) presence of the alleged incapacitated person at the hearing; (4) use of functional evaluation; (5) use of limited orders. Results-CO more frequently utilized all five practices, whereas PA used diversion to less restrictive alternatives and less frequent emergency procedures, but not other practices. MA files rarely showed evidence for use of any of these reforms. Implications-Statutory reform may improve court practice. More study of the effects of reform on court practices, and the vulnerable adults served by these courts, is needed.
Institute informs and stimulates public debate on the issues we face as we age. Through research,... more Institute informs and stimulates public debate on the issues we face as we age. Through research, analysis and dialogue with the nation's leading experts, PPI promotes development of sound, creative policies to address our common need for economic security, health care, and quality of life. The views expressed herein are for information, debate, and discussion, and do not necessarily represent official policies of AARP. The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association and should not be construed as representing the policy of the American Bar Association.
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