Limit-Setting in Managed Care and Other Health Delivery Systems: Legitimacy, Fair Process, and the Goals of Health Care Reform

Award Year: 1997	Investigator: Norman Daniels	Budget: $250,013	Categories: Ethical Dilemmas and Resource Allocation, Managed Care
Abstract: This project integrates theoretical work on justice and health care with practical research on decision-making and limit-setting in managed care organizations (MCOs). Dr. Daniels explores the issue of legitimacy and its role in decisions by private insurers and governments that affect patient welfare. Among the areas his study addresses are: 1) how conditions needed to establish legitimate limit-setting can be applied to create detailed and specific regulatory requirements; 2) how MCOs can use concepts of legitimacy to improve decisions about coverage of new technologies, treatment guidelines, and disease management; 3) incorporating these processes into regulatory requirements; 4) including specific features of fair process in benchmarks of fairness; and 5) using them to address issues of access, benefits, efficiency, and process in nations' health reform efforts and in developing countries. Dr. Daniels explores the conditions under which limit-setting decisions can achieve legitimacy and develops a matrix for evaluating fairness of health care reforms that can be used by the World Health Organization.