Improving Dispute Resolution in Health Care

我在法律和卫生服务研究方面的培训使我对卫生法、卫生政策和医学伦理产生了兴趣。迄今为止的研究主要集中在医疗事故上。然而，最近，我的兴趣被吸引到医疗差错和医疗纠纷的法律问题上。本建议概述的议程涉及后者。它的前提是一个总体假设，即对医疗保健纠纷知识的进步，特别是关于纠纷产生的原因、解决方式和争议方身份的信息，将有助于指导政策和实践，取得三个积极成果：(1)提高医疗质量；(2)管理式医疗参保人的程序更加公正和公平；(3)降低成本。在接下来的四年里，有两个项目将占据我大部分的时间。第一项研究始于1999年10月，研究的是管理式医疗机构的覆盖决策。其目标是描述和分析在管理医疗人群中拒绝保险覆盖的情况，特别关注弱势参保者（如穷人、少数民族、缺乏医生支持的人）在上诉保险决定时的表现。该项目的数据来自加州的两家大型健康计划和两家医疗集团。第二项研究也有类似的培训目标，但主要集中在对保险诉求的外部审查上，特别是在管理医疗的医疗保险受益人中。我们目前正在与国内最大的外部审稿人健康纠纷解决中心（Center for Health Dispute Resolution）的合作者一起制定一项提案。除了提供机会进行一系列与上述研究相关的令人兴奋的规范性和描述性研究问题外，拟议的奖项还将使我有时间和灵活性在几个关键领域发展我的职业生涯：(1)与卫生法实证研究相关的定量和定性技能；(2)论文撰写经验；(3)利用现有数据来源进行政策相关分析的能力；(4)成功过渡到一个新的、很少被研究的卫生政策领域。

My training in law and health services research has led to interests in health law, health policy and medical ethics. Research to date has focused on medical malpractice. More recently, however, my interests have gravitated toward legal issues in medical error and Disputes in health care. The agenda outlined in this proposal relates to the latter. It is premised on the overarching hypothesis that advancement of knowledge about disputes in health care-in particular, information about why they arise, how they are resolved, and the identity of the disputants- will help guide policy and practice toward three positive outcomes: (1) improved quality of care; (2) greater procedural justice and fairness for managed care enrollees; and (3) reduced costs. Two projects will occupy the majority of my time over the next four years. The first, a study of coverage decision-making in managed care organizations, began in October, 1999. Its goal is to describe and analyze denials of insurance coverage within a managed care population, with a particular focus on how vulnerable enrollees (e.g. the poor, minorities, those lacking physician support for their claim) fare in appealing coverage decisions. Data for the project come from two large health plans and two medical groups in California. The second study has training similar goals but is centered on external review of coverage appeals, specifically among Medicare beneficiaries in managed care. With collaborators at the Center for Health Dispute Resolution, the largest external reviewer in the country, we are currently developing a proposal. As well as providing opportunities to pursue a range of exciting normative and descriptive research questions related to the above studies, the proposed award would allow me the time and flexibility to develop my career in several key areas: (1) quantitative and qualitative skills relevant to empirical research in health law; (2) grant-writing experience; (3) capacity to pursue policy-relevant analyses from existing data sources; and (4) successful transition into a new, little-studied area of health policy.