Decisions about access to health care and accountability for reasonableness

Insurers make decisions that directly limit access to care (e.g., when deci ding about coverage for new technologies or formulary design) and that indi rectly limit access (e.g., by adopting incentives to induce physicians to p rovide fewer or different services). These decisions raise questions about legitimacy and fairness. By holding health plans accountable for the reason ableness of their decisions, it is possible to address these questions. Acc ountability for reasonableness involves providing publicly accessible ratio nales for decisions and limiting rationales to those that all "fair-minded" persons can agree are relevant to meeting patient needs fairly under resou rce constraints. This form of accountability is illustrated by examining it s implications for the three examples of direct and indirect limit setting noted here.