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PubMedDate not supplied

Workers' compensation: a background for Social Security professionals.

This article provides a brief history and background of workers' compensation programs for occupationally injured and ill workers in the United States. It presents the basic principle involved in workers' compensation and briefly discusses the disability benefits to which workers are generally entitled. It also discusses why there are settlements in this disability program and the availability of information about the amounts paid in workers' compensation cases for obtaining an offset for Social Security Disability Insurance benefits paid to the worker. Finally, the article explains the rationale behind the public policy on coordination of Disability Insurance and workers' compensation in the new paradigm of disability and return to work.

Eligibility Determination↗
PubMed2005

Contributions of marginal offspring to reproductive success of Nazca booby (Sula granti) parents: tests of multiple hypotheses.

While obligate siblicide is a phylogenetically widespread behavior, known from plants, insects, birds, and other taxa, with important implications for life history evolution, comprehensive evaluations of its costs and benefits to parents are rare. We used 12 years of breeding and band resight data to evaluate the importance of several potential benefits that marginal offspring (the usual victims of obligate siblicide) could provide to parent Nazca boobies (Sula granti), a seabird. We found no evidence for the resource-tracking hypothesis: 99.95% of two-chick broods were reduced to one chick before fledging, and the single exceptional brood probably lost one chick between fledging and independence. Behavioral observations indicated that siblicidal aggression caused most mortality of marginal chicks, and at least contributed to the remainder. We also found no evidence that marginal offspring provide a food resource for other family members. Marginal chicks benefit parents via adoption into other families, and possibly also in the context of progeny choice, but these benefits are minor compared to the insurance that marginal chicks provide against early failure of core (first-hatched) offspring. Further evaluation of the Insurance Egg Hypothesis showed that marginal and core offspring are functionally equivalent in the absence of sibling interactions, and that core offspring incur no detectable costs from behaving siblicidally. Nazca boobies are truly obligate brood reducers, with parents receiving principally insurance benefits from marginal offspring, but many birds and other taxa exhibiting persistent, unconditional sibling aggression do not exhibit universal brood reduction. Insurance is only one of several potential benefits that marginal offspring can confer on parents, and a multi-hypothesis approach to decompose the different types of benefits is required to understand the evolution of clutch size in other obligately siblicidal species.

Animals↗
PubMed2006

Scope of Health Care Benefits for Children from Birth Through Age 21.

The optimal health of children can best be achieved by providing access to comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 21. These services encompass medical care, critical care, pediatric surgical care, behavioral health services, specialized services for children with special health care needs, and oral health. It replaces the 1997 statement, "Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years."

Adolescent↗
PubMed1995

Analysis of private health insurance premium growth rates: 1985-1992.

The rate of increase in health care expenditures has been a central policy concern for well over a decade, yet little empirical research has been conducted to examine expenditure growth rates. This study analyzed health insurance premium growth rates for a selected sample of 95 insured groups over the period 1985 to 1992. During this time, premiums increased by approximately 150% in nominal terms and by 45% in real terms. The observed rate of growth was not constant over time, however. The most rapid growth occurred during the years 1986 to 1989; thereafter, the rate of increase in premiums declined. Multivariate analysis was conducted to assess the effects on premium growth rates of selected variables representing insurance benefit design features, market competitive factors, insurance system factors, and group-specific factors. In addition to the percentage increase in benefit payments, other factors found to affect premium growth rates were health maintenance organization market penetration, deductible level, the coinsurance rate, and state insurance mandates. Further, this analysis suggests that the insurance underwriting cycle may play an important role in influencing insurance premium growth rates. These results support the belief that health maintenance organization induced competition has potential to control the rate of increase in health care costs.

Fees and Charges↗
PubMed1996

[Differences in application and granting benefits for severely disabled patients before and after introduction of new benefits within the scope of the public health reform law].

Constituting part of the health reform in Germany ("Bundesgesundheits-Reformgesetz"), an extension of health insurance benefits for severely disabled persons was introduced in 1991. The assessment of eligibility for benefits is based on standardised medical examinations. Examinations performed in the state of Baden-Württemberg in 1990 (n = 6401) were compared with a 20% random sample of those performed in 1991 (n = 7563) in order to analyse eventual changes in acceptance rates of applications. Acceptance rates decreased from 87.9% in 1990 to 70.8% in 1991. The difference could not be explained by differences in age, sex, medical diagnosis or dependence on help in daily activities. This suggests that acceptance criteria were less restrictive before introduction of the extension of benefits.

Adolescent↗
PubMed1999

Finance issue brief: mandated benefits.

By enacting legislation to mandate a health insurance benefit, legislators require health plans to provide coverage for particular treatments, screenings, prescriptions and providers. During the 1998 state legislative sessions, several new and somewhat controversial mandates emerged at the forefront of discussion, including coverage for contraceptives, general anesthesia for dental procedures and newborn hearing screening. In 1999, all three of these mandates and others have gained speed as some sessions hit their midpoints and many adjourn.

Delivery of Health Care↗
PubMed1998

Self-Insured health care plans: are they fair to employees with HIV/AIDS?

A literature search reveals a number of instances where people with AIDS (PWAs) have limits placed on their health care by self-insured firms. Some firms cite the high cost of health care for AIDS as the motivation for their decision. Research demonstrates, however, that AIDS is not the only high-priced disease to treat. Treatment for lung cancer is costly as well. In many cases, unprotected sex leads to HIV/AIDS and lung cancer is strongly linked to tobacco use. Therefore, lung cancer can be studied as a comparison disease for issues relating to health care coverage of PWAs. A literature search also shows that no examples of limitations on health care were found among lung cancer patients. A 1992 Supreme Court decision did not restrict the inequitable access to health care through self-insured plans for AIDS patients. When employees of self-insured firms exhaust their insurance benefits, which can occur quickly, they apply for Medicaid or Medicare benefits. As a result, the government's burden is increased in the care of PWAs. The issue, therefore, should be to ensure that employees of self-insured firms have equal access to health care since there are other serious diseases, such as lung cancer, that are also expensive to treat.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Service-level costing of drug abuse treatment.

This paper presents a methodology for estimating costs of delivering specific substance abuse treatment services. Data collected from 13 programs indicate that the mean cost of residential treatment is $2,773 per patient per month, and outpatient treatment costs average $636 per patient per month. Data are presented on the cost patient per month for individual treatment and nontreatment services, average number of services, cost per unit of service, and intensity of services. In addition to their application to insurance benefit cost estimation, these data illustrate the costing of best-practice adolescent treatment consistent with a Center of Substance Abuse Treatment (CSAT) Treatment Improvement Protocol. In the emerging policy environment, detailed cost estimates like these will aid the design of cost-effective treatment programs, and serve the development of the substance abuse benefit in a health care reform insurance package.

Adolescent↗
PubMed1989

Health care needs of Hispanic Americans and the responsiveness of the health care system.

The Hispanic population in the United States is growing rapidly but this population has many health care needs that are not being met. The findings from recent research on the current health status of Hispanic people who live in the United States are presented. An assessment of how accessible and available medical care services are to Hispanic people is made. Serious gaps exist in the delivery of medical care services to this group. Human service providers, particularly social workers, can help make the current health care system more responsive to the needs of this group by helping Hispanic individuals who have no health insurance coverage to find employment that includes health insurance benefits or some other form of insurance, by establishing community-based health care centers in Hispanic communities, by developing counseling programs tailored to the alcohol and drug abuse problems of the Hispanic population, and by advocating for government agencies to improve existing sources of data on the health of this group.

Adolescent↗
PubMed1980

Cost containment through risk-sharing by primary care physicians: a history of the development of United Healthcare.

A new type of independent practice association has been organized to encourage primary care physicians in private practice to become coordinators and financial managers for their patients' medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all specialized care. The primary care physician authorizes payment from his/her own account for hospital and referral care provided to patients. He or she shares any deficit or surplus remaining at the end of the year. This is a background paper detailing the history of development and specific features contained in this new concept of putting the physician in charge and "at risk" for the costs of medical care to his/her patients. The plan has been operating in northern California, Washington, and Utah and has 40,000 members and 750 participating physicians. This historical background paper is part of a large project--State Employees' Insurance Benefits Utilization Study (SEIBUS) being done by the University of Washington School of Public Health to evaluate use and costs of medical care under this innovative plan.

California↗
PubMedDate not supplied

Medical consultant key to dealing effectively with insurance fraud and abuse.

An unexpected, but everpresent, by-product of the development of the health care insurance industry is the tendency of those using the industry's services to "game" the system. While fraud and abuse in the claiming of insurance benefits are not the only or the most significant cause of steeply rising health care costs, they certainly contribute to the problem. Payers are advised to maintain a sharp eye for potential fraud and abuse and to observe some simple rules for detecting and eliminating them.

Consultants↗
PubMed2003

COBRA compliance: how employers can successfully meet today's complexities.

Although the architects of COBRA had sound and compassionate motivations in place, administration of and compliance with this law are far from easy. COBRA assists employees that lose their jobs by allowing them to purchase insurance benefits from their former employer. Outsourcing COBRA administration can be the best way for some employers to cope with COBRA regulations, contingencies and paperwork and avoid legal fees and penalties. But look for COBRA providers that have a sound track record.

Employment↗
PubMed1991

Empire and the business of health insurance.

I examine the development of privately provided insurance since World War II, giving special attention to Empire Blue Cross, and argue that the competition between employers and unions for the loyalty of workers after the passage of the Taft-Hartley Act helped diffuse private health insurance benefits already favored by federal policies. For-profit insurers did not challenge the privileged status of Blue Cross plans because they recognized the political benefits that the plans offered and because they did not wish to offend the plans' sponsors. A relatively easy and profitable business, health insurance has been greatly disturbed by the system inflation accompanying the introduction of Medicare and Medicaid programs. Now self-insurance and various managed-care schemes are major threats. The future may bring consolidation and the strengthening of pools, just the opposite of today's system fragmentation.

Blue Cross Blue Shield Insurance Plans↗
PubMed1999

MediCaring: development and test marketing of a supportive care benefit for older people.

OBJECTIVES: To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home-based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and make a choice regarding health insurance benefits; to measure their likelihood to change from traditional Medicare to the new MediCaring benefit; and to determine the short-term stability of that choice. DESIGN: Focus groups of persons aged 65+ and family members shaped the potential MediCaring benefit. A panel of 50 national experts critiqued three iterations of the benefit. The final version was test marketed by discussing it with 382 older people (men > or = 75 years and women > or = 80 years) in their homes. Telephone surveys a few days later, and again 1 month after the home interview, assessed the potential beneficiaries' understanding and preferences concerning MediCaring and the stability of their responses. SETTINGS: Focus groups were held in community settings in New Hampshire, Washington, DC, Cleveland, OH, and Columbia, SC. Test marketing occurred in New Hampshire, Cleveland, OH; Columbia, SC, and Los Angeles, CA. PARTICIPANTS: Focus group participants were persons more than 65 years old (11 focus groups), healthcare providers (9 focus groups), and family decision-makers (3 focus groups). Participants in the in-home informing (test marketing group) were persons older than 75 years who were identified through contact with a variety of services. MEASUREMENTS: Demographics, health characteristics, understanding, and preferences. RESULTS: Focus group beneficiaries between the ages of 65 and 74 generally wanted access to all possible medical treatment and saw MediCaring as a need of persons older than themselves. Those older than age 80 were mostly in favor of it. Test marketing participants understood the key points of the new benefit: 74% generally liked it, and 34% said they would take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance. CONCLUSIONS: Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old.

Advance Care Planning↗
PubMed1992

A universal access plan: a step toward national health insurance?

There is increasing interest by the public and by many providers in the enactment of a universal access plan for the more than 60 million Americans who are now without health insurance benefits at some time during each year. After discussing the heterogeneous characteristics of those such a plan would cover, the reasons that some key players are now supporters of a minimal benefit plan, and the funding options for such a proposal, it is concluded that there is growing support for a universal access plan to be enacted soon. The almost insurmountable issues of such a plan involve the determination of eligibility and the specific benefits to be provided, the cost and administration of the new coverage, and the predictable increase in the nation's expenditure for health care services. This article concludes with the opinion that the passage of a universal access plan is a necessary and incremental step that will provide additional time for the discussion of whether and, if so, when the United States will be prepared to implement the final steps toward a more single-payer, centrally controlled health care delivery system.

American Medical Association↗
PubMed2006

Use and employer costs of a pharmacotherapy smoking-cessation treatment benefit.

BACKGROUND: Employers cite a lack of information on the cost of insurance coverage for smoking-cessation treatment as a barrier to its provision. This study describes the use of a new insurance benefit for smoking-cessation pharmacotherapy, and its pharmaceutical costs to a large public employer between 2001 and 2003. METHODS: Annual enrollment and pharmaceutical claims data were collected from the health plans that contracted with the Wisconsin Department of Employee Trust Funds (ETF). State employees, retirees, and adult dependents who obtained health insurance through the ETF constituted our sample, approximately 150,000/year. Pharmacotherapy benefit use was defined as a paid claim for one of four U.S. Food and Drug Administration-approved smoking-cessation medications. Pharmaceutical cost was defined as the ingredient cost (+) dispensing fee (-) member copayment. Analyses included estimation of the proportion of smokers who used the benefit each year and across 3 years, the average annual cost per user, and the per member per month (PMPM) pharmaceutical cost to the employer. Data were collected from 2001 to 2004 and analyzed in 2005-2006. RESULTS: Annual benefit use among smokers ranged from 6% to 7% with a 3-year rate of approximately 17%. The PMPM cost of the covered pharmacotherapy was approximately 0.13 dollars. CONCLUSIONS: The cost to employers of providing insurance coverage for smoking-cessation pharmacotherapy to their employees is low. By informing insurance purchasing decisions, these results may facilitate the adoption of such coverage, with the goal of ultimately reducing the proportion of employees who smoke.

Adolescent↗