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PubMed1977

Private industry health insurance plans: type of administration and insurer in 1974.

This report examines the major forms of administration of private health insurance plans. Plans are classified according to whether they are employer-only or joint worker-employer-operated and according to whether they are negotiated or not. A further focus of examination that often reflects industry patterns is whether the plans cover workers of a single employer or involve multi-employer arrangements. These classifications of administration and the method of insuring benefits are examined in terms of proportions of workers with specified plan characteristics and health benefits.

Blue Cross Blue Shield Insurance Plans↗
PubMed2000

Cross-subsidization in the market for employment-related health insurance.

This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of equilibrium in the market for employment-related health insurance. We examine coverage generosity, premiums, and insurance benefits net of expenditures on premiums, showing that despite a degree of market segmentation, there was a substantial amount of pooling of heterogeneous risks in 1987 among households with employment-related coverage. Our results are largely invariant to (i) firm size and (ii) whether or not employers offer a choice among plans. Our results suggest the need for caution concerning incremental reforms that would weaken the link between employment and insurance without substituting alternative institutions for the pooling of risks.

Adult↗
PubMedDate not supplied

Equity in managed care for mental disorders.

Equity of mental health care relative to general medical care is a long-standing policy issue in the mental health field, which in recent years has been debated as an issue of parity in insurance benefits. The shift toward managed mental health care makes the parity debate less controversial, because feared cost increases are an unlikely consequence under managed care. We argue, however, that managed care also makes benefit parity less relevant to the goals of achieving fairness in the delivery of mental health services. A broader policy perspective is required to encompass concerns about fairness under managed care.

Cost Control↗
PubMed1978

Considerations in the design of mental health benefits under National Health Insurance.

The existing insurance coverage for mental health benefits provides incentives for hospital as compared with community care and reinforces a medical approach to psychological disability. Moreover, the structure of benefits favors the affluent as compared with the disadvantaged and provides little assistance for the community integration of the chronic mental patient. In considering mental health benefits under National Health Insurance we must be careful to avoid reinforcing these patterns. It is suggested that NHI include a mental health resource development fund intended for building a stronger network of community mental health care and that the pattern of insurance benefits under NHI be consistent with developing psychiatric services on a capitation basis.

Community Mental Health Services↗
PubMed1987

Cost containment and child health.

Children, as consumers of health resources, have special developmental, psychological, and medical needs different from those of adults. Thus, cost containment efforts can affect children differently. Data related to insurance benefits changes, intensified market forces, and reductions in federal funding are cited. Their analysis focuses on the importance of accountability in applying cost constraints to services that can have a significant effect upon the health and well-being of one quarter of the next generation.

Child↗
PubMedDate not supplied

How will changes in health insurance tax policy and employer health plan contributions affect access to health care and health care costs?

OBJECTIVE: To understand how changes in federal taxation of and employer contributions to health insurance benefits affect the decisions of firms to offer insurance, the willingness of households to purchase different health plans, and the resultant health expenditures. DESIGN: Economic policy simulation. SETTING: Secondary data analysis. PARTICIPANTS: A total of 18,343 sampled families (representing 77 million total families throughout the United States) with a working household head from the 1988 Current Population Survey who were not covered by either Medicare, Medicaid, or CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) insurance. INTERVENTIONS: One intervention limits the amounts of tax-free employer contributions to health insurance premiums to 80% of our estimate of the base plan in the market and assumes that employer contributions will also be limited to this maximum. A second intervention eliminates the favorable tax treatment of employer-paid premiums altogether and assumes that employees will pay the full price of insurance. MAIN OUTCOME MEASURES: Change in the number of working families offered employment-based insurance, change in insurance plan choice, and change in medical spending. RESULTS: Capping the favorable tax treatment and employer contributions decreases the number of families offered employment-based insurance by approximately 91,000, increases the number of families selecting the least generous insurance plan from 20% under the current situation to 33%, and reduces overall health spending by less than 2%. By eliminating the tax exemption altogether, the number of families offered employment-based insurance decreases by approximately half a million families, the number of families selecting the least generous plan goes from 20% to 40%, and overall spending falls by about $16 billion. CONCLUSIONS: Eliminating the tax subsidy and limiting employer-paid contributions to the low-cost plan substantially increases the number of low-income uninsured under a voluntary insurance system, decreases overall spending only modestly, but would raise tax revenues by $36 billion. These tax revenues could be used to assist low-income families to obtain insurance coverage.

Competitive Medical Plans↗
PubMedDate not supplied

State mental health parity laws: cause or consequence of differences in use?

A new wave of state and federal legislation affecting mental health insurance was passed during the 1990s. Although patient advocacy groups have hailed the passage of numerous parity laws, it is unclear whether this activity represents a major improvement in insurance benefits or significantly increases access to mental health care. We investigated this issue with data from two new national studies sponsored by the Robert Wood Johnson Foundation. We found that states with below-average utilization were more likely to enact state legislation, but utilization in those states continues to lag behind the rest of the nation.

Health Care Rationing↗
PubMed1992

Judicial and legislative responses to cost containment.

Cost containment through reduction of insurance benefits and aggressive utilization review is increasingly risking the sacrifice of good clinical care in the pursuit of financial objectives. This article provides examples of judicial and legislative responses to perceived fiscal intrusions into clinical practice. Principles for asserting clinical goals in the cost containment process are also provided to assist in the inevitable negotiations and battles ahead.

Adult↗
PubMed2003

Community exercise program use and changes in healthcare costs for older adults.

BACKGROUND: Regular exercise is associated with many health benefits. Community-based exercise programs may increase exercise participation, but little is known about cost implications. METHOD: A retrospective, matched cohort study was conducted to determine if changes in healthcare costs for Medicare-eligible adults who choose to participate in a community-based exercise program were different from similar individuals who did not participate. Exercise program participants included 1114 adults aged > or = 65 years, who were continuously enrolled in Group Health Cooperative of Puget Sound (GHC) between October 1, 1997 and December 31, 2000 and who participated in the Lifetime Fitness (exercise) Program Copyright (LFP) at least once; three GHC enrollees who never attended LFP were randomly selected as controls for each participant by matching on age and gender. Cost and utilization estimates from GHC administrative data for the time from LFP enrollment to December 31, 2000 were compared using multivariable regression models. RESULTS: The average increase in annual total healthcare costs was less in participants compared to controls (+642 dollars vs +1175 dollars; p=0.05). After adjusting for differences in age, gender, enrollment date, comorbidity index, and pre-exposure cost and utilization levels, total healthcare costs for participants were 94.1% (95% confidence interval [CI], 85.6%-103.5%) of control costs. However, for participants who attended the exercise program at an average rate of > or = 1 visit weekly, total adjusted follow-up costs were 79.3% (95% CI, 71.3%-88.2%) of controls. CONCLUSIONS: Including a community exercise program as a health insurance benefit shows promise as a strategy for helping some Medicare-eligible adults to improve their health through exercise.

Aged↗
PubMed2001

TRICARE; Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); eligibility and payment procedures for CHAMPUS beneficiaries age 65 and over. Interim final rule.

This interim final rule implements Section 712 of the Floyd D.Spence National Defense Authorization Act for Fiscal Year 2001. Section 712 extends TRICARE eligibility to persons age 65 and over who would otherwise have lost their TRICARE eligibility due to attainment of entitlement to hospital insurance benefits under Part A of Medicare. In order for these individuals to retain their TRICARE eligibility, they must be enrolled in the supplementary medical insurance program under Part B of Medicare. In general, in the case of medical or dental care provided to these individuals for which payment may be made under both Medicare and TRICARE, Medicare is the primary payer and TRICARE will normally pay the actual out-of-pocket costs incurred by the person. This rule prescribes TRICARE payment procedures and makes revisions to TRICARE rules to accommodate Medicare-eligible CHAMPUS beneficiaries. The Department is publishing this rule as an interim final rule in order to meet the statutorily required effective date. Public comments, however, are invited and will be considered when the rule is published as a final rule.

Eligibility Determination↗
PubMed1992

The feasibility of a public-private long-term care financing plan.

In this study, the feasibility of a public-private long-term care (LTC) financing plan that would combine private LTC insurance with special Medicaid eligibility requirements was assessed. The plan would also raise the Medicaid asset limit from the current $2,000 to the value of an individual's insurance benefits. After using benefits the individual could enroll in Medicaid. Thus, insurance would substitute for asset spend-down, protecting individuals against catastrophic costs. This financing plan was analyzed through a computer model that simulated lifetime LTC use for a middle-income age cohort beginning at 65 years of age. LTC payments from Medicaid, personal income and assets, Medicare, and insurance were projected by the model. Assuming that LTC use and costs would not grow beyond current projections, the proposed plan would provide asset protection for the cohort without increasing Medicaid expenditures. In contrast, private insurance alone, with no change in Medicaid eligibility, would offer only limited asset protection. The results must be qualified, however, because even a modest increase in LTC cost growth or use of care (beyond current projections) could result in substantially higher Medicaid expenditures. Also, private insurance might increase personal LTC expenditures because of the added cost of insuring.

Aged↗
PubMed1977

Private industry health insurance plans: employment requirements for coverage in 1974.

In 1974, approximately 28.4 million active workers participating in almost 52,000 health plans on their jobs were covered by in-hospital health insurance benefits. A survey of these plans, conducted for the Social Security Administration by the Bureau of Labor Statistics, revealed that not all workers are automatically entitled to benefits on the first day they report for work. More than three-fifths had to fulfill at least one job-related requirement before their hospital coverage was effective. The extent and variety of employment requirements in private industry are discussed here along with data that show how plans that have such requirements differ from those that do not.

Collective Bargaining↗
PubMed1986

Self-insured health plans.

Nationwide, 8 percent of all employment-related health plans were self-insured in 1984, which translates into more than 175,000 self-insured plans according to our latest study of independent health plans. The propensity of an organization to self-insure differs primarily by its size, with large establishments more likely to self-insure. In the overwhelming majority of cases, the self-insured benefit was hospital and/or medical. Among employers who self-insure, 23 percent self-administer, and the remaining 77 percent hire a commercial insurance company, Blue Cross/Blue Shield plan, or an independent third-party administrator to administer the health plan.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Community rating in health insurance and different benefit packages.

This paper presents a model of a competitive health insurance market with two risk types and two health benefits. In the benchmark case, community rating insurers (CRIs) are only allowed to offer the basic benefit. The additional benefit is sold by risk rating insurers (RRIs). It is shown that low risk types can only be better off at the expense of high risk types if CRIs are allowed to offer the additional benefit and no additional measures are taken. However, high risk types can be made better off if CRIs must offer the additional benefit or if community rating health insurers offering the additional benefit are subsidized while those selling only the basic benefit are taxed.

Actuarial Analysis↗
PubMed1992

Legislative interventions to increase access to screening mammography.

Although numerous studies have established that breast cancer mortality can be significantly reduced through early detection, only a small percentage of women obtain screening mammograms at intervals recommended by the National Cancer Institute, the American Cancer Society, and other major medical organizations. This paper examines the importance of cost as a barrier to routine screening and the state legislative movement to make screening mammography a basic health insurance benefit. Mammography "knowledge, attitudes, and behavior" studies offer conflicting findings on the extent to which cost enters into the decision to have a mammogram. Women seldom report cost as a major reason for postponing or failing to have a mammogram; yet, descriptive studies show a consistently positive relationship between income and mammography use. State mammography reimbursement laws vary greatly with respect to whether screening mammography is a required or optional benefit, payment limits, and eligibility and referral requirements. Although state-specific data on the percentage of women with private health insurance are not available, 1987 National Medical Expenditure Survey estimates for U.S. Census geographic divisions suggest that the New England, East North Central, West North Central, Middle Atlantic, and Mountain states have the highest percentages of women who are privately-insured and, thus, potentially eligible for legislated mammography benefits. Access to screening mammography also is likely to be influenced by the proportion of employer-sponsored health plans that are self-insured and, therefore, exempt from minimum benefit mandates and the extent to which women are aware of the screening coverage.

Adult↗
PubMed1989

The other shoe drops--FASB (Financial Accounting Standards Board) issues its proposed statement on employers' accounting for postretirement medical benefits.

The Financial Accounting Standards Board recently issued an exposure draft dealing with employers' accounting for postretirement medical or life insurance benefits. Mr. Melbinger explains the implications of these proposed changes in accounting procedures and discusses the status of case law dealing with employers' rights to modify or terminate retiree medical coverage.

Accounting↗
PubMed1988

Cost-justification analysis of prenatal maternal serum alpha-feto protein screening.

The costs to an insurer of a 10-year maternal serum alpha-feto protein (MSAFP) screening program were subtracted from future medical care costs avoided by the insurer (benefits) to examine whether such a program would be cost-justified from the perspective of a managed health care system (i.e., result in net costs greater than or equal to 0). The analysis considered MSAFP screening for neural tube defects (NTDs) alone and then was repeated to consider screening for both NTDs and Down's syndrome. Using a 5% discount rate for future dollars, the costs to the insurer of a screening program for NTDs alone over 10 years exceeded costs avoided by $10.00 per person screened. Adding screening for Down's syndrome using the same MSAFP test increased the net cost by $22.00 to a total of--$32.00 per screenee. The estimate of the cost to the insurer was sensitive to assumptions regarding the costs of medical care avoided, the expense of MSAFP, the proportion of screened women requiring a genetic amniocentesis, and the cost of that procedure. The conclusion that screening would not result in a cost savings to the insurer was not changed by reasonable assumptions regarding 1) the appropriate discount rate; 2) the costs of MSAFP; 3) the costs of genetic amniocentesis; 4) the sensitivity of MSAFP; 5) the proportion of the population requiring genetic amniocentesis; and 6) the costs of 10 years of medical care for someone affected by Down's syndrome or an NTD. Other analyses suggested that screening for NTDs or Down's syndrome would be cost-justified when viewed from the perspective of society. The present work suggests this conclusion does not hold when the perspective of the insurer is taken because avoided costs of care realized by society exceed those realized by the insurer.

Adult↗