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PubMed2004

The benefit of health insurance coverage of contraceptives in a population-based sample.

This study estimated the value of contraceptives, through a random-digit-dialed survey of willingness to pay for health insurance coverage of contraceptives among 659 Washington State adults. People valued contraceptives at 5 times the actuarial cost; in general, women and reproductive-aged persons were willing to pay more, but low-income men highly valued contraceptives. Most respondents (85%) said that contraceptives should be covered by health insurance plans. The full benefit of contraceptives exceeds their cost.

Actuarial Analysis↗
PubMed1997

Issues in mental health care benefits: the costs of mental health parity.

This Issue Brief discusses issues in mental health care benefits. It describes the current state of employment-based mental health benefits and discusses studies and issues regarding full mental health parity. It also includes an analysis of the effect of full mental parity on the uninsured population and the effects of the limited mental health parity provision contained in the VA-HUD appropriations bill. The final section discusses the implications of mental health parity for health plans and health insurers. When employers began to provide health insurance benefits to their employees and their families, they extended coverage to include mental health benefits under the same terms as other health care services. Many employers continued to add mental health benefits through the 1970s and early 1980s until cost pressures required employers to re-examine all health care benefits that were offered. They quickly found that, while only a small proportion of the beneficiaries used mental health care services, the costs associated with this care were very high. As a result, employers placed limits on mental health benefits in an attempt to make the insurance risk more manageable. The general strategies employers have used to manage their health care costs are cost sharing, utilization review, managed care, and the packaging of provider services. Employers' cost management strategies may be restricted, however. Five states have mental health parity laws, but three of the states--Rhode Island, Maine, and New Hampshire--apply these laws only to the seriously mentally ill. In addition, 31 states mandate that mental health benefits be provided. However, state mandates apply only to insured plans, not to self-insured employer plans, which are exempt from state regulation of health plans under the Employee Retirement Income Security Act of 1974 (ERISA). A number of recent studies have examined the effect of mental health parity on health insurance premiums in a "typical" preferred provider organization and on the uninsured. In general, the studies concluded that mental health parity could increase health insurance premiums, decrease health insurance coverage for non-mental health related illnesses, and increase the number of uninsured individuals. All studies of mental health parity, and mandated benefits in general, assume that there is a strong likelihood that increased health benefit costs would be passed along to workers in the form of higher cost sharing for health insurance, lower wage growth, or lower growth in other employee benefits.

Cost Sharing↗
PubMed2004

Health care for older persons: a country profile-Korea.

The Korean healthcare system is faced with a crisis caused by rapidly changing social values tending toward westernization, increasing insurance benefit requests for elder health care, financial instability of the National Health Insurance (NHI) program, and a lack of social infrastructure for the elderly. The demand for health care for the elderly has increased markedly, because of a rapidly aging population, growing female participation in the labor market, elevated expectations for health care, and a change in the pattern of medical conditions in the elderly from acute illness to chronic disability. NHI lacks the finances to meet the benefit request for long-term care (LTC). Only 0.39% of the elderly can be accommodated in LTC beds. Consequently, the chronically disabled elderly overflow to acute care beds in general hospitals, which places an undue burden on the already strained NHI system in terms of longer stays and higher cost of treatment in hospitals compared with care specific to the elderly in LTC facilities. It is clear that the Korean healthcare system does not have the facilities to meet such challenges and is in a state of disorder. Korea has failed to predict and prepare for population needs before they arise, including financing and the development of appropriate care models, particularly concerning the adequate provision of LTC. This paper advocates the necessity of international discussion of the prospects for developing health care for aging populations and encourages the sharing of differing national experiences concerning care for the elderly.

Aged↗
PubMed1985

Retiree health and welfare benefits: controversy over their duration.

As the cost of providing health-care benefits skyrockets, employers have begun to reduce or even to terminate health-care and life insurance benefits for retirees, often with little awareness of the possible repercussions. Retiree groups and unions have countered these actions with claims based on such theories as the "status benefits" argument--that retirement benefits should be viewed as earned compensation for years of service--or the "vested rights" view--that retirement rights may not be altered without the pensioner's consent. Crucial to these conflicts are the terms of the collective bargaining agreement. Case law indicates that employers can never feel themselves fully protected even if the agreement contains provisions explicitly stating the benefits' scope and duration. The authors demonstrate this point in their review of recent retiree benefits cases. They then explore in detail the problem of contract and document ambiguity, and offer guidelines for ascertaining intent. They conclude with a discussion of strategies for litigating retiree benefits cases.

Insurance, Health↗
PubMed1987

The cost of disability.

Approximately 16.5% of the adult population in the United States is disabled. About half of the disabled are severely limited and unable to work regularly. Musculoskeletal disorders are the most frequent type of disability. In the United States, there are three major types of disability insurance: Social Security Disability Insurance (a federal program), Workers' Compensation Insurance (usually a state-regulated program), and private health insurance. Recent years have seen a greater demand for private long-term disability insurance, as the trend increases toward less than total reliance on public programs to support disabled workers. The most recent statistics available indicate that Social Security Disability Insurance benefits are currently about $16.8 billion per year; workers' compensation benefits, $16.1 billion; and private disability income protection benefits, $5.2 billion. These figures add up to almost $40 billion in insurance costs. However, insurance costs are only part of the total cost because not everyone is covered by insurance, and insurance does not cover all disabilities. Disability can never be totally prevented or eliminated, but disability and its costs can be substantially reduced through more effective treatment and rehabilitation, including patient education and vocational rehabilitation.

Adolescent↗
PubMed2003

A structural econometric model of family valuation and choice of employer-sponsored health insurance in the United States.

This paper estimates a fully structural unitary household model of employment and health insurance decisions for dual wage-earner families with children in the United States, using data from the 1987 National Medical Expenditure Survey. Families choose hours of work and the breakdown of compensation between cash wages and health insurance benefits for each wage earner in order to maximize expected utility under uncertain need for medical care. Heterogeneous demand for the employer-sponsored health insurance is thus generated directly from variations in health status and earning potential. The paper concludes by discussing the benefits of using structural models for simulating welfare effects of insurance reform relative to the costly assumptions that must be imposed for identification.

Adolescent↗
PubMed1991

Establishing ownership of the hospital bill in admissions: a key to protecting your facility's fiscal integrity.

You have a plan and you have educated and documented that the patient is cognizant of his/her responsibility. Reality often dictates that problems surface after discharge. How can we prevent the patient from placing the bill on a shelf and forgetting it? As a part of your hospital's bottomline, you have a responsibility to ensure that its fiscal integrity is protected. Afterall, your hospital is also a business as well as a healing institution. Taking the lead in getting the right information at the admission or precertification stage is a vital element in the collection loop. Second, realize that not all, but a majority of patients, are beginning to investigate their benefits and coverage limitations. They may be doing so without a total understanding of insurance terminology or the difference in how much of the hospital/physician charges are paid or what percent rests with them. Last, in Pennsylvania at least, the state requires active participation by hospitals in healthcare cost containment by requiring submission rate and medical outcome information. Why not take this opportunity as an admitting professional to try some of the strategies mentioned. Informing the patient of their insurance benefits and providing an estimate of the bill will increase your department's contribution, and educate the patient about "consumerism". Consumerism is developing within the healthcare industry.(ABSTRACT TRUNCATED AT 250 WORDS)

Admitting Department, Hospital↗
PubMed1984

The conversion of claims files to an episode data base: a tool for management and research.

The construction of an episode-of-care file based on utilization data from the insurance claims system of Blue Cross and Blue Shield of North Carolina was undertaken for its subscribers and Medicare beneficiaries, a data base that includes 60% of the hospital days in North Carolina. The conversion was accomplished without interfering with the integrity of the accounting system, and the resulting file provides essential data for management decisions and epidemiological research. Among the uses to which the information in the file can be put are the promotion of ambulatory surgery, the redesign of group insurance benefits by employers, and the support of statewide health planning programs.

Ambulatory Surgical Procedures↗
PubMed2001

Quality of life and employment after liver transplantation.

1. In general, the health-related quality of life (QOL) of transplant recipients is impaired before and improves after liver transplantation. 2. Transplant recipients report largest gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning. 3. No utility-based measures have been used with liver transplant recipients; therefore, the necessary QOL weights for use in cost-effectiveness evaluations of liver transplantation are lacking. 4. Pretransplantation, the percentage of candidates with alcoholic liver disease (ALD) who work is less than that of candidates without ALD. However, there is no difference in rates of employment posttransplantation. 5. No study has described types of wages and benefits associated with jobs before or after transplantation or the extent to which health insurance benefits associated with employment motivate changes in work status. 6. Many studies in this field used non-validated heterogeneous instruments to measure QOL and employment, thus limiting the opportunity to combine results across studies and compare outcomes for liver transplant recipients with other patient populations.

Employment↗
PubMed1993

Psychiatric care and health insurance reform.

Concerns about cost, access, and quality of health care in the United States have led to a variety of legislative proposals that would reform our health care system and its financing. Health insurance benefits for mental illness, including substance abuse, are treated differently from medical/surgical benefits, with stricter limits on outpatient visits and hospital days. Medicare, Medicaid, and most private health insurance plans contain this historic disparity of coverage for mental illness compared to general medical illness. Psychiatric services are also distinguishable because of the large public sector reimbursement for mental illness treatment and support. Principles for a more equitable design of mental health benefits include a non-discriminatory approach; payment on the basis of service rather than diagnosis; application of cost containment for care of mental illness on the same basis as care of general medical illness; retention of the public sector as a backup system for high-cost, long-term care; encouragement of lower-cost alternatives to the hospital through the development of a continuum of care; and a recognition of the distinction between psychotherapy and medical management. All current approaches to universal health care fall short of these principles. A research agenda is needed now more than ever in order to articulate the case for complete coverage of mental illness and substance abuse.

Ambulatory Care↗
PubMed1995

Playing by the rules and losing: health insurance and the working poor.

Using a sample of 7,734 employed adults from the National Medical Expenditure Survey, this research compares the sources of health insurance coverage and the antecedents of employer-sponsored insurance among the working poor to those at higher income thresholds. Concern with the working poor is warranted because they constitute the majority of the uninsured, they do not qualify for public health programs, and their health insurance benefits have eroded substantially. The data reveal that (1) the working poor are only one-third as likely to receive insurance from their employer as are the non-poor, and are over five times as likely to be without insurance from any source; (2) employment characteristics are critical antecedents of employer-sponsored insurance and, as a set, explain variation in coverage beyond that provided by human capital/socioeconomic factors; and (3) most employment characteristics have a similar effect on the odds of coverage across income categories, except for unionization and minimum wages. Implications for health care reform are addressed.

Adolescent↗
PubMed1998

Preventive health counseling reported by uninsured women with limited access to care.

Low-income women in the childbearing years are at an increasing risk of becoming uninsured as welfare reforms are enacted and women enter minimum-wage jobs without insurance benefits. This study contrasts preventive counseling reported by low-income uninsured mothers and mothers insured through Medicaid. Low-income women attending Women, Infant, and Children (WIC) clinics and human services offices who had received health care during the previous 12 months (N = 406) were asked if they had received counseling from a health provider regarding any of seven types of preventive health behaviors. Uninsured women were less than half as likely to receive counseling on three or more preventive topics (OR = 0.42) as were mothers on Medicaid. Risk estimates were stable on bivariate analyses and logistic regression models. Findings indicate that opportunities for preventive health counseling need to be maximized for this group already experiencing compromised access to care.

Adult↗
PubMedDate not supplied

Business opportunities in transforming health care: an interview with William W. McGuire.

After a spate of high-profile acquisitions including Oxford Health Plans, UnitedHealth Group (UHG) covers twenty-two million Americans in insured and self-insured health plans and tens of millions more through specialty products. Bill McGuire describes his strategy of growth through acquisition and through diversification into Medicaid managed care, the individual insurance market, and services for the elderly under the Medicare Modernization Act of 2003. He sees business and public policy opportunities in the unjustifiable variation in cost and quality across the health care spectrum and proposes a framework of basic insurance benefits for all Americans, with options for people to purchase additional benefits with their own money.

Economic Competition↗
PubMed2002

Association between health insurance coverage of office visit and cancer screening among women.

BACKGROUND: Little is known regarding the nuances of insurance benefit design that may affect the receipt of clinical preventive services. OBJECTIVE: To evaluate whether differences in insurance coverage of physician office visits influences the receipt of cancer screening in women who have full coverage for the screening services. DESIGN: Cohort study of women enrolled in fee-for-service (FFS) or Preferred Provider Organization (PPO) health plans, where FFS plans have less generous office visit coverage, for the period 1995 to 1997. SETTINGS AND PARTICIPANTS: General Motors Corporation's employees and their dependents. MAIN OUTCOME MEASURES: Papanicolaou and mammography rates in women aged 21 to 64 years (n = 139,294) and 52 to 64 years (n = 56,554), respectively. RESULTS: Compared with FFS plans, enrollees in PPO plans were significantly more likely to obtain a Papanicolaou smear and mammogram (adjusted relative risk [RRa] = 1.22; 95% CI, 1.21-1.24; and RRa, 1.17; 95% CI, 1.15-1.18, respectively). The association was more pronounced among hourly individuals (RRa, 1.27; 95% CI, 1.26-1.29 for Papanicolaou smears; RRa, 1.17; 95% CI, 1.16-1.19 for mammograms) than among salaried individuals (RRa, 1.10; 95% CI, 1.08-1.12 for Papanicolaou smears and RRa, 1.10; 95% CI, 1.06-1.12 for mammograms), corresponding to a greater differential in office visit coverage among the hourly group. CONCLUSIONS: Benefit structure appears to have an important effect on receipt of cancer screening in women. The findings highlight the need to ensure that future reforms of the health care system do not adversely affect the use of preventive services.

Adult↗
PubMed2005

Reimbursement for dental implants: dispelling some popular myths.

BACKGROUND AND OVERVIEW: Dental implants are being placed with increasing regularity. Many dentists do not take advantage of insurance coverages for this treatment because they are under the impression that no aspect of implant therapy is covered. This article discusses a number of insurance benefits that may be available to dental patients but not readily apparent to treating dentists and their staff members. CONCLUSIONS AND PRACTICE IMPLICATIONS: Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not consider implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Knowing that some reimbursement is available may make the difference in the patient's accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they deserve to know their options and to receive appropriate benefits.

Current Procedural Terminology↗
PubMed2000

Prescription drugs in Medicare and the ESRD program.

Prescription drugs have improved the length and quality of life for many persons, particularly those with chronic disease. However, their contribution to total health care costs has been increasing, making it difficult for patients to afford necessary medications. Current Medicare policy, derived from statutory enactments by Congress, precludes payment for prescription medications with the exception a few medications for end-stage renal disease (ESRD) patients. A more comprehensive prescription drug benefit for Medicare has been proposed that might benefit ESRD patients. Design and implementation of a medication drug benefit involves several issues including what medications should be covered, under what circumstances, how cost should be shared, the payment structure, level of payment, and management of the benefit. This report describes the experience with Medicare coverage of prescription drugs for ESRD patients and explores issues in offering a general medication insurance benefit under Medicare.

Drug Prescriptions↗