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At least 253 records · Page 14Linked to original sources
PubMed1994

Patients' rights after health care reform: who decides what is medically necessary?

President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers.

Cost Control↗
PubMedDate not supplied

The impact of a comprehensive medical benefit cost management program for the city of Birmingham: results at five years.

Double digit annual increases in the cost of medical benefits represent one of the major financial challenges for many private and public sector employers. Gaining greater control is a top priority. Since the procurement, administration, and delivery of employee/dependent medical care is a highly complex venture, it is unlikely that any one activity will contain costs effectively. This report examines a comprehensive cost management effort for the municipal government of the city of Birmingham, Alabama, which included health promotion, medical plan redesigning, managed care, and "how to use the medical system" education programs. The $3 million project was funded by the National Institutes of Health and the employer and conducted from 1985 to 1990. In 1985, medical benefits expenses for the 3,586 employees were $2,047 per employee which was about $400 above the state of Alabama per employee average. In 1990, for 4,000 employees, it was $2,075 which was $922 below the state average. While the project design does not permit a precise evaluation of the exact impact of each of the cost containment activities, attempts are made to estimate their impact. Several health promotion activities, which may be unique to this project, including the all-employee medical screen, are presented and evaluated.

Alabama↗
PubMed1999

Return to work after surgery for lumbar disc herniation. A rehabilitation-oriented approach in insurance medicine.

STUDY DESIGN: An intervention study by the medical advisers of a social security sickness fund on a mandatorily insured patient population after open discectomy for herniated lumbar intervertebral disc. The medical advisers were randomized into two groups: a control group (n = 30) and an intervention group (n = 30). OBJECTIVES: To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual claim-based practice. SUMMARY OF BACKGROUND DATA: This study included 710 patients, with a mean age of 39.2 years, who underwent surgery for herniated lumbar disc. METHODS: Medical advisers in the rehabilitation-oriented group examined the patients monthly, starting at 6 weeks after the surgical intervention. They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration. RESULTS: At 52 weeks, 10.1% of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1% of the patients in the control group. It was statistically proven that this effect also holds during the follow-up period. CONCLUSIONS: A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery.

Adult↗
PubMed1987

Medicare financing and beneficiary income.

With Medicare outlays expected to continue their upward spiral and with the growing proportion of elderly among the population, Medicare financing is likely to be closely scrutinized in the coming years. In this paper I examine the economic, demographic, and health trends likely to affect Medicare solvency in the years ahead. I then review the current debate over adding catastrophic coverage to Medicare, with special attention to the proposed financing mechanisms. I conclude with an analysis of alternative revenue sources for Medicare in the future. I propose that a fundamental reform of Medicare financing be undertaken that would merge the health insurance (HI) and supplementary medical insurance (SMI) components of the program. Funding would come from currently scheduled HI payroll taxes, general revenues projected to meet SMI expenditures, alcohol and cigarette taxes, and a new Medicare premium related to beneficiary income.

Aged↗
PubMed1980

Episodes of psychiatric utilization.

The continued growth of outpatient psychiatric care has been accompanied by a large number of research studies concerning the determinants of psychiatric utilization. One of the major limitations of these efforts has been the inability to go beyond distributional data on the use of services. This article describes a methodology for generating episodes of psychiatric care given a data set with a small amount of routinely collected data present in many medical information systems. Both demographic and medical characteristics are significantly associated with health services resource use as defined by the number of visits in an episode. A model predicting recurrent episodes of care is also described. The general utility of this approach and the substantive implications of the specific results are discussed.

Adolescent↗
PubMed1985

Who are the underinsured?

Inadequate insurance, whether private or public, can impose ruinous private hardship and unexpected public burdens. "Who are the underinsured?" is both a definitional and an empirical question. Data from the National Medical Care Expenditure Survey, applied under various concepts of risk and expense, reveal that over a quarter of the nonelderly population is inadequately protected against the possibility of large medical bills. The private burdens of the underinsured are widely distributed across the population.

Actuarial Analysis↗
PubMed1975

Impact of integration of mental health service and comprehensive medical care.

Effect of the introduction of mental health services into a comprehensive prepaid medical care facility was studied. The subjects were two independent subsamples of all individuals seen in the mental health service for the first time in 1967, and two comparison groups not seen in the mental health service. Data consisted of medical visits from 1962 through 1969 and mental health visits from 1967 through 1969. Insufficient support was found for the assertion that mental health services produce savings of medical care. Some of the complex interactions between care for somatic and mental health treatment variables, and points for future study are noted.

Comprehensive Health Care↗
PubMed1992

The impact of utilization review on costs and utilization.

This paper examines the performance of a utilization review program using data from Aetna's utilization review (UR) customers compared to a representative sample of its customers which had no utilization review during the study period. Statistical adjustments were made for the utilization management status, employee demographics, plan benefits, group size, year effects and seasonality. The study period covered from the first quarter of 1987 through the last quarter of 1988. The data suggest that UR reduces overall medical expenses by 4.4 percent, and inpatient expenses by 8.1 percent after a year of experience, largely by reducing length of stay.

Ambulatory Care↗
PubMed2006

[Integrated Health Care in cardiology: have all players used their opportunities?].

From the view of one of the largest public health insurance companies, in this paper it is outlined that Integrated Health Care provides opportunities to influence the largely regional structures of health care supply. This insurance company has specialized in contracts for Integrated Health Care in cardiology in order to achieve sustainable solutions for all providers of invasive and interventional cardiology that are economically reasonable. But first of all, only evidence-based medical procedures and interventions based on clinical pathways are eligible for the contracts of this company. In outlining this, it becomes evident that by far not all German public health insurance companies have yet used their opportunity.

Cardiology↗
PubMed1979

Focusing the catastrophic illness debate.

Unlike other aspects of the American health experience, there is a current void of information on expensive illness experiences. This paper is designed to fill this void and prrsents an analysis of the incidence and cost of catastrophic illness in the United States. Catastrophic illness is defined as an illness episode for which a person incurs $5,000 or more of medical expenses in a calendar year. This information is used to provide a framework for focusing the debate about catastrophic and national health insurance.

Adolescent↗
PubMed1976

Studying the impact of patient drug profiles in an HMO.

The objectives of the study were to determine if a drug profile quantitatively and qualitatively influenced various aspects of drug utilization. A group of 1,632 medically indigent persons enrolled in the Kaiser Health Plan constituted the study population. This population received completely prepaid medical care including drug services from the Kaiser Medical Care Program. A computer-based chronological and monthly updated listing of drugs ordered and prescriptions received was provided as the front page of the centralized outpatient medical chart for a randomly selected half of the study population for a full year. Duplicate and bound copies of these patient drug profiles were also provided each outpatient pharmacy. The findings indicated the presence of the drug profile did not quantitatively or qualitatively affect prescription receipt of the group with the profile. Although the findings must be viewed in the contexts of the population served and the medical care setting, the findings strongly indicate the need for additional research to assess additional forms of drug profiles and under conditions not addressed by this study.

Adult↗
PubMed1996

Medical savings accounts: why do they work?

This article analyzes and reviews the cost and design characteristics of medical savings accounts (MSAs). By placing premium savings from high-deductible health insurance in medical savings accounts, individuals have an incentive to shop for medical services. A more market-oriented health insurance and delivery system results, as individuals are now both users and buyers of health care. Data show that most families would accumulate balances in their MSAs that may be used for future medical expenses or savings. Through program design, the potential problems of adverse selection and cost to risk can be greatly reduced.

Cost Sharing↗
PubMed2000

An efficient employer strategy for dealing with adverse selection in multiple-plan offerings: an MSA example.

This paper outlines a feasible employee premium contribution policy, which would reduce the inefficiency associated with adverse selection when a limited coverage insurance policy is offered alongside a more generous policy. The "efficient premium contribution" is defined and is shown to lead to an efficient allocation across plans of persons who differ by risk, but it may also redistribute against higher risks. A simulation of the additional option of a catastrophic health plan (CHP) accompanied by a medical savings account (MSA) is presented. The efficiency gains from adding the MSA/catastrophic health insurance plan (CHP) option are positive but small, and the adverse consequences for high risks under an efficient employee premium are also small.

Community Participation↗