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Medicare program; establishing procedures for transmitting information between Medicare carriers and Medicare supplemental insurers--HCFA. General notice.

This notice announces and describes the procedure for the automatic transfer of claims information from Medicare carriers to Medicare supplemental (Medigap) insurers when a beneficiary has assigned his or her right of payment to a participating physician or supplier. It delineates the roles of the Medicare carriers, Medigap insurers, State insurance departments, beneficiaries, physicians and suppliers, and HCFA. The procedure for the automatic transfer of claims is required by section 1842(h)(3)(B) of the Social Security Act, as added by section 4081(a) of the Omnibus Budget Reconciliation Act of 1987 and is intended to speed payment of Medicare supplemental insurance benefits to participating physicians and suppliers.

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

Blue Cross/Blue Shield president strives for 'grass roots' cooperation.

Walter J. McNerney, recently chosen president and chief executive of the newly consolidated Blue Cross and Blue Shield Associations, discusses future plans and goals of the organizations, emphasizing the positive effects the consolidation will have on insurance benefit programs and on the plans' relationships with hospitals and physicians.

Blue Cross Blue Shield Insurance Plans↗

Equity in paying for health care services under a national insurance system.

The debate over the future of the health care delivery system evolves around the policy issue of what constitutes a fair distribution of the medical services which are considered essential to prolonging life, curing disease, and relieving pain. A case can be made that a socially equitable distribution implies that consumption of medical services is independent of the consumer's income and payment for them unrelated to utilization. The present paper examines to what extent the provisions for financing a national health insurance system are likely to advance or hinder the fair distribution of health care services. Almost all bills specify a mix of direct (cost-shared) and indirect (prepaid) financing. When cost-sharing is based on the quantity of services or on the level of medical expenditure, it helps divert medical care and health insurance benefits to high-income persons at the expense of their low-or moderate-income counterparts. When indirect payments or premium levels are determined by insurance risks rather than by income, they may be too high for persons with moderate means, and are likely to exclude such persons from the national insurance program. When health insurance is tied to salaried employment, it discriminates against the unemployed and the self-employed. To rectify such inequities, some NHI proposals specify separate insurance plans for the disadvantaged. Such programs, which require income-testing to determine eligibility, are likely to be plagued by administrative complications currently engulfing other means-tested social welfare programs. The present paper makes some recommendations for the purpose of avoiding these difficulties and fostering equity in health care.

Deductibles and Coinsurance↗

No care for the caregivers: declining health insurance coverage for health care personnel and their children, 1988-1998.

OBJECTIVES: This study examined trends in health insurance coverage for health care workers and their children between 1988 and 1998. METHODS: We analyzed data from the annual March supplements of the Current Population Survey (CPS), a Census Bureau survey that collects information about health insurance from a nationally representative sample of noninstitutionalized US residents. RESULTS: Of the health care personnel younger than 65 years, 1.36 million (90% confidence interval [CI] = 1.28 million, 1.45 million) were uninsured in 1998, up 83.4% from 1988; the proportion uninsured rose from 8.4% (90% CI = 7.8%, 9.1%) to 12.2% (90% CI = 11.5%, 12.9%). Declining coverage rates in the growing private-sector health care workforce---and declining health employment in the public sector, which provided health insurance benefits to more of its workers---accounted for the increases. Households with a health care worker included 1.12 million (90% CI = 1.05 million, 1.20 million) uninsured children, accounting for 10.1% (90% CI = 9.5%, 10.8%) of all uninsured children in the United States. CONCLUSIONS: Health care personnel are losing health insurance coverage more rapidly than are other workers. Increasingly, the health care sector is consigning its own workers and their children to the ranks of the uninsured.

Adolescent↗

Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study.

STUDY DESIGN: Population-based, incidence cohort. OBJECTIVES: To evaluate a government policy of funding community and hospital-based fitness training and multidisciplinary rehabilitation for whiplash. SUMMARY OF BACKGROUND DATA: Although insurance benefits commonly include rehabilitation for whiplash, its effectiveness is unknown. METHODS: All Saskatchewan adults treated for whiplash (n = 6,021) over a 2-year period were followed up at 6 weeks, 3, 6, 9, and 12 months. Recovery was defined by self-report of improvement. Recovery times were compared between those attending fitness training at health clubs (n = 833), multidisciplinary outpatient rehabilitation (n = 468), and multidisciplinary inpatient rehabilitation (n = 135) to those receiving usual insured individual care. RESULTS: Recovery was 32% slower in those receiving fitness training within 69 days of injury (P = 0.001) and 19% slower when received within 119 days of injury (P = 0.041). Recovery was 50% slower in those receiving outpatient rehabilitation within 119 days of injury (P = 0.001). Attending inpatient rehabilitation did not influence recovery rates during the follow up (P = 0.131). Multivariable adjustment for important prognostic factors did not change these results. CONCLUSIONS: We found no evidence to support the effectiveness of a population-based program of fitness training and multidisciplinary rehabilitation for whiplash. Rehabilitation programs should be tested in randomized trials before being recommended to injured populations.

Adult↗

Returning to work after liver transplant: experiencing the roadblocks.

Liver transplant has been the treatment of choice for people with end-stage liver disease since the mid-1980s. The theme of returning to work after liver transplantation emerged from the data of a phenomenological study examining the lived experience of people with liver transplants. Thirteen liver recipients were interviewed using a semistructured approach. Only one of the first nine participants was able to return to work after the transplant; therefore, the last four participants were purposely chosen because they had been able to return to work. The possibility of losing health insurance benefits and disability benefits prevented many participants from working. Those able to return to work had professional careers that afforded them flexibility in their work schedule. Some implications for health professionals lie in the area of healthcare and health insurance policy change. Avenues for health insurance reform could be explored in an effort to empower the transplant recipient.

Adaptation, Psychological↗

National health insurance reconsidered: dilemmas and opportunities.

Changing social and economic constraints are precipitating a reformulation of the role of government in the provision of social welfare services. The authors conclude that government intervention in the health sector is bound to expand rather than contract because centralization is the key to reconciling otherwise divergent political demands for spending controls and greater equality of access to quality care for the increasing number of uninsured or underinsured persons. In the past eight years, the federal government has unleashed competitive market principles that have had negative side effects on the nation's health services. Payers, providers, and consumers will likely seek to protect themselves by forming coalitions, as happened recently in Massachusetts where the law now requires employers to provide minimum health insurance benefits to their employees. Escalating pressures to correct the damages from short-term piecemeal solutions to problems of health finance and delivery will provide the chief dynamic for universal health insurance in the United States. New economic, social, and political realities suggest, however, an eclectic strategy for attaining this goal that bears little resemblance to the conventional wisdom that guided health policy throughout the postwar period.

Health Expenditures↗

Soft-tissue injury of the neck in a hospital based material.

In a study from northern Sweden, 139 patients with a history of a soft-tissue injury of the neck were studied. The incidence was 1 per 1000 inhabitants. Male patients in the age group 20-29 years were most commonly injured. Traffic accidents constituted the major group with 96 (69%) and falls with 24 (17%). Forty-one cases received sickness benefit for a median time of 16 days for males and 25 days for females. Five persons were on sick-leave for over a year. The calculated total cost of treatment and sickness insurance benefit was about 0.9 million SEK/year.

Adolescent↗

The critical role of ERISA in state health reform.

Despite prominent roles for employers and state regulation in the Clinton administration's Health Security Act, relatively little attention has been accorded to the impact of federal preemption of state legislation through the Employee Retirement Income Security Act (ERISA). As interpreted by the U.S. Supreme Court, ERISA permits state regulation of insured employee health plans but otherwise preempts analogous regulation relating to self-insured benefit plans. This has prompted lower courts to find that hospital rate-setting legislation, regulation of preferred provider organizations (PPOs), and medical malpractice suits for utilization review decisions are preempted by ERISA. Several issues with major implications for health reform remain unresolved, such as the availability of ERISA preemption to self-insured health alliances and health maintenance organizations (HMOs).

Health Benefit Plans, Employee↗

The cancer patient at work.

The person who has been treated for cancer may have unique problems resuming employment or starting a new job. Cancer represents a spectrum of diseases, and posttreatment impairments may vary from none, in the majority of cases, to major functional disability. Employers understandably have difficulty recognizing the variability that exists, both in terms of functional capacity and prognosis, and they are often unaware of the improved prognosis for many cancers. Today, many patients receive adjuvant chemotherapy or prolonged intermittent treatment and need to adjust their work schedule to allow for this. Some people need job training or vocational counseling; in many states, vocational rehabilitation agencies now have an increased interest in providing services to cancer patients. Discrimination against the cancer patient has been demonstrated; the major problems are in the area of hiring practices. Efforts need to be continued to educate employers and the public and to ensure that the rights of the cancer patient are recognized. We may, however, do our patients a disservice if we overemphasize potential problems to a degree that increases patient fear and insecurity in regard to employment. Instead, we as physicians may be able to help prevent problems by more effective communication with employers on behalf of our patients, as well as by direct patient counseling. The insurance problems of cancer patients, particularly those relating to health insurance, do require major attention. The potential productivity, as well as the quality of life, of the cancer patient are jeopardized when he or she feels unable to change jobs because of fear of loss of insurance coverage. The relatively high number of reported cancellations and changes in insurance benefits that have been reported by cancer patients also represents an area of concern, since some of these appear medically unjustified. The physician's opinion and input may be of importance in preventing or solving individual insurance problems. The physician can also help the cancer patient who has employment problems by providing information about available resources. The above-mentioned employment booklet (#4585-PS), available from the ACS, may be useful and contains information about legal resources. Referral to a vocational rehabilitation agency may be indicated. The best medicine of all may be a positive and optimistic attitude toward the patient's participation in the work force.

Adaptation, Psychological↗

[Shoulder dislocation and periarthrosis humeroscapularis].

1232 injuries involving shoulder luxations in 1984 were investigated on the basis of the insurance dossier. 1/3 of the injured persons have sequelae: 10.5% habitual tendency to luxation, 9% peritendinitis, 2% omarthritis and 2% a shoulder instability. 1/5 in each case still experience pain and restricted movement. The 108 cases where peritendinitis has occurred following shoulder luxations are shown divided up according to various symptoms. Peritendinitis ankylosis or frozen shoulder represents the major share in almost half of the cases. Various characteristics, complications and risk factors for the possibility of contracting peritendinitis following shoulder luxation are being worked out. In conclusion, the insurance-relevant parameters for peritendinitis after shoulder luxation are shown: in cases with peritendinitis, integrity compensation was awarded 12 times more frequently than in cases without peritendinitis; in the case of shoulder luxation with peritendinitis, the entire insurance benefits were 10 times higher than in cases without peritendinitis.

Adult↗

AIDS in the workplace: a program that's still relevant.

A new AIDS-in-the-Workplace program being implemented in Québec emphasizes the rights of workers living with HIV/AIDS. The program tackles issues such as confidentiality of HIV status, access to insurance benefits, discrimination, and the need for employers to take reasonable measures to accommodate the disabilities of workers.

Civil Rights↗

Snowmobiling injuries: types and consequences.

In a prospective study from northern Sweden, a series of 137 persons injured in snowmobiling accidents was analyzed. Most of the injured riders were males aged 10 to 39 years. Almost two-thirds of the accidents occurred at week-ends and the frequency was highest in the months of March and April. Three of four persons were injured during racing or leisure activities. The accidents most often involved sudden arrest of the snowmobile due to collision with an obstacle, or fall from the machine while driving it. The injuries were of major degree (MAIS greater than or equal to 2) in almost half of the cases and the lower extremities were the most commonly injured sites. In-patient care was required by 28% of the injured, for on average 11 days. Sickness insurance benefit was received by 64%, mean 48 days. The cost of treatment and sickness benefit averaged 8 000 SEK per case.

Accident Prevention↗

Employment-based health insurance: analysis of rural-urban differences in one state.

This study estimates the propensity of firms to offer health insurance in a simultaneous equation model to control for the endogeneity between wages and health insurance. Previous research finds differences in rural and urban employer behavior with respect to health insurance benefits fully explained by differences in wages and firm size. In contrast, this study finds residual unexplained differences in the propensity to offer coverage that may be attributable to differences in plan supply, plan distribution, or differences in availability of substitutes for coverage (safety net care). Rural worker participation in offered coverage is more responsive to wage level than is the participation decision of urban workers. Together, these results imply that some of the differences in health insurance coverage rates for rural workers could be amenable to policy interventions.

Adult↗

Patients' rights to care under Clinton's Health Security Act: the structure of reform.

Like most reform proposals, President Clinton's proposed Health Security Act offers universal access to care but does not significantly alter the nature of patients' legal rights to services. The act would create a system of delegated federal regulation in which the states would act like federal administrative agencies to carry out reform. To achieve uniform, universal coverage, the act would establish a form of mandatory health insurance, with federal law controlling the minimum services to which everyone would be entitled. Because there is no constitutionally protected right to health care and no independent constitutional standard for judging what insurance benefits are appropriate, the federal government would retain considerable freedom to decide what services would and would not be covered. If specific benefits are necessary for patients, they will have to be stated in the legislation that produces reform.

Facility Regulation and Control↗

The picture of health for midlife and older women in America. Older Women's League.

This report overviews the major health problems of middle aged and older women and health care access issues. The relationship of labor force involvement to health status and insurance benefits is considered. Other payment sources such as Medicaid and Medicare are critiqued for their failure to finance needed prevention and other services.

Aged↗

[Health policy aspects: role of the government in the prevention of tobacco abuse].

Possible instruments for control of tobacco-abuse available in a liberal and democratic country are discussed. Prohibition-strategies including bans on advertisement and non smoking areas, reduction of insurance benefits and modifications of liability rules are valued with reservation. Emphasis is placed on fiscal measures and on support of preventive measures exerted by family physicians.

Advertising↗

[Medical expenses by site of cancer and survival time among cancer patients in the last one year of life].

OBJECTIVES: To analyze medical expenses by cancer site and survival time among cancer patients in their last year of life. METHOD: The study subjects were 45,394 people that had died of cancers in 2002, were registered by the Korea Central Cancer Registry and received National Health Insurance benefit in the last year (360 days) of life. Personal identification data, general characteristics, dates of death and cancer incidence, and site of cancer were collected from the National Statistical Office and the Korea Central Cancer Registry, and merged with the data of the individual medical expenses of the Health Insurance Review Agency. RESULTS: Average monthly cost curves were U-shaped with high costs near the time of diagnosis and death, and lower costs in between. Medical expenses in the last year of life were around 30.3, 16.7, 13.0, and 12.1 million won among leukemia, lymphoma, ovarian cancer, and breast cancer patients, respectively. Digestive organ cancers including stomach, esophagus, liver, pancreas, and colorectal cancers had relatively low medical expenses. Medical expenses in the last year of life were inverse Ushaped with high expenses near one year of survival. Average monthly cost in the 12 months before death among the patients who had survived 10-15 years were more than two-fold greater than the cost before diagnosis among those who had survived for less than one year. CONCLUSIONS: Leukemia was the most expensive cancer. It is possible that once diagnosed as cancer, medical expenses do not return to the level before diagnosis. Further research will be needed to understand the magnitude and change of the medical expenses among cancer patients with long term follow up data.

Adolescent↗