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PubMed2006

Changes in reimbursement rates and rules associated with the Medicare Prescription Drug Improvement and Modernization Act. Introduction.

PURPOSE: Future trends in the Medicare population and drug expenditures, the organizational structure of the Medicare program, and recent changes in Medicare rules and rates for pharmaceutical reimbursement are described. SUMMARY: Large increases in the number of Medicare beneficiaries and drug spending are anticipated in the future. Medicare Part A provides insurance benefits for hospital inpatients, nursing home patients, home health care patients, and hospice care patients. Part B provides benefits for physician services, durable medical equipment, oral chemotherapy, and end-stage renal disease services. For hospitals, Part B rules are followed for ambulatory services, but these services are administered through the Part A Outpatient Prospective Payment System. The average sales price plus 6% is now used for pharmaceutical reimbursement, although physician-owned clinics may participate in a competitive acquisition program under Part B. Payments are the same for generic drugs and brand name products, although they differed in the past. Pharmaceutical reimbursement is available for uses listed in compendia approved by the Centers for Medicare & Medicaid Services and possibly some other authoritative sources. CONCLUSION: Medicare rules and rates for pharmaceutical reimbursement have undergone substantial changes in recent years and will continue to change in the future, with a potentially large impact on health systems and patients.

Aged↗
PubMed2004

The effect of deinsuring chlorpropamide on the prescribing of oral antihyperglycemics for Nova Scotia Seniors' Pharmacare beneficiaries.

On behalf of the Nova Scotia Seniors' Pharmacare Program, the Drug Evaluation Alliance of Nova Scotia developed a multicomponent intervention plan to facilitate the removal of chlorpropamide as an insured benefit. Chlorpropamide has caused serious hypoglycemia in seniors to a greater extent than some other agents. Pharmacy administrative claims were used to compute monthly use rates for insulin and each oral antihyperglycemic drug from January 1, 2000-December 30, 2002, in an intervention cohort (patients receiving chlorpropamide) and a control cohort (patients receiving an antihyperglycemic agent other than chlorpropamide). Initially, 630 patients were receiving chlorpropamide therapy. By the time chlorpropamide was deinsured, only 10% of the treatment cohort continued receiving chlorpropamide; shortly after deinsurance, no beneficiaries continued receiving the drug. The antihyperglycemics with the greatest increase in prescription were glyburide and gliclazide. The deinsuring of chlorpropamide and the educational strategies that accompanied it resulted in the selection of more appropriate antihyperglycemics for Nova Scotia seniors.

Aged↗
PubMed2003

[Are mental disorders given due consideration in the adjustment of stage of care according to the German Health Care Act? Assessment of cognitive impairment by medical expert record (MDK) and standardised methods of the research team].

Fifty-eight recipients of long-term care insurance benefits were interviewed during home visits by a research team. Fourty-eight percent of the interviewees achieved less than 22 points in the Mini-Mental State Examination (MMSE), clearly indicating cognitive impairment. Comparison of the authorized examination on the one hand and the findings of the research team on the other showed: neither CNS-specific diagnoses (77.8% sensitivity) nor CNS malfunction adequately recognised cognitive impairment. In 41% of the cognitively impaired, authorised examination found only minor or no functional CNS disorders. A comparison of the 'recognised' and 'not recognised' cognitively impaired and physically handicapped applicants found that a higher stage of care was allocated to the group with recognised dementia but that, in all MDK parameters, there was no judgmental difference in medical expert records between patients with unrecognised cognitive impairment and physically handicapped persons.

Activities of Daily Living↗
PubMed1996

Evaluation of Medicaid managed care. Satisfaction, access, and use.

OBJECTIVE: To evaluate the effects of managed care on Medicaid beneficiaries' satisfaction with, access to, and use of medical care during early implementation of an enrollment initiative. DESIGN: Cross-sectional survey of a random sample of Medicaid beneficiaries in 5 managed care plans and in the conventional Medicaid program. SETTING: New York, NY. PARTICIPANTS: Adults aged 18 to 64 years who received Medicaid insurance benefits through Aid to Families With Dependent Children or State Home Relief and had been enrolled in a managed care plan or receiving benefits under conventional Medicaid for at least 6 months. Of the 2500 enrollees in managed care plans and the 600 other beneficiaries in conventional Medicaid whom we surveyed, 1038 enrollees and 410 nonenrollees responded. OUTCOME MEASURES: Beneficiaries' ratings of overall satisfaction and 13 dimensions of satisfaction related to access, interpersonal and technical quality, and cost; reports of access, including regular source (location) of care, waiting time for appointment, waiting time in office, and ability to obtain care; and reports of use, including inpatient, emergency department, and ambulatory visits. RESULTS: Compared with beneficiaries in conventional Medicaid, managed care enrollees in general gave higher ratings of satisfaction. The results were not consistent, however, between the proportion who were extremely satisfied and the proportion who were extremely dissatisfied. Managed care enrollees had significantly greater odds of being extremely satisfied (excellent and very good ratings), but fewer differences were statistically significant for levels of extreme dissatisfaction (fair and poor ratings). With regard to access, managed care enrollees had significantly greater odds of having a usual source of care (odds ratio [OR], 2.33) and seeing the same clinician there (OR, 2.72) and had significantly shorter appointment and office waiting times. Managed care and conventional Medicaid beneficiaries reported no significant differences in obtaining or delays in getting needed care and in inpatient or emergency department use. CONCLUSIONS: Medicaid managed care enrollees in New York City reported better access to care and higher levels of satisfaction compared with conventional Medicaid beneficiaries. Differences between these findings and those for privately insured populations highlight the pitfalls of generalizing from other groups to Medicaid for policy purposes. Given growing reliance on consumer satisfaction surveys for clinical and public policy, future research should focus on factors that explain extreme satisfaction vs extreme dissatisfaction. New York State's initiative, which has been associated with careful state and local monitoring, merits continuing evaluation as managed care enrollment grows and may become mandatory.

Adult↗
PubMedDate not supplied

Subjective health measures and state dependent reporting errors.

The use of subjective health measures in empirical models of labour supply and retirement decisions has frequently been criticized. Responses to questions concerning health may be biased due to financial incentives and the willingness to conform to social rules. The eligibility conditions for some social security allowances, notably Disability Insurance benefits, are contingent upon bad health. Even if the decision to apply for a disability allowance is to some extent motivated by financial considerations or a relatively strong preference for leisure, respondents will be inclined to play down these motives and emphasize the importance of their health condition. As a consequence, reporting errors may depend on the labour market status of the respondent and self-reported health variables will be endogenous in labour supply and retirement models. The objective of this paper is to assess the importance of state dependent reporting errors in survey responses and to propose and estimate a model that can be used to account for this kind of systematic mis-reporting. The estimation results indicate that among respondents receiving Disability Allowance, reporting errors are large and systematic. Using such subjective health measures in retirement models may therefore seriously bias the parameter estimates and the conclusions drawn from these.

Adult↗
PubMed2005

Health care in China: the role of non-government providers.

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.

Adolescent↗
PubMed1994

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.

Canada↗
PubMed1980

Receipt of multiple benefits by disabled-worker beneficiaries.

In 1971, 44 percent of workers who had been currently entitled to social security disability insurance (DI) benefits for 1 year or more also received benefits from at least one other source. Their average disability insurance benefit was higher than that of persons who received only DI benefits. On the average, total benefits to those receiving multiple benefits were double the amounts paid to those receiving only DI benefits. The combined benefits for the former produced median replacement rates about 50 percent larger than the median replacement rates for the latter. High replacement rates--defined here as more than 80 percent of predisability earnings replaced by benefit--predominate among those with multiple benefits. Considering replacement rates based solely on disability insurance benefits substantially understates the extent to which benefits from public and private programs actually replace predisability earnings. Replacement rates based solely on DI benefits are generally higher for those receiving DI benefits only than for persons receiving multiple benefits. Limiting DI benefits to the replacement rate from DI benefits alone is disadvantageous for persons who receive only DI benefits, compared with those who also receive other benefits.

Adult↗
PubMed2004

[Demands on and benefit from insurance-orientated hospital management - findings from qualitative interviews with executive members of statutory health insurance].

PURPOSE: Starting from the fact that statutory health insurance bodies are increasingly important hospital stakeholders, the article focuses on the question of demands on and benefit from an insurance-orientated hospital management. METHOD: A methodological approach is chosen which takes the views of the stakeholder health insurance as a starting point: Semi-structured interviews were conducted with 14 executives of different statutory health insurance. Data analysis was based on the "zusammenfassende Inhaltsanalyse" (literal translation: summarizing content analysis), developed by Mayring. RESULTS: From the participants' points of view the highly regulated relationship between hospitals and insurances offers opportunities for active development. The analysis of expectance distinguishes between five areas of demand: "Hospital services", "service development", "case management", "management of conflicts/reviews" and "budget negotiations". Within these areas dimensions of demand are differentiated. Most participants feel that an insurance-oriented hospital management is beneficial to the hospital. CONCLUSION: A number of specific demands is identified on which management activities can be based. Hospitals need to consider carefully the benefit of insurance-orientation and suitable measures in the light of hospital-specific aims and strategies.

Budgets↗
PubMed1994

Eating disorders and health insurance.

Eating disorders are being diagnosed and managed by an increasing number of pediatricians and practitioners of adolescent medicine. These physicians are increasingly discovering the power and importance of their patients' health insurance status in the management of these conditions because the lack of appropriate insurance may often pose obstacles and barriers to care. This article provides an analysis of this situation through brief case presentations followed by a discussion and recommendations.

Adolescent↗
PubMed2006

Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003.

CONTEXT: Policymakers as well as physicians need to understand how rapidly rising health care costs are affecting specific groups of patients. OBJECTIVE: To estimate the number and characteristics of individuals in the United States faced with very high financial burdens for health care. DESIGN, SETTING, AND POPULATION: Data from a nationally representative sample of civilian, noninstitutionalized US individuals younger than 65 years from the Medical Expenditure Panel Surveys were used to calculate 2 measures of financial burden as a function of tax-adjusted family income. Total burden included all out-of-pocket expenditures for health care services, including premiums. Health care services burden excluded premiums and, when applied to the insured population, was used to identify the underinsured. We defined the underinsured as insured persons with health care service burdens in excess of 10% of tax-adjusted family income. MAIN OUTCOME MEASURES: Total and health care services burdens exceeding 10% and 20% of family income in 1996 and 2003. RESULTS: In 2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage. CONCLUSIONS: Our analysis identifies patients at greatest risk of health-related financial burdens that may adversely affect their access and adherence to recommended treatments. Our study also highlights the high costs associated with nongroup health insurance policies.

Adult↗
PubMedDate not supplied

Choice of health insurance by families of the mentally ill.

This paper investigates whether choice of health insurance is influenced by the perceived mental and physical health of family members among a sample of policy-holders with private health insurance. A multinomial probit model of the choice among major medical coverage only, traditional full coverage, and coverage through a health maintenance organization is estimated. Results indicate that the presence of at least one family member who rates his or her general health as poor does not affect the policy-holder's choice of health insurance. However, the presence of at least one family member considered at risk of mental illness does in some instances affect the policy-holder's choice of health insurance: We observe significant effects for policy-holders who are female, black, have some college education, work for a large firm, and live in an urban area. These findings suggest that adverse selection may arise when individuals are able to choose between health insurance policies with different degrees of coverage for mental health care and that such effects are far more pronounced for those people who consider themselves at risk for mental illness than physical illness.

Black or African American↗
PubMed1989

Lack of correlation between the Steinbrocker staging of hand radiographs and the functional health status of individuals with rheumatoid arthritis.

We evaluated the correlation between destructive changes seen on hand radiographs and disability in 54 patients with definite or classic rheumatoid arthritis. No statistically significant correlation was found between radiographic findings and patient disability as determined by patient and physician assessment or by the patient's score on the Arthritis Impact Measurement Scales questionnaire. These findings call into question the appropriateness of using hand radiographs as a determinant of disability or as a criterion for disability insurance benefits.

Adolescent↗
PubMed1995

Health insurance problems among insured rheumatoid arthritis patients.

OBJECTIVE: To describe limitations in insurance coverage and their financial impact among a sample of rheumatoid arthritis (RA) patients. METHODS: A national sample of RA patients followed since 1988, completed a telephone interview about health insurance coverage, experiences with preexisting conditions clauses, and the financial impact of arthritis. Descriptive and multivariate logistic regression techniques were used to analyze the demographics and health status data. RESULTS: Trends in insurance coverage among people in this sample showed that participants were more likely to be in an HMO or PPO currently than 5 years previously. A majority of participants (67%) experienced financial impact from arthritis; 35% said that arthritis limited their ability to earn a living. Twenty-one percent had some insurance limitation because of arthritis as a preexisting condition. Eleven percent had been denied insurance. Those who had higher scores on the Stanford Health Assessment Questionnaire, were younger, were covered by Blue Cross/Blue Shield, and were more likely to be affected by a preexisting condition limitation. CONCLUSION: The data clearly indicate that even well-insured RA patients receiving care from rheumatologists experience limitations related to preexisting conditions and considerable financial impact.

Adult↗