SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Why do provider-sponsored health plans have 20% lower administrative expenses than Blue Cross commercial plans? Here's some detailed data that you can use to benchmark your own administrative costs.
Explore the source record for details and available documents.
Following on the heels of the first national study demonstrating differences in the community benefits provided by not-for-profit and for-profit health maintenance organizations (HMOs) (Schlesinger, Mitchell, and Gray 2003), this study of the New York state market shows significant differences in premiums, administrative overhead and commitment to safety net coverage between nonprofit and for-profit health plans. This study shows that for-profit health plans do act differently than not-for-profit plans in terms of performance, efficiency, and contribution to safety net programs. Moreover, it suggests that not-for-profit health insurers operating in a predominantly for-profit market act in many ways like for-profits. The New York state insurance market provides an ideal study environment because one can compare a large number of policyholders and plans in both business models (for-profit and not-for-profit) that share an identical legislative and regulatory environment. New York has large populations being provided coverage under both models and no allowances had to be made for state-to-state political and/or legal differences. Specifically, this study shows that: The downstate insurance market is predominantly for-profit, while the upstate market is almost entirely not-for-profit. The recent conversion of Empire Blue Cross Blue Shield to a for-profit model moves the downstate market further into the for-profit column, while the upstate region remains not-for-profit. Insurers in the upstate not-for-profit market are more administratively efficient than insurers in the downstate region. Compared to the downstate region, insurers in upstate New York spent 1.5% less of their operating revenues on administrative expenses. The additional 1.5% of spending on administrative expenses downstate totals dollars 137,000,000. Upstate insurers spend significantly more of the revenues received on payments for medical care. Downstate insurers spent 80.4% of operating revenues on medical care. Upstate insurers spent 87.7% of operating revenue on medical care. If health care spending patterns downstate were similar to upstate, the additional 7.3% allocated to medical care would total dollars 678,000,000. A lower level of investment in medical care in the downstate region translated into higher underwriting gains, which totaled 8.1% of operating revenue. Plans in the upstate region reported underwriting gains of only 2.3%. Not-for-profit insurers offer more cost effective (i.e., lower) premium options for consumers. In 2002, the upstate market had the lowest operating revenues (premiums) statewide, averaging dollars 184 per member per month (pmpm); the not-for-profit plans downstate averaged dollars 203 pmpm. Premiums in the for-profit segment of the downstate market averaged dollars 221 pmpm in 2002. The not-for-profit upstate market has proved its viability, while maintaining commitments to New York safety net and Medicare programs. The not-for-profit upstate market experienced a dollars 12 million loss in New York safety net programs in 2002, but generated dollars 131 million in underwriting gains for all product lines combined. Furthermore, upstate revenue gains in 2002 exceeded 2001 results by dollars 45 million. Not-for-profit HMOs, both upstate and downstate, participate in state-sponsored safety net programs to a far greater degree than the downstate for-profit managed care organizations. Within the plan group selected for this study, the not-for-profit plans supported 88% of the enrollment in New York state-sponsored programs, compared with for-profit plans' support of only 12% of safety net membership. Not-for-profit plans have also demonstrated a higher level of dedication to the Medicare Plus Choice product line than for-profit insurers downstate. In 2002, not-for-profit plans enrolled 73% of this population of 385,000 elderly statewide. Despite the favorable financial returns in the product line, for-profit insurers downstate enrolled only 105,000 Medicare risk members in 2002, or 27% of the statewide total. The emergence in New York of health care insurance markets that are predominantly for-profit raises significant public policy issues, especially with reference to community benefits and services. Should the upstate health insurance environment change with the entrance of for-profit plans or conversion of existing plans to for-profit status, the upstate market is likely to look very similar to the downstate in that there will be diminished access to care for the at-risk population; premium costs will be higher and administrative costs will be higher. The health care insurance market upstate would become less attentive to the provision of public goods as insurers strive to maximize their economic advantages.
Enrollment decisions of a sample of an employed population choosing among open-panel and closed-panel HMOs and Blue Cross/Blue Shield are analyzed. This report, unlike previous ones, overcomes some of the difficulties of bivariate analysis by the use of the multivariate logistic probability model, logit. The results show that there are four consistent predictors of enrollment choice: previous source of care as the measure of access; family life stage and chronic conditions per family member as indicators of health risk; per capita income as the measure of economic vulnerability; and health concern. Having a private physician as the source of care is the best single predictor, its absence predicting a higher probability of enrollment in the closed, and its presence in the open-panel HMO. Higher risk life stage families, younger and with more children, are more likely to join the open-panel plan than the closed or retain BC/BS; higher incomes and larger numbers of chronic conditions appear to have the same effects. Higher levels of health concern, on the other hand, predict a greater probability of choosing the closed-panel plan. The probability of enrollment in any HMO is predicted with more than 50 per cent accuracy for 60 per cent of the sample. Choice between open and closed-panel plans is predicted with an accuracy in excess of 50 per cent for 80 per cent, and with an accuracy greater than 90 per cent for over 10 per cent of potential enrollees. The applicability of this approach to HMO feasibility analysis and planning is clearly indicated.
Blue Shield plans often are granted regulatory advantages by the states in which they operate. Run efficiently, such not-for-profit firms should use these lower costs to eliminate their less advantaged rivals, the commercial insurers. However, these higher-cost commercial providers have been able to offer insurance coverage at prices competitive with the Blues, as evidenced by the fact that Blue plans have, on average, less than 50 percent market share. Similar prices with lower overall costs implies that economic rents are being earned, rents which a not-for-profit firm cannot distribute to owners. In this paper we argue that when there are competing goals among the groups controlling the Blue Shield plans, the different possible "uses" of the regulatory advantage become endogenously determined, necessitating the use of simultaneous equation estimation. Testing this model we find the major effect of doctor-control of Blue Shield plans is to raise doctors' fees while lowering the amount of rents captured by both consumers and administrators.
The attempted for-profit conversion of CareFirst BlueCross BlueShield culminated in two decades of drift from its nonprofit mission and opened a window of opportunity for Maryland to deny the proposal, replace the board majority, and impose oversight. Maryland rejected the approach used by some states, which have permitted conversion and used the erstwhile nonprofit's assets to endow a health-related foundation, because it sought an insurer with dominant market share to promote coverage expansions. Coupled with the ensuing conflict with insurance commissioners and nearby Blues plans, this incident signals the end of the "trust-me" era of nonprofit accountability in health insurance.
It's been a strained few months at Blue Cross and Blue Shield of Rhode Island. Outrage over corporate excess led to a flurry of reforms at the insurer, headed by Chairman Frank Montanaro, left, including banning loans to employees and dropping lavish perks. Other Blues have been catching flak for their burgeoning bottom lines, but executives say they need ample reserves since that's their only capital.
In its realignment of physician incentives, a California plan has taken money away from the utilization management bonus pool and put it into quality. Here are the details.
This paper presents an empirical analysis of the impact that resulted from phase-in of Medicare's Prospective Payment System (PPS) on hospital utilization and payments for the Blue Cross and Blue Shield (BCBS) plans. A pooled cross-sectional time series econometric model was specified and estimated using quarterly hospital utilization and payments of the BCBS plans over the period 1980 to 1987. The results indicate that the implementation of PPS was significantly associated with a lower rate of hospital admissions, days and deflated inpatient payments for the BCBS plan members under age 65. A 1% increase in the proportion of hospital days reimbursed under PPS resulted in a .032% decrease in BCBS plan admissions per 1,000 members, a 0.017% decline in days per 1,000 members and a 0.016% decline in deflated inpatient payment per 1,000 members. The reductions in hospital utilization resulted in lower payments by BCBS plans to participating hospitals suggesting a positive spill-over effect of PPS for private insurers. This research underscores the importance of interaction between federal health policy and the private health insurance market.
Independent Blue Cross and Blue Shield plans are adopting RBRVS-based fee schedules for reimbursing physicians. Some argue that private payers should follow suit.
The Associations' "Initial Statement on Hospice Care and Payment for Hospice Services" comprises three criteria and many recommendations. The statement can guide local Plans and other third party payers, wary of repeating past mistakes that increased costs without improving care.
This article describes the reasons given by employees for choosing between an indemnification -type health insurance plan (Blue Cross/Blue Shield) and a health maintenance organization (group health plan). A population of 1,003 matched pairs was determined and questionnaires were sent to 1,861 individuals remaining in the company, with a response rate of 74%. Many of the reasons listed as important for joining one or the other plan were alike for both groups. However, the members of the group health plan felt that preventive care and regular checkups were more important than did the Blue Cross/Blue Shield members. The latter group felt that free choice of physician was very important, whereas the subscribers to the group health plan did not place such importance on this factor. Both groups were satisfied with their care, although there were some expected differences.
Physicians want the right to know how plans decide how much to pay them. Should they be able to find out? The Georgia Supreme Court is asked to decide.
A study was conducted to capture information on health plans' initiatives to promote physical activity among members and in community settings. This investigation was based on a descriptive nationwide study of American Association of Health Plans- and Blue Cross and Blue Shield Association-member plans conducted from October 2001 to February 2002. Sixty individuals with responsibility for health-promotion programs were surveyed, and 24 provided in-depth interviews. The measures used in this evaluation were the number and type of member- and community-based physical activity programs/initiatives offered by health plans, and the types of programs evaluated. Information was captured on more than 373 physical activity initiatives. Thirty-five percent of surveyed health plans responded, representing more than 62 million health plan members; the participation rate for in-depth interviews was 80%. Most health plans integrate physical activity messages into routine services for members (92%) and sponsor community races/walks and health fairs (85%). Physical activity programs are offered to improve member health (92%), increase member satisfaction (80%), and reduce long-term health care costs (62%). Few rigorous evaluations have been conducted on these programs, and return-on-investment data are scarce. Although some health plans currently play a relatively active role in promoting physical fitness to their members and the community, multiple opportunities exist for health plan involvement in various settings with different populations.
A look at how three local Blue Cross and Blue Shield Plans have developed energy management programs illustrates certain similarities and differences based on the local environment.
This Notice requests comments on two staff reports dealing with medical participation in control of Blue Shield and certain other open-panel medical prepayment plans and on alternative courses of action that the Commission might take to deal with this subject, one of which might be rulemaking.
The major considerations that affect hospital participation in HMOs are motivation, governance, medical staff involvement, financing, and planning and operations/These considerations are discussed in general and as they apply to one particular hospital's experience.
Funded by Blue Cross Plan, day hospital care provided benefits for hospital staff and patients and proved to be 23% less expensive than inpatient care.