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PubMed1987

Analysis of 2932 workers' compensation back injury cases. The impact on the cost to the system.

In 1982 the Workers' Compensation Board of New York State authorized payment of +42,084,999 for closed cases of spinal injuries; 30 states paid a combined +1.9 billion for medical treatment and/or compensation for back injuries. The other states did not have the requested information available. Analysis of 2932 spinal injury cases evaluated for disability in a 7-year period showed a mean of 23.4 months of medical treatment in 1706 cases concluded with no disability. Also, 91% of the claimants represented by counsel were not working, whereas 77% not so represented were working. Most of the consultative medical reports, insurance carriers' and claimants', veered on the adversarial and favored the respective interested party. The cost of workers' compensation back injury claims is very high. The conclusion is inescapable that iatrogenic and jurisgenic factors have a direct effect (in the cohort of cases analyzed) on the prolongation of medical care, and delay in returning to gainful employment, and, consequently, contributing to the high cost.

Accidents, Occupational↗
PubMed2001

An assessment of implant coverage in dental benefit plans.

In the last 30 years, dental implantology has undergone widespread advances in technology and now complex, high-risk procedures are routine. Patients are becoming more vocal in their requests for this service from dentists in private practice and academic institutions. Unfortunately, although treatment modalities have improved, the cost for this service remains beyond the reach of the average patient. The purpose of this article is to assess the present status of implant coverage in dental benefit plans in the US.

Dental Implants↗
PubMed1987

An analysis of the liability insurance crisis.

The problem of the growing liability insurance crisis is examined from historical, economic, policy, and legislative perspectives. Specifics of arguments presented by physicians, nurses, lawyers, and insurers are provided to illustrate the conflict inherent in the situation. Reports of policy actions accomplished by these groups are presented with a discussion of related bills proposed in past years. Specific nurse populations directly affected by the insurance crisis are presented and actions to be taken by nurses and legislators to deal with the problem are suggested.

Delivery of Health Care↗
PubMed1999

Criteria for selection of patients for bariatric surgery.

International criteria for bariatric surgery and bariatric surgeons have been well-defined in terms of the current state of the art and are presented together with weight tables and a list of co-morbidities of morbid obesity. The bariatric surgeon should make the primary judgement concerning bariatric surgery using these criteria as guidelines only, not strict rules; others who use these criteria should govern themselves in a like, fair-minded, fashion. Medical insurers' and their agents' criteria, if excessively restrictive relative to the guidelines, may reflect an ingrained prejudice against the morbidly obese, manifesting itself in an unfair, unethical and immoral bias. It is the essence of humane and equitable behaviour on the part of all concerned that the morbidly obese receive non-discriminatory, appropriate treatment, care and medical insurer coverage for their disease and its comorbidities.

Body Weight↗
PubMed1993

Accreditation policies in occupational health care.

Occupational health practitioners have striven for 60 years to develop and implement appropriate accreditation policies and procedures to promote quality assurance of occupational health practice. In 1987 the American Occupational Medical Association affiliated with the Accreditation Association for Ambulatory Health Care, an independent ambulatory health care accreditation organization, to advance this movement. This paper explores the history of occupational health care accreditation and identifies potential incentives needed to encourage accreditation of occupational health care. The Occupational Safety and Health Administration, industry, labor, insurance carriers, and professional organizations collectively must develop strategies to promote accreditation and ensure that workers receive the maximum standard of occupational health care.

Accreditation↗
PubMed1997

Public and private workers' compensation insurance.

Utilizing unique data from the federal government's Social Security office, we analyze the costs of providing workers' compensation by public vs private insurers. Our analysis has the advantage that public and private recipients are likely to be more similar than public (Medicare, Medicaid) and private recipients of health insurance in the US or Canadian economies. We find that public firms appear to provide workers' compensation insurance more efficiently than private firms.

Canada↗
PubMed1998

Healthcare utilization and referral patterns in the initial management of new-onset, uncomplicated, low back workers' compensation disability claims.

Most episodes of low back pain are considered non-specific in nature, with the vast majority resolving within 2 weeks and almost all resolving within 6 weeks regardless of the medical intervention. Recently published clinical guidelines have clearly delineated a limited set of circumstances that would indicate the need for specialist referral. The purpose of this study was to describe the healthcare utilization and physician referral patterns for new-onset, uncomplicated, low back workers' compensation disability cases randomly selected from a large insurance carrier data source. The provision of care in urgent care centers and emergency departments for both initial and main sources of care occurred more frequently than was probably indicated. For this selected group of uncomplicated low back pain cases, specialist care was provided more commonly than would be expected or indicated (36% of the sample was seen by a surgeon, while only 2% received surgery). In addition, referral to specialists (other than occupational medicine specialists) was often made sooner than would be expected or indicated, with a median of 13 days for such referrals. Such overutilization of resources can reasonably be expected to increase overall medical costs.

Adolescent↗
PubMed2000

Professional liability insurance for health care organizations--several significant considerations.

The purchase of professional liability insurance coverage represents one of the more important financial and administrative decisions in terms of managing a health services organization. This manuscript outlines a decision process for evaluating and determining the most viable option(s). Also addressed are some significant caveats in assessing the strengths and weaknesses of various coverage options.

Decision Making, Organizational↗
PubMed2003

Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia.

A number of studies have documented subjective improvement in somatic and psychological symptoms following breast reduction surgery. Objective data demonstrating improved postoperative function have been more difficult to assess, and particularly with respect to pulmonary function, the results have been contradictory. In this prospective study, patients completed a comprehensive preoperative questionnaire modified from the American Thoracic Society Division of Lung Diseases Epidemiology Standardization Project (1978). This questionnaire noted subjective pulmonary symptoms and pulmonary medical history. In addition, subjective symptoms related to breast size, including back and neck pain and shoulder pain and grooving, and a subjective evaluation of body image, were evaluated. All subjects received preoperative pulmonary function testing, including spirometry, lung volume measurements, and measurement of peak inspiratory and expiratory flow rates and pressures. Eight weeks after breast reduction, a repeat questionnaire and pulmonary function testing were administered. Preoperative and postoperative pulmonary function values were compared using Cochran-Mantel-Haenszel tests, and correlations were tested between changes in pulmonary function test values and subjective symptom improvement. Forty-four patients underwent an average of 2228-g bilateral reduction. All of these patients had their surgical procedures preauthorized as medically necessary by their insurance carriers. All subjective parameters examined were statistically significantly improved following breast reduction (p < 0.001). Of the 17 patients with preoperative complaints of shortness of breath, all noted significant improvement following breast reduction surgery (p < 0.001). Of the objective pulmonary criteria evaluated, inspiratory capacity, peak expiratory flow rate, and maximal voluntary ventilation showed a statistically significant improvement following surgery (p < 0.05). These changes correlated with body mass index; the greater the index, the greater the change in maximal voluntary ventilation and peak expiratory flow rate. Smokers in this group had the largest change in maximal voluntary ventilation (p < 0.008). No correlation could be found between preoperative pulmonary symptoms, a single subjective symptom, or grams of breast weight reduction and changes in pulmonary function tests. The results show that pulmonary parameters, related primarily to work of breathing (inspiratory capacity, maximal voluntary ventilation, peak expiratory flow rate), were statistically improved following breast reduction surgery, and these changes correlated with body mass index.

Adolescent↗
PubMed2004

Documentation of posttraumatic nerve compression in patients with normal electrodiagnostic studies.

BACKGROUND: Electrodiagnostic evaluation may suggest the absence of posttraumatic nerve compression in the presence of patient symptoms. Computer-assisted neurosensory testing documents peripheral nerve sensory impairment. In the setting of trauma, where there are often legal implications, documentation of peripheral nerve compression is important. This is highlighted in the diabetic, who may have neuropathy. METHODS: A prospective study tracked trauma-related peripheral nerve problems in patients with "normal" electrodiagnostic studies, and for whom surgical care or legal outcome was determined by documentation of abnormalities by testing with the Pressure-Specified Sensory Device. Eight patients were identified, four of whom had diabetes. RESULTS: In all eight patients, neurosensory testing documented peripheral nerve problems, which was critical in obtaining approval from workers' compensation insurance carrier for decompression of the nerve and facilitating legal settlement. CONCLUSION: Neurosensory testing with the Pressure-Specified Sensory Device identifies peripheral nerve compression related to trauma, facilitating management of the patient, even in the presence of diabetic neuropathy.

Diabetic Neuropathies↗
PubMed2000

The role of independent agents in the success of health insurance market reforms.

The impact of reforms on the health insurance markets cannot be understood without more information about the role played by insurance agents and a closer analysis of their contribution. An in-depth, qualitative study of insurance-market reforms in seven illustrative states forms the basis for this report on how agents help to shape the efficiency and fairness of insurance markets. Different types of agents relate to insurers in their own ways and are compensated differently. This study shows agents to be almost uniformly enthusiastic about guaranteed-issue requirements and other components of market reforms. Although insurers devise strategies for manipulating agents in order to avoid undesirable business, these opportunities are limited and do not appear to be seriously undermining the effectiveness of market reforms. Despite the layer of cost that agents add to the system, they play an important role in making market reforms work, and they fill essential information and service functions for which many purchasers have no ready substitute.

Health Care Reform↗
PubMed2006

A measure of trust in insurers.

BACKGROUND: Patient-centered assessments are increasingly important. Patients repeatedly emphasize the importance of trust in health care institutions and personnel. OBJECTIVES: (1) Develop a conceptual framework for trust in health care organizations and a comprehensive, reliable measure of trust in health insurers. (2) Examine predictors and correlates of trust in insurers. STUDY DESIGN: A conceptual framework for trust in health organizations based on theory and empirical studies was used to develop items for a structured telephone survey, which also included measures of health and utilization, doctor-patient trust, and satisfaction with care. Principal components factor analyses identified hypothesized domains of trust in health insurers and identified items for scales. Internal consistency assessment used Cronbach's alpha. Univariate analyses used Pearson's r or Student's t-tests. SAMPLE: Insured residents of Southeastern Michigan (n=400). RESULTS: Respondents were diverse in age, gender, ethnicity, health, and socioeconomic status. One dominant factor (eigenvalue>10) included hypothesized domains: administrative competence, clinical competence, advocacy and beneficence, fairness, honesty and openness, and one global item. Multidimensional scales were reliable (long version 13 items, alpha=0.95, short: 9 items, alpha=0.91). Insurer trust correlated strongly with trust in doctors (r=0.49 and 0.46) and satisfaction with care (r=0.70 and 0.66), and with an item assessing overall worry about health insurance (r=-0.37 and -0.35). Those with less trust in their insurer were more likely to say that they would change insurance plans (p<.001). CONCLUSIONS: This well-grounded, reliable measure of enrollee trust in insurers can be a useful patient-centered assessment tool.

Aged↗
PubMed2006

Restrictions on provider access in health plans and socioeconomic status.

OBJECTIVE: To model the socioeconomic determinants of restrictions on provider access and choices in health plans. DATA SOURCES: Data from the 1996-97 Community Tracking Study are used. Publicly available enrollee data including enrollee reports of health care plan characteristics are linked with restricted use data with insurer reports of health plan characteristics. STUDY DESIGN: This is an observational study. A mixed multinomial logit model is used to model the enrollees' choice between health plans, each plan being treated as a bundle of attributes formed from restrictions on provider access. PRINCIPAL FINDINGS: There are important differences between the enrollee responses and the insurer reports, which may be due to poor information dissemination on the part of health plans and/or lack of attention on the part of enrollees. There is no evidence of selection into plans with restrictive attributes on the basis of observed health status but there is evidence of selection on the basis of race, ethnicity, gender and other socioeconomic characteristics. Determinants of plan supply, i.e., employment characteristics, are the most important determinants of plan attribute choices. CONCLUSION: The finding suggests that plan designs optimized using "objective" knowledge and with the best intentions may not receive favorable reviews from enrollees because enrollees have different perceptions of these plans.

Adolescent↗
PubMed2006

How much risk pooling is there in the individual insurance market?

OBJECTIVE: To examine how much pooling of risks occurs among potential purchasers in the individual market, how much pooling occurs among those who purchase coverage, and whether there is greater pooling among longer-term enrollees. DATA SOURCES: The data are administrative records for enrollees in individual insurance plans in California in 2001, and from a survey of Californians enrolled in the individual insurance market and the uninsured. STUDY DESIGN: Logit models were estimated for 5 health outcome measures to compare the insured and uninsured after adjusting for other factors that affect insurance status and health. Multivariate models were also estimated to explore the relationship between health and three measures of pooling in the market: plan type, pricing tier, and the actuarially adjusted premium paid by the enrollee. PRINCIPAL FINDINGS: Those who purchase individual health insurance are in better health than those who remain uninsured. On the other hand, a large share of people with health problems does obtain individual insurance. The distribution of subscribers across plan type and pricing tier varies with their health status. Those in poor health are less likely to purchase low benefit plans. There is less separation of risks for those who become sick after enrollment based on the measure of pricing tier. The distribution of subscribers across plan type for those who have health problems at enrollment and those who become sick differs, but so does the distribution of those who become sick and those who remain healthy. CONCLUSIONS: Despite small differences among the healthy and sick, our results support the conclusion that there is considerable risk pooling in the individual market. To some extent, this pooling occurs because underwriting happens at the time people enroll and there is greater pooling among those who become sick than those who enroll sick. Our results however suggest that health savings accounts may further fragment the market.

California↗
PubMed2006

Impact of alternative interventions on changes in generic dispensing rates.

OBJECTIVES: To evaluate the effectiveness of four alternative interventions (member mailings, advertising campaigns, free generic drug samples to physicians, and physician financial incentives) used by a major health insurer to encourage its members to switch to generic drugs. METHODS: Using claim-level data from Blue Cross Blue Shield of Michigan, we evaluated the success of four interventions implemented during 2000-2003 designed to increase the use of generic drugs among its members. Around 13 million claims involving seven important classes of drugs were used to assess the effectiveness of the interventions. For each intervention a control group was developed that most closely resembled the corresponding intervention group. Logistic regression models with interaction effects between the treatment group (intervention versus control) and the status of the intervention (active versus not active) were used to evaluate if the interventions had an effect on the generic dispensing rate (GDR). Because the mail order pharmacy was considered more aggressive at converting prescriptions to generics, separate generic purchasing models were fitted to retail and mail order claims. In secondary analyses separate models were also fitted to claims involving a new condition and claims refilled for preexisting conditions. RESULTS: The interventions did not appear to increase the market penetration of generic drugs for either retail or mail order claims, or for claims involving new or preexisting conditions. In addition, we found that the ratio of copayments for brand name to generic drugs had a large positive effect on the GDR. CONCLUSIONS: The interventions did not appear to directly influence the GDR. Financial incentives expressed to consumers through benefit designs have a large influence on their switching to generic drugs and on the less-costly mail-order mode of purchase.

Advertising↗
PubMed1991

Typical patterns and cost of alcoholism treatment across a variety of populations and providers.

This paper presents data on the utilization of alcoholism treatment services in three populations of insurance enrollees: enrollees covered by the insurance plan of a large midwestern manufacturing firm, 1981-1987 (N = 1.425); enrollees of the California Health Insurance Plan of the Public Employees Retirement System, 1974-1976 (N = 766); U.S. government civilian employees enrolled with the Aetna Insurance Company, 1980-1983 (N = 1,697). The average age of the treated alcoholics in these three groups ranged from 37 to 51. Between two-thirds and three-quarters were male. Inpatient alcoholism treatment services were more frequently used than outpatient, with inpatient admissions averaging between 1.2 and 1.5 per person. For enrollees of the midwestern manufacturing firm, total alcoholism treatment costs averaged $4,665 per person (December 1985 dollars). The influence of insurance plan coverage and other factors on utilization patterns is discussed.

Adult↗