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PubMed2003

Insurance coverage and health care consumers' use of emergency departments: has managed care made a difference?

How successful has managed care been in controlling costs and consumers' inappropriate use of health care services? This study compares national data from 1992 and 1996 to determine the effect of managed care on appropriateness of ED utilization. ED utilization was described in two ways as defined in Gooding, Smith, and Peyrot (1996): (1) urgency of visit (urgent vs. non-urgent), and (2) appropriateness of visit taking into account the care provided upon visits (including treatment and diagnostic procedures) and disposition of visit (admit, transfer, and discharge against medical advice). Potentially appropriate visits were the non-urgent cases at which treatment procedures and/or non-routine diagnostic procedures were performed. All urgent visits were defined as appropriate. Study results reveal that consumers' ED misuse changed in complex ways over the period examined. Contrary to our assumptions based on earlier research, the pattern of change was not the same for the two different measures of misuse. Non-urgent use decreased, as hypothesized, but there was an increase in non-urgent use which we have defined as inappropriate (i.e., no treatment and no non-routine diagnostic tests). ED misuse did not decrease more for insured than uninsured consumers, nor more for managed care than fee-for-service consumers. These findings bring into question the efficacy of efforts to address rising health care costs through controlling consumer utilization of services via managed care, efforts mirrored by many fee-for-service indemnity plans. Future research is needed to determine why this consumer misuse of the ED appears to continue and how the recent increase in the marketing of ED services may exacerbate this problem.

Community Participation↗
PubMed2001

Increasing health insurance coverage through an extended Federal Employees Health Benefits Program.

The Federal Employees Health Benefits Program (FEHBP) could be combined with health insurance tax credits to extend coverage to the uninsured. An extended FEHBP, or "E-FEHBP," would be open to all individuals who were not covered through work or public programs and who also were eligible for the tax credits on the basis of income. E-FEHBP also would be open to employees of very small firms, regardless of their eligibility for tax credits. Most plans available to FEHBP participants would be required to offer enrollment to E-FEHBP participants, although premiums would be rated separately. High-risk individuals would be diverted to a separate high-risk pool, the cost of which would be subsidized by the federal government. E-FEHBP would be administered by the states, or if a state declined, by an entity that contracted with the Office of Personnel Management. While E-FEHBP would provide group insurance to people who otherwise could not get it, premiums could exceed the tax-credit amount and some people still might find the coverage unaffordable.

Adult↗
PubMed2003

Assessing the validity of insurance coverage data in hospital discharge records: California OSHPD data.

OBJECTIVE: To assess the accuracy of data on "expected source of payment" in the patient discharge database compiled by the California Office of Statewide Health Planning and Development (OSHPD). DATA SOURCES: The OSHPD discharge data for the years 1993 to 1996 linked with administrative data from the University of California (UC) health benefits program for the same years. The linked dataset contains records for all stays in California hospitals by UC employees, retirees, and spouses. STUDY DESIGN: The accuracy of the OSHPD data is assessed using cross-tabulations of insurance type as coded in the two data sources. The UC administrative data is assumed to be accurate, implying that differences between the two sources represent measurement error in the OSHPD data. We cross-tabulate insurance categories and analyze the concordance of dichotomous measures of health maintenance organization (HMO) enrollment derived from the two sources. PRINCIPAL FINDINGS: There are significant coding errors in the OSHPD data on expected source of payment. A nontrivial percentage of patients with preferred provider organization (PPO) coverage are erroneously coded as being in HMOs, and vice versa. The prevalence of such errors increased after OSHPD introduced a new expected source of payment category for PPOs. Measurement problems are especially pronounced for older patients. Many patients over age 65 who are still covered by a commercial insurance plan are erroneously coded as having Medicare coverage. This, combined with the fact that during the period we analyzed, Medicare HMO enrollees and beneficiaries in the fee-for-service (FFS) program are combined in a single payment category, means that the OSHPD data provides essentially no information on insurance coverage for older patients. CONCLUSIONS: Researchers should exercise caution in using the expected source of payment in the OSHPD data. While measures of HMO coverage are reasonably accurate, it is not possible in these data to clearly identify PPOs as a distinct insurance category. For patients over age 65, it is not possible at all to distinguish among alternative insurance arrangements.

California↗
PubMed2005

Trends in insurance coverage for bariatric surgery and the impact of evidence-based reviews.

The recent increase in demand for bariatric surgery has placed mounting economic pressure on insurance companies and other third-party payers (TPPs). As a result, some of the TPPs have responded by excluding or limiting their coverage of all or certain types of bariatric surgical procedures, and cite as their reason, a lack of evidence that supports the safety and efficacy of such procedures. Over the years, so-called "evidence-based reviews" have been used to back these claims. Some of these reviews have significant flaws and limitations that are discussed.

Bariatrics↗