Court finds that RICO statute can be applied in noncriminal cases.
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American Dental Association↗
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Neonatal hospital lengths of stay, readmissions, and charges.
OBJECTIVE: To evaluate trends in length of hospital stay, hospital charges, and readmission rates of Wisconsin newborns from 1989 through 1994 in light of recent policies requiring earlier discharges after delivery of newborns. METHODOLOGY: Two data sources were used: 1) 1989-1994 Hospital Inpatient Discharge Data from the Wisconsin Office of Health Care Information, and 2) 1994 birth certificate and matched infant mortality data from the Wisconsin Center for Health Statistics. Average lengths of stay and average hospital (delivery and readmission) charges were calculated, and readmission rates were estimated for full-term, premature, and sick newborns. RESULTS: There were 368 955 full-term and 26 668 premature newborns in Wisconsin from 1989 through 1994. The average length of stay decreased by 24% in full-term newborns from 1989 through 1994, while average hospital (delivery and readmission) charges rose over 40% during the same period. Average length of stay for premature infants increased by 24% while their hospital delivery charges increased 214% during the study period. Readmission rates halved, yet charges per readmission doubled for full-term infants. More than twice as many full-term newborns were classified as sick in 1994 (43%) compared with 1989 (19%). CONCLUSIONS: Managed care efforts to control costs of neonatal care through earlier newborn discharge policies may have limited impact. Physicians or hospitals may be compensating for these policies by classifying more newborns as sick, thereby allowing for longer hospital stays to be reimbursed by the insurance carriers. Premature infants, <7% of the total births, account for half of all hospital delivery charges. Efforts to reduce premature births may have a greater impact on neonatal health care costs than efforts to discharge full-term newborns earlier.
Birth Weight↗
Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program.
BACKGROUND: Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. OBJECTIVES: The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. METHODS: Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. RESULTS: Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. CONCLUSIONS: Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.
Adolescent↗
Model contractual language for medical necessity for children.
The term "medical necessity" is used by Medicare and Medicaid and in insurance contracts to refer to medical services that are generally recognized as appropriate for the diagnosis, prevention, or treatment of disease and injury. There is no consensus on how to define and apply the term and the accompanying rules and regulations, and as a result there has been substantial variation in medical-necessity definitions and interpretations. With this policy statement, the American Academy of Pediatrics hopes to encourage insurers to adopt more consistent medical-necessity definitions that take into account the needs of children.
Adolescent↗
[Health insurance in the contributive and subsidized regimes and its impact on the service providers].
The performance of 18 private Health-promoting (EPS) and Family Compensation (CCF) entities, as well as their general balances for 1997, 1998 and 1999, were studied to determine the profit margins achieved by EPS's in their work of administering health insurance. The average behavior of each EPS balance sheet was analyzed to reduce the effect produced by extreme cases; each EPS's value was thus weighted by the number of its affiliated people. The expected behavior of the costs and expenses of companies whose main business is providing health insurance could thus become determined. The main source of operational income for a private EPS is the contributive regime's per capita unit of payment (UPC). Subsidized regime participation and that of other sources of income has decreased year by year. By contrast, public EPS's have shown decreasing participation in income obtained from UPC (contributive and subsidized) and growing dependence on other sources of income; this can be interpreted as being a symptom of weak commercial management. According to the balance sheets provided by the SNS, the EPS (public, private and Family Compensation entities), including the Social Security Institute (ISS), together obtained a total of 4.18 billion pesos operational income in 1999, an increase of 21.7% as compared to 1998. Income received from the ISS amounted to 1.93 billion dollars in 1999 (46% of the total). At 2000 prices, the total amount of operational income was 4.54 billion pesos in 1999 (15.6% real increase). Taking the behavior of 4 EPS's as our reference point (Sanitas, Humana Vivir, Coomeva and Famisanar), it can be concluded that an EPS whose main business is health insurance needs a 17.2% gross margin to cover its operational and non-operational costs and a 1.1% margin before tax.
Accounting↗
Devastating injuries in healthcare workers: description of the crisis and legislative solution to the epidemic of back injury from patient lifting.
The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.
Adult↗
Controlling the cost of dental care.
Methods for controlling dental care expenditures are taking on greater importance with the rapid increase in prepaid dental plans. The use of regulatory systems to monitor provider performance are necessary to prevent gross over-utilization but are unlikely to result in net savings of more than five per cent of total gross premiums. Theoretically, prepaid group dental practice (PGDP) may reduce expenditures by changing the mix of services patients receive. The modest estimated savings and the small number of PGDPs presently in operation limit the importance of this alternative for the next five to ten years. If substantial reductions in dental expenditures are to be obtained, it will be necessary to limit dental insurance plans to cover only those services which have demonstrated cost-effectiveness in improving health for the majority of people. The concept that richer benefit plans may have small marginal effects on improving oral health may not be easy for the public to accept but, until they do, expenditures for dental care will be difficult to control.
Cost Control↗
Health insurance and AIDS: the status of state regulatory activity.
Information collected by the National Gay Rights Advocates in 1986 and by the authors in the spring of 1987 was used to determine the extent to which the states currently regulate the practices of the health insurance industry specific to acquired immunodeficiency syndrome (AIDS). Of the 10 states reporting the greatest number of AIDS cases, six prohibit insurers form denying coverage to group policy applicants because of human immunodeficiency virus (HIV) infection. These findings refer only to the status of state regulatory activity specific to AIDS.
Acquired Immunodeficiency Syndrome↗
The role of government and private insurers in guiding and implementing pharmacoeconomic analyses.
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Economics, Pharmaceutical↗
Well-healed: inside lobbying for health care reform, Part II. Center for Public Integrity.
The Center for Public Integrity conducted a year-long investigation of the decision-making processes of the U.S. government during its work on health care reform. The results suggest that health care reform has become the most heavily lobbied legislative initiative in recent U.S. history. In 1993 and 1994, hundreds of special interests spent over $100 million to influence the outcome of this public policy issue. In Part II, the authors describe some of these special interests, including the insurance industry, both the largest companies and those that make up the Health Insurance Association of America; doctors, hospitals, and other health care providers; the pharmaceutical industry; businesses of all sizes; and the tobacco industry.
American Hospital Association↗
A review of data on the U.S. health sector spring 2006.
This report presents information on the state of the U.S. health system in the spring of 2006. It includes data on the uninsured and underinsured and their access to health care, on socioeconomic inequality in health care, and on the rising costs of the U.S. health system. It also presents information on the role of corporate money in health care, focusing on the pharmaceutical industry, Medicare HMOs, and corporate-government conflicts of interest. The author includes a survey of recent public opinion polls on health care and health system reform and an update on the U.S. national health insurance legislation. The article ends by reviewing recent data on international health systems and international system comparisons.
Attitude to Health↗
The U.S. health insurance industry: an alternative view.
The health insurance industry in the U.S. can be characterized as a concentrated industry. It has evolved into its current structure as a result of certain historical conditions, particularly those following the Great Depression. The structure of the industry has had an effect on the manner in which the industry functions and the cost increases in the health care sector. Specifically, the pricing mechanism is that of a price leader setting a limit price; health premium prices are higher than would be expected under a competitive structure. Regulation has been ineffective, because it has been dominated historically by health care providers and insurers. The costs of health care in general, and hospital care in particular, have increased beyond what would be expected as a result of "cost-pass-through."
Blue Cross Blue Shield Insurance Plans↗
Independent of what? The independent medical examination business.
Workers suffering from a work-related health condition frequently are required to undergo examination by a physician chosen by the employer or a Workers' Compensation Insurance Carrier. While the opinions of physicians performing these "Independent Medical Examinations" (IMEs) have been criticized as biased by a conflict of interest, IME advocates assert that the methods used by the IME result in an objective and superior opinion. This article explores this claim to objectivity and superiority. It argues that pro-employer/carrier bias is embedded in the methodology IMEs advocate, and that the practical impact of the IME approach is to reduce the recognition of occupationally related health conditions and to minimize the disability associated with such conditions. The IME approach is more accurately characterized as a tool to standardize a product that can be marketed to corporate clients, rather than a way to precisely assess work-related health conditions.
Journal Article↗
Health planning as a regulatory strategy: a discussion of its history and current uses.
Federally mandated health planning is one of the most significant responses to the cost crisis of American medicine. Portrayed as an objective and rational mechanism of determining the future, planning is a socially acceptable means of exerting third-party control over a sector of the economy long able to escape meaningful controls on its growth and development. However, far from being the neutral science which it is heralded to be, the planning process serves the interests that are able to control its use. Health planning agencies must be studied in the context of the current emphasis on cost containment and reorganization of health services. Supported and enfranchised largely by major third-party payors, planning smooths the implementation of changes in the health sector. Despite its progressive potential, planning serves the interests of these third-party payors by masking their attempts to control the future development of the health system.
Delivery of Health Care↗
Premiums without benefits: waste and inefficiency in the commercial health insurance industry.
The U.S. system of health insurance is wasteful and inefficient. For every dollar the commercial health insurance industry paid in claims in 1988, the industry spent 33.5 cents for administration, marketing, and other overhead expenses. Thus, not including profits, the commercial insurance industry spent 14 times as much on administration, overhead, and marketing per dollar of claims paid as did the Medicare system, and 11 times as much per dollar of claims paid as the Canadian national health system. Had an efficient public program such as Medicare or the Canadian system provided the same amount of benefits, consumers and businesses served by commercial insurers would have saved $13 billion. The sources of waste include excessive marketing costs and administrative costs bloated by discriminatory underwriting practices that segregate the profitable groups and individuals--people who are healthy, young, and in "safe" professions--from everyone else.
Canada↗
A review of data on the U.S. health sector: fall 2004.
This report presents information on the state of the U.S. health sector in late 2004. It includes data on the uninsured and underinsured and their access to health care, underinsurance for long-term care and mental health, and the rising costs of health insurance and health care. The author presents data on the increasing social inequalities in health and access to health care; the role of corporate money in health and health care; and the hospital and pharmaceutical industries. The article also includes updates on the consequences of the Medicare prescription drug bill and the state of Medicare spending, and seniors' spending, on drugs; the results of some recent public opinion polls on health care; information on labor, labor unions, and health insurance; and some international comparisons of health insurance. The article concludes with some useful sources of information on single-payer, universal health care.
Drug Industry↗
Insurance and the disabled.
The provision of life insurance for the disabled has been investigated to determine the extent to which the perceived disadvantage expressed by some disabled groups was real and, if real, justified. Life cover for a particular disability is likely to be offered only by the few companies with experience of it; however, the ratings charged appear usually to be a fair reflection of the limited and often poor information available. The response of organizations for the disabled to this problem has been reviewed, and possible strategies to enable the disabled to obtain insurance are suggested.
Actuarial Analysis↗
Incorporating nutrition into pediatric practice: physicians and dietitians working together to improve children's health.
Clinicians are needed to include nutrition in the routine care of infants and children in office practice. Physicians play an important role in assessing nutritional status, diagnosing nutritional problems, providing a rationale for treatment, prescribing, performing brief counseling, referring to other resources if needed, and following up on the progress of their patients. Registered dietitians are the consultants of choice to assist pediatricians in the care of patients with nutrition-related disorders and are skilled in providing pediatric health promotion and disease prevention information. Consultant dietitians in the community can be found through contacting the local department of health or local hospital outpatient department. The American Dietetic Association also maintains a list of consulting dietitians throughout the United States. Funding mechanisms for engaging dietetic services vary from contracting with dietitians in private practice, local health departments, or hospital outpatient clinics, to employing dietitians on-site to provide counseling services in the office. Availability for third party payment for nutrition services varies with insurance carriers, individual policies, and region of the country. Incorporating nutrition into pediatric practice is important. Together, physicians and dietitians can work together to improve children's health.
Child↗