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PubMedDate not supplied

Individual insurance: how much financial protection does it provide?

This paper examines the comparative financial protection provided by individual and group health insurance. Data sources include two national surveys of employer-based health plans and e-health insurance listings for individual coverage on the World Wide Web. Data on the use and cost of services are from the National Medical Expenditure Survey (NMES), a national household survey of Americans. We estimate that individual insurance pays on average 63 percent of the health care bill, whereas group health insurance pays 75 percent. Deductibles are much higher in individual insurance, and covered benefits are more meager. At 200 percent of poverty, the top 25 percent of health care users with individual coverage would spend 11 percent of their income for out-of-pocket health care expenses, as opposed to 6 percent for persons with group coverage.

Actuarial Analysis↗
PubMed1988

Insurance principles and the design of prospective payment systems.

This paper applies insurance principles to the issues of optimal outlier payments and designation of peer groups in Medicare's case-based prospective payment system for hospital care. Arrow's principle that full insurance after a deductible is optimal implies that, to minimize hospital risk, outlier payments should be based on hospital average loss per case rather than, as at present, based on individual case-level losses. The principle of experience rating implies defining more homogenous peer groups for the purpose of figuring average cost. The empirical significance of these results is examined using a sample of 470,568 discharges from 469 hospitals.

Costs and Cost Analysis↗
PubMed1995

The introduction of deductibles for prescription drugs in a national health insurance: compulsory or voluntary?

We consider a situation of full insurance coverage for prescription drugs where, at a certain point in time, people are given the opportunity to take a deductible in exchange for a lower premium. Four determinants of this premium reduction can be considered: expected out-of-pocket payments, adverse selection effects, moral hazard effects, and administration costs. The purpose of this study is to analyse the first two determinants. Survey data of 17,242 insureds in the Netherlands have been used for this research. Results show that the expected out-of-pocket expenditures in case of a certain deductible amount depend strongly on age and gender. People in poor health could be given a larger premium discount if they would take a deductible than those in good health. This implies that a uniform premium discount would induce adverse selection. The effects of such selection have been simulated by using a survey question about the preference to take a general deductible. If the premium reductions for policies with a deductible are adjusted for age and gender, the selection effect will halve but will still be substantial. We conclude that, in the situation considered here, it is largely immaterial whether deductibles are compulsory or voluntary, provided premium reductions are allowed to depend on relevant risk factors.

Adolescent↗
PubMed1988

Insurance coverage and the demand for dental care. Results for non-aged white adults.

The fraction of the U.S. population with private dental insurance coverage increased considerably during the past two decades. Experimental data from the Rand Health Insurance Study have revealed that dental insurance is an important determinant of demand. In this analysis, detailed health insurance data from the National Medical Care Expenditure Survey are used to study the effects of insurance on demand by a standard population of white adults aged 16 to 64. Results from this national probability sample are generally comparable to those from the Rand experimental data. Estimates indicate that the primary effects of dental insurance are to facilitate access to care and to increase dental expenditures. Results are consistent with the notion that first-dollar coverage exerts a greater effect on demand than insurance which requires payment of a deductible. Findings also suggest that insurance affects the mix of dental services received. Loss of dental benefits because of cost containment efforts will result in significant reductions in demand for dental services.

Adolescent↗
PubMed1996

Medical savings accounts. American College of Physicians.

This position paper examines medical savings accounts (MSAs) as a supplemental mechanism for financing health care services. Although federal legislation to encourage MSAs did not pass in 1995 and is not likely to pass in 1996, MSAs will continue to be seriously considered by public policymakers. Individual retirement accounts accumulate funds for retirement; MSAs could be used to accumulate funds for health care expenditures. Changes in the federal tax code would be required to permit tax-deductible contributions and tax-free earnings to individual MSAs. To be withdrawn without penalty, funds from an MSA could only be used to pay for approved medical or health insurance expenses. Each person would own and control his or her account, regardless of changes in employment. Coupled with high-deductible health insurance, MSAs could empower cost-conscious patients in health care decision making, increasing competitive pressure to reduce health care costs. Administrative costs and paperwork associated with health insurance might also be reduced, and some people who currently do not have health insurance might be able to obtain some financial protection. Medical savings accounts may not help unemployed persons or low- and middle-income persons who cannot afford to contribute to such accounts. These accounts may result in reduced health insurance protection and greater out-of-pocket expenses for those most in need of health care. Problems of adverse risk selection could arise if healthy persons choose insurance options involving MSAs; this choice would cause premiums to increase for persons who desire traditional health insurance.

Deductibles and Coinsurance↗
PubMed2000

Waiting periods and health-related absenteeism: the need for program integration.

This article discusses evidence that the reduction of waiting period deductibles in disability insurance plans increases the amount of lost time utilized by insured workers and also increases the cost of sick leave. The authors posit that the evidence supports the need for an integrated disability insurance product, which could be offered at lower costs than the current system that provides fragmented lost time coverage.

Absenteeism↗
PubMed2000

Small employers and health benefits: findings from the 2000 Small Employer Health Benefits Survey.

Many small employers (between two and 50 workers) are making decisions about whether to offer health benefits to their workers without being fully aware of the tax advantages that can make this benefit more affordable. Fifty-seven percent of small employers did not know that they can deduct 100 percent of their health insurance premiums. Nearly one-half of small employers are not aware that workers who purchase health insurance on their own generally cannot deduct 100 percent of their health insurance premiums. Small employers are largely unaware of the laws that have been enacted by nearly all states and the federal government with the intent of making health insurance more accessible and more affordable for many small employers. More than 60 percent did not know that insurers may not deny health insurance coverage to small employers even when the health status of their workers is poor. Most employers offer sound business reasons for offering health benefits to workers. Many have found that it helps with employee recruitment and retention, increases productivity, and reduces absenteeism. Nearly 50 percent of the employers offering dependent (family) coverage report that the workers do not take coverage for their dependents because the dependents have coverage from somewhere else. Twenty-seven percent report their employees decline dependent coverage because they cannot afford the premiums. Many small employers that do not offer health benefits are potential purchasers. Twelve percent are either extremely or very likely to start offering health benefits in the next two years, and 17 percent are somewhat likely to start offering health benefits. A number of factors would increase the likelihood that a small business would seriously consider offering a health benefits plan. Two-thirds of small-business owners said they would seriously consider offering health benefits if the government provided assistance with premiums. Almost one-half would consider doing so if insurance costs fell 10 percent. In addition, one-half would be more likely to seriously consider offering a health benefits plan if employees demand it. Many small employers with health benefits have recently switched health plans, and 34 percent report that they did so within the past year. Affordability for the employer and the worker is clearly a critical factor affecting the likelihood of switching health plans. Nearly all employers who have switched health plans within the past five years cite cost as the main reason. One-third of companies offering health benefits think they will change coverage, and 5 percent think they would drop coverage if the cost of health insurance were to increase by 5 percent.

Commerce↗
PubMed2000

An insurer's perspective on reform.

Individual health insurance markets differ from state to state, and as a result approaches to individual market reforms need to be different. In evaluating approaches, policy makers need to remember that since the decision to purchase health insurance coverage is voluntary, the potential for adverse selection exists. In addition, rather than putting the focus of individual market reforms almost exclusively on access to health insurance for a small number of persons with high-cost health conditions, more attention needs to be put on how to decrease the number of uninsured persons. This includes making the premiums paid for individual health insurance 100 percent tax deductible, similar to those of employer-based health insurance. Finally, market reforms need to treat all types of coverage issued in the individual market the same, whether they are purchased direct for the insurer or through an out-of-state association.

Health Care Reform↗
PubMed2001

Income-based drug benefit policy: impact on receipt of inhaled corticosteroid prescriptions by Manitoba children with asthma.

BACKGROUND: Drug benefit policies are an important determinant of a population's use of prescription drugs. This study was undertaken to determine whether a change in a provincial drug benefit policy, from a fixed deductible and copayment system to an income-based deductible system, resulted in changes in receipt of prescriptions for inhaled corticosteroids by Manitoba children with asthma. METHODS: Using Manitoba's health care administrative databases, we identified a population-based cohort of 10,703 school-aged children who met our case definition for asthma treatment before and after the province's drug benefit policy was changed in April 1996. The effects of the program change on the probability of receiving a prescription for an inhaled corticosteroid and on the mean number of inhaled corticosteroid doses dispensed were compared between a group of children insured under other drug programs (the comparison group) and 2 groups of children insured under the deductible program: those living in low-income neighbourhoods and those living in higher-income neighbourhoods. All analyses were adjusted for a measure of asthma severity. RESULTS: For higher-income children with severe asthma who were covered by the deductible program, the probability of receiving an inhaled corticosteroid prescription and the mean annual number of inhaled corticosteroid doses declined after the change to the drug policy. A trend toward a decrease in receipt of prescriptions was also observed for low-income children, but receipt of prescriptions was unaltered in the comparison group. Before the policy change, among children with severe asthma, the mean annual number of inhaled corticosteroid doses was lowest for low-income children, and this pattern persisted after the change. Among children with mild to moderate asthma, those covered by the deductible program (both low income and higher income) were less likely to receive prescriptions for inhaled corticosteroids than those in the comparison group, and this difference was statistically significant for the higher-income children. INTERPRETATION: The change to an income-based drug benefit policy was associated with a decrease in the use of inhaled corticosteroids by higher-income children with severe asthma and did not improve use of these drugs by low-income children.

Administration, Inhalation↗
PubMed1996

Congress advances on health care reform: one step at a time.

In adopting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress made a series of small but significant steps toward improving access to health care benefits. The Act's centerpiece is its new requirements for group health plans and for the health insurance industry for assuring portability, access, and renewability of health insurance coverage. Of nearly equal importance is the pilot program established for testing the viability of medical savings accounts. Other health-related changes include adjustments in the rules governing duplication and coordinating of Medicare-related plans, recommendations with respect to privacy of health information of employees, an increase in the deduction for health insurance costs for self-employed individuals, and permission for unemployed persons to make withdrawals from IRAs and other qualified plans for certain medical services' costs. This article summarizes these and other key provisions of HIPAA.

Cost Sharing↗
PubMed1986

Preferred provider organizations: today's models and tomorrow's prospects.

Preferred provider organizations (PPOs) have recently attracted much attention as an alternative to both traditional fee-for-service medicine and health maintenance organizations. To examine their development and structure, we conducted a telephone survey with executives of more than 130 operational PPOs. We describe typical examples of the three most common types of PPOs-those sponsored by providers, insurers, and entrepreneurs-and identify problems each faces in the increasingly competitive health care environment. We then cite approaches that innovative PPOs are using to deal expressly with these problems.

Blue Cross Blue Shield Insurance Plans↗
PubMed1978

The norms hypothesis and the demand for medical care.

Our results cast doubt on the validity of the norms hypothesis--that physicians treat patients in accordance with the average or modal insurance coverage in an area. The one study in the literature directly supporting this hypothesis is misspecified; when more correctly specified, it provides no support for the hypothesis. Two versions of the hypothesis are distinguished. the stronger maintains that physicians do not take account of within-area variation in insurance coverage. This version is firmly rejected by the data. A weaker version says that the physician does take account of within-area variation but that between-area differences in average coverage have an independent effect on demand. Little or no support is found for this version, but our data do not permit very powerful tests.

Blue Cross Blue Shield Insurance Plans↗