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PubMed2003

Risk adjustment and risk sharing: the Israeli experience.

Israel, like several other countries, introduced a national risk adjusted capitation system during the 1990s. However, the Israeli move was drastic, implementing from the beginning a fully prospective risk adjustment scheme based on age, supplemented by a 100% five condition-specific risk sharing. That scheme, together with open enrollment (periodic switching options), was intended to transform an unregulated competitive health insurance market, characterized by adverse selection and preferred risk selection, into managed competition assuring quality of care, efficiency and fairness. This paper presents the Israeli experience during the first 6 years of the reformed system, focusing on issues related to the risk adjustment and risk sharing arrangements.

Adolescent↗
PubMed2004

MassHealth succeeds in expanding coverage for adults.

This study provides the first rigorous evaluation of the impacts of MassHealth, Massachusetts' ambitious effort in the late 1990s to expand coverage to the entire low-income population. We find clear evidence that MassHealth led to an expansion of insurance coverage relative to what was happening to similar populations in comparison states. The success of MassHealth provides support for the value of investing in ambitious new state efforts to find effective strategies to reach the remaining uninsured populations. While current budget shortfalls have forced many states, including Massachusetts, to scale back their expansion efforts, the current economic downturn is not permanent. Understanding the impacts of the expansion efforts in Massachusetts adds to the base of knowledge that will be critical for guiding states when the economy recovers and the resources needed for expansion again become available.

Adult↗
PubMed2000

Universal healthcare: a bold proposal.

One problem with the American health-care system today is not that it's too expensive but that it's too wasteful. The amount spent on health-care in the United States is sufficient to take care of the medical needs of every citizen. The reason that it does not is that the money is far too often is misspent. America already is spending 14% of the gross domestic product and yet we have health-care chaos and 44 million uninsured. Another problem is the lack of trust between payors, insurance carriers, regulators, employers, employees, providers, and patients. Although the financing aspect of health-care is tremendously important, it is even more important to design a plan to spend the money wisely, align the incentives of insurers, payors, patients, and providers, and restore trust between parties. Otherwise we shall continue to be in chaos regardless of how much money we spend on health-care. In this article, we outline our proposal for an ideal comprehensive national health-care plan that will guarantee that we spend our health-care dollars wisely. Our plan would cover all Americans, including the 44 million uninsured, and it would do so at less than the cost of the current system. Because insurance companies are not equipped to oversee medical practice, our plan would place the day-to-day management of the health-care system in the hands of physicians and local physician-run, physician-owned "provider groups." The physicians in these provider groups would be charged with two primary responsibilities: 1) clinically, they would be responsible for providing total quality cradle-to-grave health-care for every patient in their group and 2) economically, they would be responsible for the budget and to spend it wisely. Physicians will be compensated fee-for-service plus an incentive for efficiency, patient satisfaction, and outcome in a broad sense. Physicians would enjoy wide latitude in clinical decision-making without being second-guessed by distant third parties. Our plan places the fiscal responsibility on physicians while at the same time establishing a system of checks and balances to ensure that patients are protected and well cared for. Unlike outwardly similar plans, under this proposal the physicians are owners of the provider groups and the incentives between payors, insurers, providers, and patients are better aligned. It will eliminate the debate about giving patients the right to sue health plans and employers. It would empower large legally organized physician groups to negotiate with insurers. Our plan is a model for spending money wisely. We believe it would benefit, and therefore be embraced, by all parties--physicians, other healthcare providers, employers, insurance companies, the government, and above all the American public.

Budgets↗
PubMed2004

ACOG Committee Opinion No. 308. The uninsured.

The United States is one of the.few industrialized nations in the world that does not guarantee access to health care for its population. Access to health care for all women is a paramount concern of obstetrician-gynecologists and the American College of Obstetricians and Gynecologists. Lack of health care coverage creates access issues that affect women, practitioners, and the health care system as a whole. The number of women in the United States without health care coverage grew 3 times faster than the number of men without such coverage during the late 1990s and early 2000s. A change in our currently fragmented health care system is warranted because the lack of coverage clearly matters to the millions of uninsured Americans. Pregnant women and infants are among the most vulnerable populations in the country and the American College of Obstetricians and Gynecologists believes that providing them with fill insurance coverage must be a primary step in the process of providing coverage for all Americans. However, it is only the first step; it is critical to expand coverage for all Americans. Health professionals can play a pivotal role in improving access to needed health care by helping society understand the importance of broadening health insurance coverage.

Female↗
PubMed2005

Insuring the uninsured: finding the road to success.

This article outlines various strategies that have been proposed to expand health insurance. Many have been tried in limited ways, and the article describes the experience with those attempts. The discussion is organized from the perspective of the opposing points of view: approaches that would support private coverage and largely rely on demand incentives and approaches that presuppose a more direct government role. The article reaches no conclusion about which strategy might be a wiser course of action. However, it does take measure of the likely effects of each strategy where early experience or objective analysis is available.

Commodification↗
PubMedDate not supplied

Health care reform in Japan: the virtues of muddling through.

Japan's universal and egalitarian health care system helps to keep its population healthy at an exceptionally low cost. Its financing and delivery systems have been adapted over the years in a gradual way that preserves balance. In particular, its mandatory fee schedule has proved to be effective in controlling spending by manipulating prices. Today, with severe fiscal problems, pressures are mounting for more radical reforms. However, these proposals attack the wrong problems and are impractical. Real problems include inequitable health insurance financing and insufficient regard for quality of hospital care. We suggest incremental reforms that would improve these situations.

Cost Control↗
PubMed1995

Out-of-pocket health expenditures by elderly households: change over the 1980s.

This study compares out-of-pocket health expenditures of elderly and nonelderly households over the past decade, using descriptive statistics and two-stage least squares analysis of Consumer Expenditure Survey data for 1980-1981 and 1989-90. This empirical analysis provides a basis for discussion of both efficiency and equity issues in health policy. We find that increases in out-of-pocket medical care expenditures over the last decade were mainly for insurance premiums rather than medical goods and services, which indicates potential inefficiencies in health care markets. We also find that Medicare promoted equity of out-of-pocket expenditures on health care among elderly persons over the 1980s, which implies that universal national health insurance would enhance distribution equity.

Aged↗
PubMedDate not supplied

The patients' complaints system in New Zealand.

Since 1996 New Zealand has had a Code of Patients' Rights enforceable by complaints to an independent ombudsman. Patients are entitled to receive health care of an appropriate standard, to give informed consent, and to complain to a health commissioner about perceived malpractice. The commissioner investigates and reports on complaints, recommends practice changes by providers, is a gatekeeper to discipline by professional boards, and acts as a public advocate for patient safety. In this paper the current commissioner describes New Zealand's experience with the patients' complaints system and discusses the implications for the quality of health care.

Administrative Personnel↗
PubMed1999

Health insurance, health reform, and outpatient mental health treatment: who benefits?

This research examines how extending health insurance coverage to the previously uninsured impacts outpatient mental health treatment use among adults with different needs. Using data from the Epidemiologic Catchment Area Study and the 1987 National Medical Expenditure Survey, I develop simulations based on estimates of treatment demand. I find that insurance substantially increases demand by the mentally ill, but increased coverage alone cannot meet their treatment needs. Those in better mental health account for significant proportions of additional demand when coverage is expanded. Policies intended to increase access to mental health treatment among targeted groups should carefully consider the costs of increased use by other people.

Adult↗
PubMed2006

Diabetes management in the USA and England: comparative analysis of national surveys.

OBJECTIVES: To compare diabetes management in adults between England and the United States, particularly focusing on the impact of a universal access health insurance system. DESIGN: Analysis of the nationally-representative surveys Health Survey of England, 2003 (unweighted n =14 057) and the National Health and Nutrition Examination Survey, 2001-2002 (unweighted n =5411). SETTING AND PARTICIPANTS: Adults 20-64 years of age; individuals >65. MAIN OUTCOME MEASURES: Glycaemic, lipid and blood pressure control and medication use among individuals with previously diagnosed diabetes. RESULTS: Among those aged 20-64 the prevalence of diagnosed diabetes was lower in England (2.7%) than in the USA (5.0%). The proportion with diabetes receiving treatment was similar for the two countries. However, the mean HbA1c in England was 7.6%: in the USA it was 7.5% for those with insurance and 8.6% for those without insurance. The proportion of individuals on ACE inhibitors in England was 39%: in USA it was 39% for those with insurance, and 14% for those without. CONCLUSIONS: Individuals in a healthcare system providing universal access have better managed diabetes than those in a market based system once one accounts for insurance.

Adult↗
PubMed1999

What determines the need for nursing home admission in a universally insured population?

OBJECTIVES: People in lower socio-economic groups are more likely to experience disability and cognitive impairments at earlier ages than those in higher status groups. As a result, the need for nursing home care would be expected to be greater among older people of lower socio-economic status. This study examines the effects of income and education on the probability of nursing home entry in a universally insured elderly population. METHODS: Using a prospective observational study design, a range of predictors of nursing home admission was examined over a three-year period in a representative sample of 7220 residents, aged 60 years or older, in a Canadian province. Individual census records and computerized administrative records of health care utilization were linked to form a database for analysis. RESULTS: An increased risk of institutionalization was associated with older age, male gender, unmarried status and self-reported disability. In addition, lower household income and lower attained education were independently associated with a higher risk of nursing home admission. CONCLUSIONS: These results emphasize the independent role of socio-economic status in accentuating or accelerating the need for institutional care towards the end of life. It is important that these effects are recognized in policies that determine the finance of both nursing home care and formal community-based supportive care.

Aged↗
PubMed2003

Evaluations of health interventions in social insurance-based countries: Germany, the Netherlands, and Austria.

Health Technology Assessment (HTA) in social insurance-based, or so-called 'Bismarck' health care systems (Germany, Austria, and the Netherlands) has taken a different course than in either taxed-based (Sweden, Norway, United Kingdom, and Spain) or private health care systems (such as the United States). The culture of informed decisions supported by transparent and evidence-based evaluations of health interventions was hindered by the strong professional autonomy and sectoral interests in Germany and Austria for a long time. On the other hand, HTA has a long-standing tradition in the Netherlands. In all three countries sickness funds play an important role in implementing evaluations-as a policy tool-by linking reimbursement to explicit proof of effectiveness in both new and established interventions. This article focuses on the obstacles and opportunities for HTA in Germany, Austria and the Netherlands as countries with insurance-based health care systems.

Austria↗
PubMed2004

Is universal coverage a solution for disparities in health care? Findings from three low-income provinces of Thailand.

The policy on universal coverage (UC) of health care has been adopted and implemented incrementally by the government of Thailand since April 2001 with the aim of providing the access to care for the uninsured population. The success of UC, however, depends on how effective its design and implementation arrangements are in reaching population and affecting households' health seeking behavior and abilities to take up benefits of UC. The results from the household survey of 1834 respondents conducted in three low-income provinces (Tak, Sakol Nakorn, Narathiwat) show that the Gold card with exemption scheme was pro-poor while other insurance schemes tended to favor the rich with 2.6% of respondents reported having more than one type of health insurance coverage and 8.9% without health insurance. The insurance status had statistically significant association with health care use, and knowledge on family planning method and sexually transmitted diseases. Additionally, consumer preferences and socioeconomics factors are a key to disparities in health care utilization.

Adolescent↗