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PubMed2003

Association between insurance status and admission rate for patients evaluated in the emergency department.

OBJECTIVES: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. METHODS: This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for under insured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. RESULTS: Compared with the other insured group, under insured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed under insured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Under insured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. CONCLUSIONS: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference.

Adult↗
PubMed1997

Sources of health insurance and characteristics of the uninsured: analysis of the March 1997 Current Population Survey.

This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to individuals' health insurance status. Based on EBRI analysis of the March 1997 Current Population Survey, it represents 1996 data--the most recent data available. In 1996, 82.3 percent of nonelderly (under age 65) Americans had private or public health insurance. Seventy-one percent had private insurance, 64 percent through an employment-based plan. Sixteen percent had public health insurance. The percentage of uninsured Americans has been increasing since at least 1987. In 1987, 14.8 percent of the nonelderly population was uninsured, compared with 17.7 percent in 1996. However, the erosion of employment-based health benefits cannot fully explain this increase since 1993. Instead, the decline in public sources of health insurance would partly explain it. It may be that, while the percentage of individuals with employment-based coverage is rising, individuals previously covered by Medicaid and CHAMPUS/CHAMPVA are not being fully absorbed into the employment-based health insurance market. Between 1995 and 1996, the percentage of nonelderly Americans without health insurance coverage increased from 17.4 percent to 17.7 percent. Further examination indicates that children completely accounted for this increase. In 1995, 13.8 percent of children and 19 percent of persons ages 18-64 were uninsured, compared with 14.8 percent of children and 18.9 percent of persons ages 18-64 in 1996. With the recent passage of legislation designed to reduce the number of uninsured children, the next focal point for health care reform could be early retirees and unemployed persons. President Clinton and some members of Congress have expressed an interest in improving access to and affordability of coverage for these groups. Currently, health care cost inflation is at its lowest point in years, but there are signals indicating that it is about to rise above current levels. The federal government's recent announcement that health insurance premiums will rise for federal employees an average of 8.5 percent in 1998 may portend higher future health care costs. Similarly, disappointing earnings announcements from several large insurers because of higher medical costs and lower-than-expected revenues may indicate that health insurance plans will increase premiums. Employment and income play a dominant role in determining an individual's likelihood of having health insurance. Age, gender, firm size, work hours, and industry are also important determinants; however, these variables are also closely linked to employment status and income. Some of the widest variations involve factors that are not always looked at in traditional demographic assessments, such as citizenship. However, variations by race, ethnicity, and citizenship are also closely linked to employment status and income.

Adolescent↗
PubMed2000

Are insurance companies liable under the Americans with Disabilities Act?

Federal courts have split on the question of the applicability of the Americans with Disabilities Act to insurance coverage decisions that insurance companies make on the basis of disability; they have similarly split on other issues pertaining to the scope of that Act's application. In deciding whether to read the Act as prohibiting discrimination in insurance decisions that are often crucial in the lives of people with disabilities, courts have faced two problems. First, where it prohibits discrimination in the equal enjoyment of the goods and services of places of public accommodation, the Act's area of concern may be limited to the ability of people with disabilities to gain physical access to facilities; or that area may extend to all forms of disability-based discrimination in the provision of goods and services. This Comment argues that the language and legislative history of the Act are consistent only with the latter view. Second, the provision limiting the Act's applicability to insurance may create an exemption for all insurance decisions; or it may protect only the ability of an insurance company to make an insurance decision to the disadvantage of an insured with a disability where actuarial data support the decision. This comment argues that the ambiguous language of the limiting provision should be resolved in favor of the latter view. Legislative history and the broader background of the history of insurance discrimination law support this resolution. Consequently, the Act should be interpreted as prohibiting disability-based discrimination by insurance companies in selling insurance policies and as defining discrimination as making disability-based insurance decisions without the support of actuarial data. By accepting this interpretation, courts can help stop the pattern of judicial narrowing of the Act's application through inappropriately restrictive statutory construction.

Activities of Daily Living↗
PubMedDate not supplied

Dental check-up of California's State Children's Health Insurance program.

PURPOSE: The purpose of this study was to compare dental utilization rates and related factors for children in California's State Children's Health Insurance dental program (SCHIP) to those for children with other types of dental insurance coverage or no coverage. METHODS: Data from the cross-sectional 2001 California Health Interview Survey for 10,454 children 2 to 11 years old were used. Data analyzed included: (1) the child's most recent dental visit; (2) dental insurance status; and (3) type of health insurance coverage. RESULTS: In 2001, 5% (+/-SE=0.3) of California children had SCHIP dental coverage, 19% had Medicaid dental insurance (Denti-CAL), and 52% had private dental insurance. Twenty-three percent (+/-0.5) of children, however, had no dental insurance. Dental utilization rates varied significantly according to type of dental insurance. Compared to uninsured children, SCHIP children were more likely to use dental services within the past year (58% vs 72%). Annual dental utilization rates were even higher for Denti-CAL and privately insured children (76% and 80%, respectively). Factors associated with disparities in dental utilization included lack of a usual source of health care and lack of continuous health insurance. CONCLUSIONS: Significant disparities occurred by dental insurance status and type. Annual dental utilization rates for SCHIP children lagged behind those of children with Denti-CAL or private dental insurance.

Analysis of Variance↗
PubMed1994

Mortality in the uninsured compared with that in persons with public and private health insurance.

OBJECTIVE: To compare mortality in persons with employer-provided health insurance, Medicare, Medicaid, military health benefits, other private health insurance, and no health insurance, before and after adjustment for income and employment status. DESIGN: Cohort study using national survey data containing information on social, economic, and demographic factors and health insurance, with deaths identified through matching to the National Death Index resulting in a mortality follow-up period of 5 years. SETTING: Noninstitutionalized population of the United States. PARTICIPANTS: Approximately 150,000 respondents to national surveys conducted by the US Bureau of the Census (Current Population Surveys), aged 25 to 64 years. RESULTS: After adjustment for age and income, persons with Medicare and Medicaid had the highest mortality in comparison with those with employer-provided insurance, with relative risks generally greater than 2. With adjustment for age and income, persons without insurance had higher mortality than those with employer-provided insurance, with relative risks of 1.2 for white men and 1.5 for white women. These relationships held after adjustment for employment status, with the working uninsured showing mortality between 1.2 and 1.3 times higher than that of the working insured. Mortality was higher in those with lower incomes after adjustment for insurance status. Those with annual income of $10,000 or less per year had mortality about two times that of persons with incomes greater than $25,000 per year. CONCLUSION: Mortality was lowest in employed persons with employer-provided health insurance. The higher mortality in those with public insurance or with no insurance reflects an indeterminate mix of selection on existing health status and access to medical care.

Adult↗
PubMed1995

Health insurance and use of medical services by men infected with HIV.

Among 178 HIV-infected men from the San Francisco City Clinic Cohort (SFCCC), we examined the association between health insurance and use of outpatient services and treatment. For men with private insurance, we also assessed the frequency of avoiding the use of health insurance. Men without private insurance reported fewer outpatient visits than men with fee-for-service or managed-care plans. Use of zidovudine for eligible men was similar for those with fee-for-service plans (74%), managed-care plans (77%), or no insurance (61%). Use of Pneumocytstis carinii pneumonia prophylaxis was similar for those with fee-for-service (93%) and managed-care plans (83%) but lower for those with no insurance (63%). Of 149 men with private insurance, 31 (21%) reported that they had avoided using their health insurance for medical expenses in the previous year. In multivariate analysis, the independent predictors of avoiding the use of insurance were working for a small company and living outside the San Francisco Bay Area. Having private insurance resulted in higher use of outpatient services, but the type of private insurance did not appear to affect the use of service or treatment. Fears of loss of coverage and confidentiality may negate some benefits of health insurance for HIV-infected persons.

Adult↗
PubMed2002

Policy change and private health insurance: did the cheapest policy do the trick?

From the introduction of Australia's national health insurance scheme (Medicare) in 1984 until recently, the proportion of the population covered by private health insurance declined steadily. Following an Industry Commission inquiry into the private health insurance industry in 1997, a number of policy changes were effected in an attempt to reverse this trend. The main policy changes were of two types: "carrots and sticks" financial incentives that provided subsidies for purchasing, or tax penalties for not purchasing, private health insurance; and lifetime community rating, which aimed to revise the community rating regulations governing private health insurance in Australia. This paper argues that the membership uptake that has occurred recently is largely attributable to the introduction of lifetime community rating which goes some way towards addressing the adverse selection associated with the previous community rating regulations. This policy change had virtually no cost to government. However, it was introduced after subsidies for private health insurance were already in place. The chronological sequencing of these policies has resulted in substantial increases in government expenditure on private health insurance subsidies, with such increases not being a cause but rather an effect of increased demand for private health insurance. The paper also considers whether the decline in membership that has occurred since the implementation of lifetime community rating presages the re-emergence of an adverse selection problem in private health insurance. Much of the decline to date may be attributable to failure on the part of some members to honour premium payments when they first fell due. However, the changing age composition of the insured pool since September 2000, resulting in an increasing average age of those insured, suggests the possible reappearance of an adverse selection dynamic. Thus the 'trick' delivered by lifetime community ratings may not be maintained in the longer term.

Australia↗
PubMedDate not supplied

Self-insurance in times of growing and retreating managed care.

This paper examines trends in self-insurance and in the content of self-insured plans from 1993 to 2001. The percentage of employees enrolled in self-insured plans fell during these years. Much of the decrease was attributable to the decline of indemnity insurance and the rise of HMO and point-of-service plan enrollment. If the product mix had remained constant throughout these years, self-insured enrollment would have grown between 1993 and 1996 and then declined to its current 50 percent level. As a result of the Health Insurance Portability and Accountability Act (HIPAA), the use of preexisting condition clauses declined dramatically in self-insured plans. Self-insured and purchased plans cost similar amounts and provide similar benefits. Cost sharing is somewhat lower in self-insured PPO plans. During periods of rapid inflation, premiums increase more slowly for self-insured than for fully insured plans.

Cost Sharing↗
PubMed1990

Insurability and the HIV epidemic: ethical issues in underwriting.

The HIV epidemic has focused criticism on standard underwriting practices that exclude people with AIDS or at high risk for it from insurance coverage. Insurers have denied the charge that these practices are unfair, claiming instead that whatever is actuarially fair is fair or just. This defense will not work unless we assume that individuals are entitled to gain advantages and deserve losses merely as a result of their health status. That assumption is highly controversial at the level of theory and is inconsistent with many of our moral beliefs and practices, including our insurance practices. We should reject the insurers' argument. Justice in health care requires that we protect equality of opportunity, and that implies sharing the burden of protecting people against health risks. In a just healthcare system, whether mixed or purely public, the insurance scheme is in systematic terms actuarially unfair, for its overall social function must be to guarantee access to appropriate care. This does not mean that in our system insurers are ignoring their obligation to provide access to coverage. The obligation to assure access is primarily a social one, and the failures of access in our system are the result of public failures to meet those obligations. In a just but mixed system, there would be an explicit division of responsibility among public and private insurance schemes. In our mixed but unjust system, both legislators and insurers cynically pretend that the uninsured are the responsibility of the other. The attempt to treat actuarial fairness as a moral notion thus disguises what is really at issue, namely, the risk to insurers of adverse selection and the economic advantages of standard underwriting practices. Standard underwriting practices will be fair only if they are part of a just system, not if they simply are actuarially fair. The failure of the argument from actuarial fairness means that we must face an issue private insurers had hoped to avoid if we are to defend standard underwriting practices at all. In view of the clear risk that a mixed system will fail to assure access to care, the burden falls on defenders of a mixed system. They must show us that its social benefits outweigh its social costs, and that it is possible to have a mixed system that is not only just, but also is superior to a compulsory, universal insurance scheme.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

[The problem of private insurance for patients with epilepsy (author's transl)].

324 epileptics were questioned about their approach to private insurance. Only 9,26% of them were covered by a life or accident insurance policy: 3,70% had life insurance, 3,70% accident insurance and 1,86% both. None of the patients had declared his disability to the insurance company. In 6,17% of the 324 epileptic cases an insurance policy had been taken out by their parents. In comparison about 35% of the Italian population in general are insured. A questionnaire was sent to 20 insurance companies; only 5 of them replied, saying that as far as accidents were concerned, they considered epileptics uninsurable. As for life insurance, policies can be contracted at increased premiums, according to the individual case (including the severity of the illness). Physicians must give epileptics fuller information about their insurance plans because, if their illness is detected after an accident, they will find themselves not covered by insurance. Government intervention is called for with the setting-up of special funds for this purpose.

Cost Control↗
PubMed2000

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery.

CONTEXT: Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. OBJECTIVE: To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. DESIGN: A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. SETTING: Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). PATIENTS: A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. MAIN OUTCOME MEASURE: Probability of a patient receiving CABG surgery at a lower-mortality hospital. RESULTS: Compared with patients with private FFS insurance (n = 18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n = 31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). CONCLUSIONS: Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.

Aged↗
PubMed2000

State parity legislation and changes in health insurance and perceived access to care among individuals with mental illness: 1996-1998*

BACKGROUND: The 1990's witnessed a new wave of state and federal legislation affecting mental health insurance in the United States. Although patient advocacy groups have hailed the passage of numerous "parity" laws that require insurance coverage for mental illnesses to equal that for physical ailments, it is unclear whether this activity represents a major improvement in insurance benefits among mentally ill or significantly increases their access to care. AIMS: This paper contrasts how insurance coverage has changed among individuals with mental health problems in states with and without parity legislation. METHODS: National survey data from 1996 to 1998, subset to a panel of 1220 individuals exceeding clinical screeners for a mental health disorder. Dependent variables are change in insurance status, insurance generosity and perception of access to care. The analysis contrasts changes in dependent variables between states with and without parity legislation (a difference-in-differences analysis). RESULTS: There are no statistical significant effects of state parity; point estimates suggest that parity mandates are associated with a slightly higher number of mentally ill reporting improved insurance generosity and access to care, but also with a higher number of mentally ill losing all insurance coverage in parity states. The estimated effects are too small to be statistically significant, although the sample size is limited and the study had only good statistical power to detect large effects. DISCUSSION: At the population level, state parity legislation appears to have not had large effects on the insurance coverage of the group that was intended as the primary beneficiary of legislation. Likely reasons include the limited scope of the actual legal requirements and large numbers of mentally ill that are not covered by health insurance subject to such legislation. The results do not exclude the possibility that some subgroups experienced substantial improvements in their insurance coverage. At the population level, large effects experienced by small subgroup are diluted by groups that experienced no similar changes. However, parity legislation was not considered a minor issue by advocates and opponents and this analysis has the statistical power to detect the sizeable differences that were argued in the policy debate. IMPLICATIONS FOR HEALTH POLICIES: While state parity legislation may have improved insurance benefits for some, it appears not to have resulted in substantial improvements for the mentally ill as a whole. The results could be very different, however, if strong federal legislation were passed that has a broader scope than state legislation. IMPLICATIONS FOR RESEARCH: The parity debate provides an important reminder of how little research is available to inform policy. This study provides a crude picture, but it is far from being a conclusive evaluation. The most urgent need is for data that continue to track changes in markets and policies.

Journal Article↗
PubMed2006

Protecting low-income children's access to care: are physician visits associated with reduced patient dropout from Medicaid and the Children's Health Insurance Program?

OBJECTIVE: Dropout among patients who are enrolled in Medicaid and the Children's Health Insurance Program contributes to a lack of health care access among millions of Americans. The purpose of this study was to determine which, if any, types of clinical contact with physicians are associated with reduced dropout among children who are enrolled in Medicaid and the Children's Health Insurance Program. METHODS: The data are from the nationally representative Medical Expenditure Panel Survey, 1998-2002. The sample is composed of all children (n = 3043) who were reported to have Medicaid or Children's Health Insurance Program coverage throughout their first year in the survey and who did not acquire other insurance during the study period. The outcome measure is whether an individual remained enrolled in Medicaid or the Children's Health Insurance Program by the end of the following year. Exposure variables were clinical contact during an individual's first year in the survey: numbers of office visits, hospital outpatient department visits, emergency department visits, inpatient hospital stays, and dental visits. The analysis uses multivariate logistic regression to control for patient and family characteristics-most important, health status, functional status, and overall health care expenditures. RESULTS: Eight percent of the children in the sample had left Medicaid/the Children's Health Insurance Program by the end of the second year in the survey. More frequent contact with clinicians in an office setting was associated with a significantly lower risk for dropping out of Medicaid/the Children's Health Insurance Program among children, even controlling for demographics, health and functional status, and overall health care expenditures. After multivariate adjustment, more frequent contact in hospital outpatient departments also was associated with reduced dropout, with a borderline statistically significant odds ratio. Notably, emergency visits and inpatient stays were not associated with any significant change in the risk of Medicaid/Children's Health Insurance Program dropout. CONCLUSIONS: These results suggest that some but not all types of clinician visits are serving an important function in maintaining Medicaid and the Children's Health Insurance Program coverage among low-income patients. Two possible approaches to improve access to care among low-income children therefore would be (1) increased awareness among clinicians, especially in hospitals and emergency departments, regarding Medicaid/Children's Health Insurance Program retention as an issue in the ongoing care of their patients and (2) Medicaid/Children's Health Insurance Program reimbursement of clinicians and their staff for assisting patients with the public insurance renewal process.

Aid to Families with Dependent Children↗
PubMed1992

Reducing the number of uninsured by subsidizing employment-based health insurance. Results from a pilot study.

OBJECTIVE: To evaluate whether employers who do not provide health insurance would offer such benefits after a 50% reduction in the price of health insurance. DESIGN: Using a survey of 530 firms at two sites in New York State, we estimate the number of firms that added insurance during 1988 as a percentage of firms that were eligible for the subsidy. We use this proportion as an estimate for the number of firms that would have added insurance in the absence of the subsidy program. We then estimate the number of firms adding insurance during the initial year of the program, 1989. SETTING: The subsidized health insurance pilot projects were available in Brooklyn and in the Albany-Plattsburgh-Poughkeepsie region of New York State. INTERVENTION: New York State subsidized the price of health insurance, reducing it by 50%. Eligible employers were responsible for paying the remaining portion of the premium. RESULTS: The subsidized health insurance products increased the number of small firms (under 20 employees) offering insurance by a small amount, approximately a 3.5 percentage point increase. When fully implemented and assuming all eligible employers were aware of the program, the subsidy would increase the proportion of firms offering insurance by 16.5 percentage points. We view this as an upper boundary. CONCLUSIONS: Increased program visibility and allowing the employee to share in the premium payment may increase the number of employers offering insurance. Even under ideal conditions, however, the results highlight the limitations of voluntary programs to increase the number of employers offering health insurance.

Health Benefit Plans, Employee↗
PubMedDate not supplied

How will changes in health insurance tax policy and employer health plan contributions affect access to health care and health care costs?

OBJECTIVE: To understand how changes in federal taxation of and employer contributions to health insurance benefits affect the decisions of firms to offer insurance, the willingness of households to purchase different health plans, and the resultant health expenditures. DESIGN: Economic policy simulation. SETTING: Secondary data analysis. PARTICIPANTS: A total of 18,343 sampled families (representing 77 million total families throughout the United States) with a working household head from the 1988 Current Population Survey who were not covered by either Medicare, Medicaid, or CHAMPUS (Civilian Health and Medical Program of the Uniformed Services) insurance. INTERVENTIONS: One intervention limits the amounts of tax-free employer contributions to health insurance premiums to 80% of our estimate of the base plan in the market and assumes that employer contributions will also be limited to this maximum. A second intervention eliminates the favorable tax treatment of employer-paid premiums altogether and assumes that employees will pay the full price of insurance. MAIN OUTCOME MEASURES: Change in the number of working families offered employment-based insurance, change in insurance plan choice, and change in medical spending. RESULTS: Capping the favorable tax treatment and employer contributions decreases the number of families offered employment-based insurance by approximately 91,000, increases the number of families selecting the least generous insurance plan from 20% under the current situation to 33%, and reduces overall health spending by less than 2%. By eliminating the tax exemption altogether, the number of families offered employment-based insurance decreases by approximately half a million families, the number of families selecting the least generous plan goes from 20% to 40%, and overall spending falls by about $16 billion. CONCLUSIONS: Eliminating the tax subsidy and limiting employer-paid contributions to the low-cost plan substantially increases the number of low-income uninsured under a voluntary insurance system, decreases overall spending only modestly, but would raise tax revenues by $36 billion. These tax revenues could be used to assist low-income families to obtain insurance coverage.

Competitive Medical Plans↗
PubMed1998

Health insurance and access to primary care for children.

BACKGROUND: Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of children's access to primary care. We studied the effect of health insurance on children's access to primary care. METHODS: We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care. RESULTS: An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression. CONCLUSIONS: Among children, having health insurance is strongly associated with access to primary care. The new children's health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Adolescent↗
PubMed1992

Public and private insurer designation of transplantation programs.

In an effort to assure quality and contain costs, several major private health insurers now restrict payment of transplantation procedures to designated programs, often referred to as centers of excellence. These insurers underwrite coverage for over 100 million people. Few transplantation programs meet the criteria set forth by insurers, thus raising concerns about patient access to care. The criteria being used by five private insurers and Medicare were obtained and reviewed. Insurers now designate kidney, heart, liver, heart-lung, pancreas, and bone marrow transplant programs based upon total annual transplant volume as well as one- and two-year patient and graft survival rates. Transplant center criteria vary according to procedure and type of recipient (i.e., pediatric vs. adult). Most insurers require hospitals to perform a minimum of at least 6, and up to 50 procedures annually. Expected one-year patient survival rates may exceed 90% and are often higher than 80%, although standards are usually lower for heart-lung and bone marrow transplantation. In addition, if centers meet the minimum volume and outcome criteria, insurers expect transplant centers to discount per procedure changes by as much as 25%. Patients are often offered incentives to use designated centers with insurers frequently paying travel costs and reducing or waiving copayment amounts. The designation of transplant programs by third-party payers has merit, although program volume requirements may have less validity than individual transplant surgeon and physician experience. Other problems are also apparent. For example, discount pricing is suspect, given the lack of data on actual transplant procedure costs. Also, some insurers intend to regionalize transplant programs, thus unnecessarily limiting patient access to care. Alternatively, the concentration of transplant activity at a smaller number of centers may enhance research opportunities. Nonetheless, transplant professionals, hospital administrators, and patient advocates remain wary of insurer objectives. There is concern that the designation of centers is simply another method by which insurers can avoid paying for transplants.

Costs and Cost Analysis↗
PubMed1998

Relationship between type of insurance and care during the early course of psychosis.

OBJECTIVE: Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission. METHOD: Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care. RESULTS: At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission. CONCLUSIONS: During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission.

Adult↗