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PubMed1996

Infertility treatment dropout and insurance coverage.

OBJECTIVE: To assess early patient dropout rates during infertility treatment as a potential measure of wasted resources. METHODS: The study involved multifaceted population cohorts, including a prospectively observed captive health maintenance organization (HMO) population and retrospectively selected preferred provider organization (PPO) patients. One hundred twenty-eight HMO couples were followed prospectively for 6 months. The insurance carrier retroactively selected 96 couples from their PPO population who were believed to be infertility patients. They were matched by date, age, and time of hysterosalpingography to infertility patients in the carrier's HMO population. Patients were considered treatment dropouts if they either requested their provider to abandon further work-up or treatment, or if they failed to return for an appointment for 3 months. RESULTS: Forty-six of 128 (36%) HMO patients followed prospectively discontinued care within 180 days, with only eight (6.3%) providing defined reasons. Preferred provider organization patients uniformly demonstrated significantly higher dropout rates than HMO patients, a finding already apparent at 60 days (P < .002; odds ratio [OR] 3.67, 95% confidence interval [CI] 1.47-9.97) and 120 days of treatment (P = .002; OR 2.87, 95% CI 1.39-6.06). Among PPO patients, dropout rates were especially pronounced if infertility care was provided by generalists. At billing levels of at least $2000, HMO patients also demonstrated less dropout than PPO patients (P < .001; OR 6.14, 95% CI 2.72-14.79), with generalists again demonstrating a significantly larger patient loss than infertility specialists (P < .001; OR 0.18, 95% CI 0.66-0.49). CONCLUSION: Infertility patients demonstrate a surprisingly large early dropout rate, which is significantly larger if patients receive infertility care from generalists rather than specialists. Newly presenting infertility patients should be carefully evaluated, especially in indemnity situations, before expensive diagnostic and therapeutic interventions are ordered.

Adult↗
PubMed1994

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study.

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1995

Reimbursement and insurance coverage in cases of suspected sexual abuse in the emergency department.

OBJECTIVE: To characterize third party payor types and rates of reimbursement for hospital costs in emergency department (ED) evaluations of preadolescents presenting as suspected victims of sexual abuse (SSA). DESIGN AND METHODS: Retrospective chart review, comparing a set of 186 SSA patients with 623 evaluated for upper limb fracture and cumulative reimbursement and insurance data for all patients presenting to the ED during a 12-month period. RESULTS: A greater percentage of SSA patients was uninsured (N = 96, 52%) as compared to patients with fractures (N = 9, 1%); 23% of all ED billing came from the uninsured. Of the 96 self-pay SSA patients' bills only 4% reimbursement was received. Of the insured, a greater percentage of the SSA patients was covered by publicly-funded plans (n = 59, 66%) as compared to fracture patients (N = 327, 52%). A lower percentage of insured SSA bill reimbursement was received from publicly-funded insurance than from commercial insurance (28% vs. 58%). CONCLUSIONS: Hospital costs of SSA patients are more often and to a greater degree underwritten by the hospital itself as a result of lower reimbursement and a higher percentage of uninsured and publicly-funded plans in that group, raising critical questions about how care for children with serious socially-based diagnoses is delivered and funded.

Arm Injuries↗
PubMed2002

Within-state geographic patterns of health insurance coverage and health risk factors in the United States.

BACKGROUND: A number of health risk factors have been associated with the incidence and mortality of common diseases. Although knowing risk factor patterns at a small-area level would be useful for ecologic analyses and prevention program planning, risk factor data are generally published only at the state or regional level in the United States. This study presents maps of within-state patterns of several such factors. METHODS: Responses to Behavioral Risk Factor Surveillance System (BRFSS) questions about smoking, obesity, health insurance, and mammography use were aggregated for 1992-1998 by county. These data were then geographically smoothed by adjusting each county's proportional response based on the responses of its neighboring counties. RESULTS: The maps show risk factor patterns consistent with published state-level maps, but also identify within-state variations masked by aggregation to the larger geographic units. CONCLUSIONS: The risk factor maps presented should permit a better understanding of localized patterns of health risk behaviors and access to health care as well as help to target intervention activities in the U.S. areas that most need them.

Adult↗
PubMedDate not supplied

The effect of medical insurance coverage on the obtainment of pressure garments.

Pressure garments are used to alter the appearance of immature burn scars. These garments are costly, and delays in obtaining them are frequent. The purpose of the study was to determine the nature of the delays in the obtainment of pressure garments and to examine the role that the payer plays in these delays. The billing and medical records of all patients with burns measured for pressure garments between January 1, 1998, and August 1, 1999, were reviewed. The distribution of payers was as follows: workers' compensation, 37%; state-funded insurance, 32%; health maintenance organizations, 12%; private insurance, 16%; and other, 3%. Payment authorization time for pressure garments was 37 days for state payers and less than 10 days for all other groups. Patients with state-funded insurance waited an average of 67 days to receive their garments as opposed to a wait of 20 to 30 days for other payers. The percentage of billed charges paid was least for patients with state-funded and HMO insurance (58% and 51%, respectively). The interval to payment of charges was longer than 60 days for all groups. Marked delays in authorization exist for state-funded reimbursement of pressure garments. Reimbursement for patients with state- and HMO-funded insurance was lower than for other payers. These differences may have an adverse effect on outcome.

Adult↗
PubMed1995

The growing epidemic of uninsurance: new data on the health insurance coverage of Americans.

Despite a massive expansion of Medicaid and an upswing in the economy, the total number of Americans uninsured in 1993 was 39.7 million, more than at any time since the passage of Medicaid and Medicare in the 1960s. Since 1989, the ranks of the uninsured have swelled by 6.3 million. Millions more would be uninsured if Medicaid enrollment had not risen dramatically, by 10.5 million people since 1989. Loss of health coverage is a growing problem for middle-income families, women, and children, as it has long been for low-income families. Even in Hawaii, whose employer mandate program is often cited as a model of universal coverage, there was a large increase in uninsurance. Nationwide, the sharp upswing in the number of Americans who are uninsured has coincided with government and corporate policies to encourage medical competition and push people into managed care plans. Republican proposals to limit AFDC benefits threaten to further increase uninsurance, particularly among women and children. Only a Canadian-style single-payer reform can assure universal coverage and simultaneously contain costs.

Adolescent↗
PubMed1989

The impacts on hospital costs between 1980 and 1984 of hospital rate regulation, competition, and changes in health insurance coverage.

In this paper, we report the results of an analysis of hospital expenses in 43 large SMSAs between 1980 and 1984. We found that hospital rate regulation--specifically Medicare's TEFRA and PPS and state multi-payer systems--was the single most important factor leading to the slowdown in the rate of increase in hospital costs between 1980 and 1984. In 1984, hospital costs covered by Medicare's PPS were 12.5% lower than they would have been in the absence of rate regulation, and in the four states covered by all-payer rate regulation, hospital costs were between 11% and 15% lower. In contrast, changes in the proportion of people either covered by employer-group health insurance or enrolled in HMOs, reduced hospital costs by less than 1%. Measures of competition suggest that hospital costs are higher where there is more competition. We also found that almost all of the effect of regulation on costs came from gains in the efficiency of producing hospital care and/or from reductions in the quality of care. It appears that controlling hospital payment rates gave hospitals a strong incentive to provide care at lower cost.

Catchment Area, Health↗
PubMed1990

Socio-cultural inequities in access to prenatal diagnosis: the role of insurance coverage and regulatory policies.

The article presents the results of a 4-month-period survey by questionnaire among all women attending the Marseille Centre for Prenatal Diagnosis for amniocentesis. Socio-cultural status of women getting access to amniocentesis is significantly higher than in the general population of pregnant women in the same geographic area of south-eastern France. Socio-cultural status is also higher among women who have to cover costs of procedure to get access to amniocentesis than among those who benefit from it free-of-charge according to French Social Security regulations. In contrast, risk perception and attitudes toward termination of pregnancy are similar in these two groups. A total of 24.4 per cent of respondents declared that they got access to amniocentesis 'on their own initiative', the remaining 75.6 per cent declaring that they 'were following medical advice'. Multidimensional analysis shows that the women who do not benefit from free-of-charge amniocentesis, and who have a high level of education and no antecedents of fetal and perinatal deaths, are more likely to perceive themselves as 'self-referring'. The study indicates that institutional coverage may be effective in reducing socio-cultural inequities in access to prenatal diagnosis. But such a policy may conflict with the respect of women's individual autonomy in the amniocentesis decision.

Adult↗
PubMed1991

Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans.

This investigation examines data on 13,000 Mexican Americans, Puerto Ricans, and Cuban Americans between 6 months and 74 years of age who were interviewed from 1982 through 1984 in the Hispanic Health and Nutrition Examination Survey. In addition, data from the 1989 Current Population Survey (N = 145,000) conducted by the US Bureau of the Census are presented for the white and black non-Hispanic populations as well as the three Hispanic national origin groups. The study revealed that over one third of the Mexican-American population, one fifth of the Puerto Rican population, and one fourth of the Cuban-American population is uninsured for medical expenditures compared with one fifth of the black, non-Hispanic population and one tenth of the white, non-Hispanic population. Furthermore, compared with Hispanics with private health insurance, uninsured Hispanics are less likely to have a regular source of health care, less likely to have visited a physician in the past year, less likely to have had a routine physical examination, and less likely to rate their health status as excellent or very good.

Adolescent↗
PubMed1990

Florida orthopedic surgeons react to liability concerns. Lower insurance coverage, protect assets, avoid trauma.

Three hundred thirty-six Florida orthopedic surgeons, an estimated 40% of those in active private practice, responded in a survey regarding liability effects on their practice. They indicated an average of 1.9 suits per surgeon, up from an average of 1.3 two years previously. Seventeen percent reported no professional liability coverage and combined with those who had dropped "tail" coverage to lower their premium, 29% are partially or completely uninsured. Half the surgeons responding reported $250,000 coverage or less; many more indicated their intention to reduce or eliminate coverage soon. Sixty-three percent have carried out estate planning asset protection steps. Responding to liability threats, 70% report significant recent practice style changes, the most common being avoidance of trauma patients and increasing the number of x-rays and tests ordered for patients. Origin of patients who subsequently became plaintiffs was usually the emergency room; however, the alleged injury usually occurred in the operating room later in that hospitalization.

Adult↗
PubMed2000

Qualified medical child support orders--California health insurance coverage assignment orders--national medical support notices: what's a plan administrator to do?

Many employer-sponsored health plans and multi-employer health benefit trusts have seen an increase in medical child support orders (MCSOs), and they can anticipate receiving a greater number in the future. Once regulations are final for the national medical support notice (NMSN) required by the Child Support Performance and Incentive Act of 1998, plans should also begin receiving these. In preparation, plan administrators should ensure that they have proper procedures in place for determining whether MCSOs and NMSNs constitute QMCSOs.

California↗
PubMed1993

An economic analysis of heart-lung transplantation. Costs, insurance coverage, and reimbursement.

Rarely has the cost of heart-lung transplantation received attention. Although the procedure is still largely regarded as experimental, this does not diminish the significance of costs. The National Cooperative Transplantation Study was undertaken to better understand the costs of all transplants, including heart-lung transplantation. Data on transplantation charges from date of procedure to discharge were obtained from more than 65% of all heart-lung transplantation programs active in 1988. These programs accounted for 61% of all transplantations performed in 1988. Valid sample survey data (no more than 25 procedures per center) were obtained for 42 patients, or approximately 58% of all procedures done in the United States. Detailed data were also collected on sources of payment and amount reimbursed. Because of outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for heart-lung transplantation was $134,881, with an average hospital stay of 31 days. Total charges fell between $99,535 and $216,639 for 50% of the cases studied. Half of the patients spent between 23 and 49 days in the hospital. Because of the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables. More than 78% of the procedures studied were paid for by private insurers. Reimbursement exceeded 90% of billed charges for 84.6% of the cases analyzed. Despite the experimental status of heart-lung transplantation, insurance reimbursement has been favorable for those heart-lung transplantations that insurers have covered. Nevertheless, the future of heart-lung transplantation is unclear. The availability of donors remains a serious constraint, as is seen in the decrease of procedures performed annually. In fact, lung transplantation now appears to be the preferred approach to the treatment of pulmonary disease.

Fees and Charges↗
PubMed1979

Rationales for public health insurance coverage of geriatric day care: issues, options, and impacts.

America's long-term care system has been widely criticized for many shortcomings. It relies too heavily upon institutional services, it is too costly, it forces inappropriate levels of care upon patients by offering too few options, in too many instances it offers inferior quality care, and it places too much emphasis on caring for physical ills without concern for enhancing patients' quality of life. Alternative modes and settings now under consideration could solve one or more of these problems, but the choices would be constrained by financial and technical barriers. Different choices have profoundly different consequences for costs and numbers and types of patients served. This paper considers different roles and their consequences for one alternative: geriatric day care. The issues raised apply to other alternatives.

Aged↗
PubMed1993

An economic analysis of pancreas transplantation: costs, insurance coverage, and reimbursement.

Since 1988 the demand for the pancreas transplantation has continued to increase. This has been accompanied by a growth in the number of centers offering the procedure, and an increase in the number of transplants performed. The National Cooperative Transplantation Study was undertaken to document the costs of all transplants, including pancreas transplantation. Data on transplantation procedure charges, from date of transplant to discharge, were obtained from 66.7% of all pancreas transplantation programs active in 1988. These programs accounted for 72% of all transplants performed that year. Valid sample survey data (no more than 25 transplants per center) were obtained for 133 randomly selected patients. This constituted 54% of all procedures done in the United States in 1988. Detailed data were also collected on sources of payment and amount reimbursed. Due to outlier data, we report statistical medians, rather than means, as our measure of central tendency. The median charge for a pancreas transplant with or without a kidney was $66917, with a hospital length of stay of 21 days, compared with a kidney transplant alone at $39625 and a hospital length of stay of 14 days. Total pancreas transplant charges fell between $45260 and $105375 for 50% of the cases studied. Half of the patients had a hospital length of stay between 16 and 33. Due to the small number of cases available for analysis, it was not meaningful to cross-classify the data according to various prognostic variables.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2003

Universal health insurance coverage does not eliminate inequities in access to cardiac procedures after acute myocardial infarction.

BACKGROUND: It remains unclear whether socioeconomic status (SES) influences access to invasive cardiac procedures after acute myocardial infarction (AMI) in a universal health care system. The objective of this study was to evaluate the effect of SES on access to cardiac procedure after AMI in a universal health care system. METHODS: This was an observational cohort study of all patients with a first AMI in the province of Quebec, Canada, between 1985 to 1995. Information on treatment was obtained from the discharge and physicians' claims databases. SES was obtained from census data by linking postal codes. SES-independent predictors of use were identified, then incorporated in hierarchical models to predict use in low, medium, and high SES areas. The main outcome measures were rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) as a function of SES. RESULTS: SES data were available for 62,364 individuals with a first AMI. Of these, 65% were men and the mean age was 64 +/- 13 years. Rates of cardiac procedures rose with an increase in several SES measures. After adjustment for individual-level predictors of use of cardiac catheterization, average rent, (odds ratio per $100 difference: 1.57, 95% credible interval: 1.36 to 1.80) and proportion of renters, (odds ratio, 2.2; 95% CI: 1.21 to 3.73) in the area were independent SES predictors. Patients in low SES areas (median family income: $ 30,809 CDN) were less likely to undergo cardiac catheterization than patients in high SES areas ($92,169 CDN) (men: 33%; compared with 47%; women: 18%; compared with 47%). However, among patients with cardiac catheterization, SES was not associated with the use of revascularization procedures. For example, PCI rates for men within 90 days after AMI were 26%, compared with 25% in low and high SES areas, respectively. CABG rates were 15%, compared with 19%. CONCLUSIONS: We found that in the universal health care system of Canada, access to cardiac catheterization after AMI varied according to SES. Among those with cardiac catheterization, SES did not appear to influence further use of revascularization procedures.

Aged↗