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PubMed2006

Making the normal deviant: the introduction of predictive medicine in life insurance.

Over the past years, one of the most discussed topics in policy debates on genetics has been the use of genetic testing in insurance. Many of these debates have been rather speculative and abstract. In a recent contribution to this journal, Kaufert therefore urged for "a proper research agenda" to study the issue, arguing for the need of anthropological and sociological research of the insurance world. This article will make a start with this. Based on ethnographic fieldwork in two Belgium insurance companies, this study analyses the ways insurers account for predictive medicine (lifestyle, genetics) during underwriting. We demonstrate how insurers highlight predictive lifestyle health information and how this articulates with a fault based approach in underwriting. Individual responsibility for health risks becomes the golden standard for assessing one's fitness for membership of the insurance pool. Moreover, these developments imply a changed concept of "normal standard" in insurance, increasing the conditions to fulfil to be part of the insurance group. Predictive medicine constitutes new ground in the old debates about individual control, responsibility and blame for health. This goes to the heart of the basis for citizenship and how this articulates with membership--or, if you want, exclusion--of the insurance pool.

Belgium↗
PubMedDate not supplied

Guaranteed renewability and the problem of risk variation in individual health insurance markets.

Consumers should be protected against fluctuations in premiums for private individual health insurance associated with the onset of high-cost chronic conditions. The most commonly discussed way to do so is through community rating, which provides protection but can require a heavy regulatory burden and can create incentives for adverse selection and cream skimming. This paper describes an alternative method of providing the same type of protection: insurance contract provisions that guarantee renewability for the next coverage period at class-average rates. Drawing on recent work in insurance theory, the paper shows that such protection is feasible in competitive insurance markets. Guaranteed renewability, which is required of all individual health insurance by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, is incomplete because the law fails to require that premiums be the same for all insured persons in a rating class. However, the paper reports the results of a recent survey of state insurance regulation, which indicates that all but three state insurance departments report having such a requirement. The paper concludes with a discussion of possible threats to the protection guaranteed renewability provides against risk segmentation.

Actuarial Analysis↗
PubMed1997

The effect of health maintenance organization vs commercial insurance status on obstetrical management and outcome.

OBJECTIVE: To compare obstetrical management and birth outcomes between patients with health maintenance organization (HMO) insurance and those with private commercial insurance. DESIGN: Retrospective population-based cohort study. SETTING: King County, Washington. PATIENTS: Among newborns delivered in 1992 and 1993, a random sample of 4000 birth records listing HMO insurance for prenatal care was compared with a random sample of 4000 birth records listing private commercial insurance as the primary coverage. MAIN OUTCOME MEASURES: Use of ultrasonography and amniocentesis; rate of primary cesarean section performed; adequacy of prenatal care; incidence of maternal medical complications, low birth weight, and congenital malformations; and length of hospital stay. RESULTS: Women covered by HMO compared with commercial insurance were more likely to undergo ultrasonography (relative risk [RR], 1.4; 95% confidence interval [CI], 1.3-1.4). Inadequate prenatal care was less frequent among HMO-insured patients (RR, 0.6; 95% CI, 0.5-0.7), as was the incidence of birth weight below 2500 g (RR, 0.7; 95% CI, 0.6-0.9). No differences in rates of cesarean section and congenital anomalies were observed. Among women without obstetrical risk factors, HMO-insured mothers were at an increased risk of labor and delivery complications (RR, 1.4; 95% CI, 1.3-1.5); their infants were at an increased risk of infant distress (RR, 1.8; 95% CI, 1.5-2.2). CONCLUSIONS: Patients with HMO insurance have improved access to prenatal care and screening when compared with privately insured patients. The reasons for increased risks of abnormal maternal and infant outcomes observed among a subset of HMO-insured patients are unclear. A study with more detailed prospective data collection is warranted.

Female↗
PubMedDate not supplied

Long-term breast cancer survivors: confidentiality, disclosure, effects on work and insurance.

UNLABELLED: As more women are diagnosed with breast cancer, more will survive the illness from a few years to a lifetime. This study sought to determine the experience of Canadian breast cancer survivors with respect to the impact of cancer on confidentiality, work and insurance. METHOD: Women who had survived breast cancer without recurrence for at least 2 years completed a mail survey about the effect of their illness on confidentiality, disclosure, work and insurance. RESULTS: 378 (75.6%) women breast cancer survivors responded to the survey. Their mean age was 61.0+/-10.9 years, and 67.6% had been recurrence free for more than 5 years. The majority of women rated hospital staff, family doctors, family, friends, and support groups at the highest possible level of confidentiality. Over 70% of survivors disclosed their diagnosis to friends, children, siblings, and partners, while over 50% disclosed to work colleagues and supervisors. However, over 40% felt cancer had altered their priorities or progress at work, and 5% were afraid to change jobs in case they became ill again. There was a lack of knowledge about insurance but, of the types of insurance identified, life insurance (17.9%), extended health insurance (7.7%), and private disability insurance (4.4%) were reported to have been refused or offered only with higher premiums as a result of a past diagnosis of breast cancer. DISCUSSION: A substantial minority of women perceived that cancer had substantially affected their personal and work lives. Although most felt their illness confidentiality was well protected and they disclosed freely to family, friends, and work, over 40% of women survivors reported that cancer had affected their work in various ways, and nearly 20% identified insurance problems. It appears that disclosure sometimes results in negative work and insurance experiences. CONCLUSIONS: Health professionals and cancer survivors should engage in education about the potential positive and negative effects of disclosure, and advocacy against cancer-based work and insurance discrimination.

Adaptation, Psychological↗
PubMed1995

Genetic information and life insurance: a proposal for an ethical European policy.

Developments in molecular biology will enable development of tests for genetic predisposition to multifactorial diseases. People identified with increased risk might be able to prevent or delay the onset of illness by medical treatment and/or changing their environmental exposure. But tests might also help organizations, such as employers, insurers, and government bodies, to minimize their future economic risks. This article searches for an ethical and feasible European policy for the use of genetic information in life insurance. It first argues that genetic information is not so relevantly different from at least one other kind of medical information, that of HIV infection, that it justifies unlike policy treatment. European life insurance is then claimed to be a non-primary social good which should be handled by the private market. The problem of adverse selection is argued to be a reasonably serious threat. Insurers should therefore be allowed to demand some genetic risk information in order to secure the sustainability of insurance schemes. However, the moral principles and values of autonomy, privacy, non-discrimination, non-deterrence, solidarity and confidentiality, put limits on insurers justified information demands. The article ends up advocating a regime of limited community-rated private life insurance, first proposed by a Dutch committee. It stipulates that insurers should be forbidden to demand genetic tests as a condition for an insurance contract, but be allowed to ask for existing genetic information when the sought insurance cover is above a certain limit.

Confidentiality↗
PubMed2001

Insurance status and admission to hospital for head injuries: are we part of a two-tiered medical system?

Previous studies have shown an association between insurance status and use of resources for inpatient care. We sought to assess whether insurance status influences decisions regarding the evaluation and treatment of head injured patients in the emergency department (ED). Head injured patients were identified from ED data from 4 hospitals reporting to the Kentucky Emergency Medical Services Information System. Multiple regression analysis using admission, ED length of stay, and ED charges as outcome variables was then performed. From 216,137 ED visits there were 8,591 (4%) head injured patients identified from the database. Eliminating those with revisits, transfers to another hospital in the database, and isolated facial lacerations, there were 3,821 cases. Controlling for age, hospital, race, primary diagnosis, and indicators of severity of the injury, insurance status was significantly associated with hospital admission. Those uninsured were the least likely to be admitted (OR 0.41; 95% CI (0.31, 0.50), whereas those with public insurance had an intermediate probability (OR 0.50 95% CI (0.37, 0.68) as compared with those with private insurance. Similarly, ED charges were lower for Medicaid patients than insured patients ($880) and tended to be slightly lower for uninsured patients ($1,043) than insured patients ($1,141) (P =.001). Length of stay in the ED was shorter for publicly insured patients (179 minutes) than uninsured (186 minutes) and privately insured patients (192 minutes) (P =.001). The extent of evaluation and admission for head injured patients is associated with insurance status. This creates a dual standard of care for patients. Practitioners should work to standardize the evaluation of patients independent of paying status.

Adolescent↗
PubMed1993

The relation between health insurance coverage and clinical outcomes among women with breast cancer.

BACKGROUND: Women without private health insurance are less likely than privately insured women to be screened for breast cancer, and their treatment may differ after cancer is diagnosed. In this study we addressed two related questions: Do uninsured patients and those covered by Medicaid have more advanced breast cancer than privately insured patients when the disease is initially diagnosed? And, for each stage of disease, do uninsured patients and patients covered by Medicaid die sooner after breast cancer is diagnosed than privately insured patients? METHODS: We studied 4675 women, 35 to 64 years of age, in whom invasive breast cancer was diagnosed from 1985 through 1987, by linking New Jersey State Cancer Registry records to hospital-discharge data. We compared the stage of disease and stage-specific survival among women with private insurance, no insurance, and Medicaid coverage through June 1992. We also estimated the adjusted risk of death for these groups, using proportional-hazards regression analysis to control for age, race, marital status, household income, coexisting diagnoses, and disease stage. RESULTS: Uninsured patients and those covered by Medicaid presented with more advanced disease than did privately insured patients (P < 0.001 and P = 0.01, respectively). Survival was worse for uninsured patients and those with Medicaid coverage than for privately insured patients with local disease (P < 0.001 for both comparisons) and regional disease (P < 0.001 for both comparisons), but not distant metastases. The adjusted risk of death was 49 percent higher (95 percent confidence interval, 20 to 84 percent) for uninsured patients and 40 percent higher (95 percent confidence interval, 4 to 89 percent) for Medicaid patients than for privately insured patients during the 54 to 89 months after diagnosis. CONCLUSIONS: The more frequent adverse outcomes of breast cancer among women without private health insurance suggest that such women would benefit from improved access to screening and optimal therapy.

Adult↗
PubMed1995

Medicare coverage, supplemental insurance, and the use of mammography by older women.

BACKGROUND: On January 1, 1991, the Medicare program began offering reimbursement for screening mammography every two years. This study examined the use of mammography in women covered by Medicare during the first two years that the screening benefit was offered. METHODS: Medicare bills for 1991 and 1992 from a nationally representative sample of 4110 women 65 years of age or older were examined to determine the degree of compliance with recognized guidelines for screening mammography and the extent to which the use of mammography was associated with having supplemental insurance, which shields patients from the out-of-pocket costs associated with using Medicare benefits. RESULTS: A total of 36.9 percent of older U.S. women had mammography during the first two years of the Medicare benefit for screening mammography. Only 14.4 percent of the women lacking supplemental insurance had mammography, as compared with 44.7 percent of those with employer-sponsored supplemental insurance, 40.1 percent of those with self-purchased supplemental insurance, and 23.9 percent of those with Medicaid supplemental insurance. These differences persisted in the stratified and multivariate analyses. As compared with women lacking supplemental insurance, women with employment-based supplemental insurance were more likely to undergo mammography (adjusted odds ratio, 3.03; 95 percent confidence interval, 2.17 to 4.23), as were women with self-purchased supplemental insurance (adjusted odds ratio, 2.97; 95 percent confidence interval, 2.13 to 4.15) and women with Medicaid supplemental insurance (adjusted odds ratio, 1.99; 95 percent confidence interval, 1.30 to 3.07). CONCLUSIONS: The use of mammography was substantially below recommended levels during the first two years of Medicare coverage for screening mammography. Women lacking supplemental health insurance were at particularly high risk of failing to undergo mammography. Requiring copayments for preventive services is an obstacle to the effective mass screening of older women for breast cancer.

Aged↗
PubMed2000

To buy, or not to buy: factors associated with the purchase of nongroup, private health insurance.

BACKGROUND: Employment-based health insurance coverage is declining in the United States. Many recent efforts to increase coverage have promoted the individual purchase of insurance, with or without subsidies. OBJECTIVES: To study the associations of factors including minority group membership, education, income, wealth, and health status with the voluntary purchase of nongroup, private health insurance. DESIGN: Analysis of the 1987 National Medical Expenditure Survey (NMES). SUBJECTS: Adult respondents to the NMES who were younger than 65 years of age in 2,574 health-insurance eligibility units (HIEUs) and who either were uninsured or who purchased nongroup, private health insurance for all of 1987. MEASURES: Adjusted odds ratios and marginal effects for the associations of minority group membership, educational attainment, income, and wealth with the purchase of nongroup insurance. RESULTS: Lower-income and less-wealthy HIEUs were much less likely to purchase insurance than higher-income and wealthier HIEUs, with income and wealth measures having relatively independent effects. With simultaneous adjustment for income, wealth, and other factors, members of minority groups had less than half the odds of non-Hispanic whites and persons with less than a high school education had less than half the odds of college graduates of purchasing nongroup insurance. CONCLUSIONS: Minorities and the less educated are much less likely to buy their own health insurance, even after adjustment for income and wealth. Programs encouraging the voluntary purchase of health insurance are likely to widen coverage gaps between historically disadvantaged groups and others.

Adult↗
PubMed2003

Public insurance expansions and crowd out of private coverage.

BACKGROUND: The extent to which persons enrolling in new public insurance programs substitute the public coverage for private insurance is of concern to policy makers. OBJECTIVE: To look at the extent of the substitution resulting from new state programs that cover a broad base of the low-income population and to look at the responses of both families and employers. METHODS: The March CPS for 1991-1993 and 1997-1998 were used to study the responses of families. Two large national surveys of employers with information about the employment-based system in 1993 and 1997 were used to study employer responses. The analysis looks at changes in coverage and employer offer rates before and after the public insurance expansions in selected states and compares these changes to those in a control group in states without expansions. RESULTS: Coverage by private insurance for low-income persons in states with expansions fell by more than expected based on the control states, indicating some substitution of public coverage for private insurance. Changes in employee coverage in own-employer sponsored insurance accord with this result. The expansion of public insurance has a bigger effect on employer offer decisions when a large share of its workers is eligible for public programs. CONCLUSIONS: The results show a significant substitution of public insurance for private coverage in the expansions studied. However, endogeneity of state expansion policies and possible confounding with other policy changes temper the conclusions. More recent public insurance expansions as part of the State Childrens' Health Insurance Program have adopted a range of methods to limit crowd out. Future research is needed to evaluate whether these procedures and rules have succeeded.

Adult↗
PubMed2005

Insurance status and the use of guideline therapy in the treatment of selected cancers.

PURPOSE: This study estimates the impact of type of insurance coverage on the receipt of guideline therapy in a population-based sample of cancer patients treated in the community. PATIENTS AND METHODS: Patients (n = 7,134) from the National Cancer Institute's Patterns of Care studies who were newly diagnosed with 11 different types of cancer were analyzed. The definition of guideline therapy was based on the National Comprehensive Cancer Network treatment recommendations. Insurance status was categorized as a mutually exclusive hierarchical variable (no insurance, any private insurance, any Medicaid, Medicare only, and all other). Multivariate analyses were used to examine the association between insurance and receipt of guideline therapy. RESULTS: Adjusting for clinical and nonclinical variables, insurance status was a modest, although statistically significant, determinant of receipt of guideline therapy, with 65% of the privately insured patients receiving recommended therapy compared with 60% of patients with Medicaid. Seventy percent of the uninsured patients received guideline therapy, which was nonsignificantly different compared with private insurance. When stratified by race, insurance was a statistically significant predictor of the receipt of guideline therapy only for non-Hispanic blacks. CONCLUSION: Overall, levels of guideline treatment were lower than expected and particularly low for patients with Medicaid or Medicare only. The use of guideline therapy for ovarian and cervical cancer patients and for patients with rectal cancers was unrelated to type of insurance. Of particular concern is the significantly lower use of guideline therapy for non-Hispanic black patients with Medicaid. After adjusting for other factors, only half of these patients received guideline therapy.

Adult↗
PubMed1997

Children at risk: their health insurance status by state.

OBJECTIVE: To inform policymakers and child health advocates about children's health insurance coverage in each state as Congress debates proposals to restructure the Medicaid program amidst declining employer-based dependent health insurance coverage. METHODS: Multiple years of data from the March supplement of the Current Population Surveys were pooled to yield more reliable estimates of changes in children's health insurance coverage in each state from 1987 to 1993. RESULTS: Overall, the number of uninsured children grew by nearly 1 million between 1987 and 1993. The proportion of infants and children <7 years old without health insurance declined; the proportion of uninsured children between the ages of 7 and 22 increased. Between 1987-1990 and 1991-1993, six states experienced a significant increase in the number of uninsured children, only two states experienced a significant decrease in the number of uninsured children, although no progress was found in reducing the number of uninsured children in 43 states. Between 1987-1990 and 1991-1993, the proportion of children covered by employer-based private insurance decreased significantly in three-fourths of the states and the proportion of children with Medicaid coverage increased significantly in four-fifths of the states. CONCLUSIONS: In a period of fast-declining employer-based health insurance coverage for dependents, Medicaid expansions have worked to moderate the surge in the number of children without health insurance. Of the 30 million children without private health insurance in 1993, nearly 18 million were insured by Medicaid. As policymakers debate the future of the Medicaid program, they must consider seriously its role as the country's largest insurer of children's health and its efficacy as a vital safety net for the nation's children.

Adolescent↗
PubMed1991

Different rates of acceptance of health examination among the people under 2 separate health insurance programs in Japan.

The entire population in Japan is covered by either workplace-based health insurance program or region-based health insurance program. While both programs were originally for curative medical care, only the former program has recently extended its financial support to preventive health examination. The attitude of the people toward health examination was studied in Miyagi prefecture in north-east Japan by questionnaires with more than 32,000 respondents to examine whether the difference in health insurance reflect on the rates of acceptance of 4 health examination items (i.e., blood pressure measurement, chest x-ray taking, and 2 screening tests for stomach and cervical cancer). Throughout the 4 items, the rate of acceptance was higher among those who were covered by workplace-based health insurance than among those covered by regional health insurance. The difference is large for the insured and less so for the family dependents of the insured. Further analysis for the preferred opportunities for health examination such as personal examination at clinics in contrast to region-based mass examination showed that the weight of clinics was quite large for the insured of national health insurance and their family dependents (i.e., 50% or even larger) but it was less so for the people covered by workplace-based insurance.

Blood Pressure Determination↗
PubMedDate not supplied

Travel insurance claims made by travelers from Australia.

BACKGROUND: Little is known about travel insurance claims made by travelers returning from abroad. This study was designed to investigate travel insurance claims made by travelers from Australia, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when treatment was sought during travel or when the problem arose, use of emergency assistance, nature of claim, and claim outcome, including cost. METHODS: A random sample of approximately one in five claims reported during the period 1996 to 1998 to a major Australian travel insurance company were examined. RESULTS: A total of 855 claims were examined, of which 42.6% (356/836) were made by male travelers and 57.1% (477/836) were made by female travelers. The majority of claimants were in the 55 years and over age groups (445/836, 53.2%). Medical and dental conditions accounted for 66.6% of claims (569/854), with the remainder associated with loss, theft, and damage (285/854, 33.4%). The most common medical conditions were respiratory (110/539, 20.4%), musculoskeletal (90/539, 16.7%), gastrointestinal (75/539, 13.9%), ear, nose, and throat (67/539, 12.4%), and dental conditions (39/539, 7.2%). Only one case of venous thrombosis was reported, secondary to a lower limb infection. Use of the travel insurance company's emergency telephone service was reported in 17.1% of claims (146/853). Almost two-thirds (559/853, 65.5%) of claims were fully accepted. Those who claimed medical treatment, assault, and theft were significantly more likely to have their claims accepted compared to those claiming dental conditions, cancellation, curtailment, loss and damage (chi2 = 127.78, df = 40, p <.00001). The majority of medical and dental conditions did not require further medical investigations (427/569, 75.0%). The mean cost of claim refunds was Australian dollars (AUD)991.31 (standard deviation [SD] 6 AUD5400.76) for males and AUD508.90 (SD 6 AUD1446.10) for females. Claims for assault, cancellation, and curtailment were significantly more expensive than other types of claims (Kruskal-Wallis one way analysis of variance [ANOVA]; chi2 = 106.87, df = 8, p <.00001). Claims for treatment of gastrointestinal, cerebrovascular, cardiovascular, musculoskeletal conditions, and pyrexias of unknown origin were significantly more expensive than other medical and dental claims (Kruskal-Wallis one way ANOVA; x2 = 61.68, df = 15, p <.00001). CONCLUSIONS: This explorative study highlights the importance of travelers taking out appropriate travel insurance. Claims for medical and dental conditions represent the majority of travel insurance claims made by Australian travelers returning from abroad, although travel insurance also covers against such contingencies as loss, theft, and cancellation. The most common medical conditions claimed were respiratory, musculoskeletal, and gastrointestinal disorders. Travelers should be advised to take out appropriate travel insurance before departure overseas and to take care with preexisting medical and dental conditions, which may not be able to be claimed against travel insurance.

Adult↗
PubMed1999

Racial and ethnic differences in health insurance coverage for adults with diabetes.

OBJECTIVE: To evaluate the extent and types of health insurance coverage in a representative sample of adults with diabetes in the U.S. RESEARCH DESIGN AND METHODS: The Third National Health and Nutrition Examination Survey included national samples of non-Hispanic whites, non-Hispanic blacks, and Mexican-Americans aged > or = 20 years. Information on medical history and treatment of diabetes was obtained to determine subjects who had been diagnosed with diabetes by a physician before the survey (n = 1,503) and subjects without diagnosed diabetes (n = 17,319). Information on health insurance coverage was obtained via a structured questionnaire for 96% of participants. RESULTS: A total of 93% of all adults with diabetes had some form of health insurance. Of these subjects, 73% had private insurance, 48% had Medicare coverage, 15% had Medicaid coverage, and 5% had Champus/Veterans Affairs coverage. Approximately 52% of adults with diabetes had multiple types of health insurance, and 54% had health care coverage through one or more government-sponsored programs. A greater proportion of non-Hispanic whites (91%) and non-Hispanic blacks (89%) than Mexican-Americans (66%) had health insurance among subjects aged 20-64 years. For those aged > or = 65 years, coverage was virtually 100% for all racial and ethnic groups. Non-Hispanic whites had the highest rate of coverage through private insurance (81%), with non-Hispanic blacks having an intermediate rate (56%) and Mexican-Americans having the lowest rate (45%). Rates of coverage were similar for adults with and without diabetes in each racial and ethnic group for any type of insurance and for private insurance. CONCLUSIONS: There are marked racial and ethnic differences in health insurance coverage for adults with diabetes, although these differences are similar to those for adults without diabetes. Whether these racial and ethnic disparities influence access to care, quality of care, or health outcomes for people with diabetes remains to be determined.

Adult↗
PubMedDate not supplied

Current trends in the integration and reimbursement of complementary and alternative medicine by managed care organizations (MCOs) and insurance providers: 1998 update and cohort analysis.

OBJECTIVES: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services into conventional medicine. METHODS: A literature review and information search was conducted to determine which insurers had special policies for CAM. Telephone interviews were conducted with a definitive sample of 9 out of 10 new MCOs or insurers identified in 1998 and a cohort of eight MCOs and insurers who responded both to the original survey in 1997 and again in 1998 to determine trends. RESULTS: This study constitutes the results of the second year of a 3-year ongoing survey. For 1998, 10 MCOs and insurance carriers initiated CAM coverage. Survey results are analyzed for these 10 new providers as well as the results of a cohort of eight insurers surveyed in both 1997 and 1998 to determine current trends. A majority of the insurers interviewed offer some coverage for the following: nutrition counseling, biofeedback, psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. All new MCOs and insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness, consumer interest, demonstrable clinical efficacy, and state mandates. Among the most common obstacles listed to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition and division, and lack of standards of practice. CONCLUSIONS: Consumer demand for CAM is motivating more MCOs and insurance companies to assess the benefits of incorporating CAM. Outcomes studies for both conventional and CAM therapies are needed to help create a health care system based upon treatments that work, whether they are conventional, complementary, or alternative.

Cohort Studies↗
PubMedDate not supplied

Variations in healthcare measures by insurance status for patients receiving ventilator support.

OBJECTIVE: To examine differences in healthcare delivery by expected health insurance status for hospitalized patients in diagnosis-related group (DRG) 475, respiratory system diagnoses requiring intubation and continuous ventilator support. DESIGN: A survey, derived from the Healthcare Cost and Utilization Project interstate database, of the care delivered to 21,149 adult patients in DRG 475 and hospitalized in one of 718 acute-care hospitals in nine states. Multivariate analysis was performed, controlling for demographic and hospital factors. RESULTS: Patients insured by health maintenance organizations (HMOs) had significantly lower rates of inpatient mortality (odds ratio [OR], 0.84; 95% confidence interval [CI95], 0.73-0.96), 14.3 more procedures performed (CI95, 11.5-17.2), 7.0% shorter hospitalizations (CI95, 12.5-1.6), and 5.2% higher charges (CI95, 0.4-10.0) than those with traditional private insurance. In addition, patients insured by Medicaid had 3.5% more procedures performed (CI95, 1.6-5.4), 10.4% longer lengths of hospitalization (CI95, 6.7-14.0), and 13.8% higher charges (CI95, 10.6-17.0) than those with traditional private insurance. Finally, the uninsured had significantly lower rates of inpatient mortality (OR, 0.87; CI95, 0.77-0.99), 8.5% more procedures performed (CI95, 6.0-11.1), 16.5% shorter hospitalizations (CI95, 21.5-11.6), and 13.4% lower charges (CI95, 17.8-9.0) than those with traditional private insurance. CONCLUSION: Variations in healthcare measures by insurance status for this DRG emphasize the importance of more careful analyses of insurance categories as a determinant of healthcare access and outcomes. Expected insurance status was an independent predictor of cost. Private insurance and HMO populations differed significantly in outcome and cannot be considered equivalent.

Adolescent↗
PubMed2000

The effect of marginal tax rate on the probability of employment-based insurance by risk group.

RESEARCH OBJECTIVE: To evaluate the effect of the tax subsidy on participation in employment-based health insurance for high- and low-risk individuals. The total exclusion of employer-paid health insurance premiums from taxable income has frequently been seen as contributing to excess insurance and hence welfare loss. However, less attention has been paid to quantifying the extent to which the tax subsidy mitigates the deleterious effects of adverse selection on the health insurance market. Adverse selection reduces pooling in an insurance market, so that high-risk individuals are either unable to obtain coverage or are forced to pay premiums that are unaffordable to all but the wealthiest. If there is an external benefit to society of an individual's purchase of medical care, then the presence of adverse selection may reduce the purchase of health care below the socially optimal level. Therefore, a mechanism for enhancing access to insurance and ultimately to medical care for high-risk individuals may be socially desirable. STUDY DESIGN: Data from the March 1996-March 1998 Current Population Survey (CPS). For each observation in the sample, state and federal income tax liability is calculated using code based on the ACIR Significant Features of Fiscal Federalism. The probability of having employment-based coverage in either one's own name or as a dependent is evaluated as a function of demographic variables such as age, education, marital status and family size, family income, type of employment, employer size, occupation, location, marginal tax rate, risk group (determined by self-assessed health status), and an interaction between risk group and tax rate. CPS data do not identify individuals who have declined offered coverage. Under alternative models of employer group decision making, the tax subsidy will have an important influence on the employer's decision to offer coverage. If offered, high-risk individuals accept coverage, while some low-risk individuals may decline coverage. PRINCIPAL FINDINGS: For all individuals, the probability of having coverage is an increasing function of the marginal tax rate. Those classified as high-risk because their own or a family member's self-assessed health status is fair or poor are less likely to have coverage than those considered low-risk. The effect of the tax subsidy on insurance coverage is greater for high-risk individuals than for individuals classified as low-risk. CONCLUSIONS: These preliminary results indicate that high-risk individuals benefit from the tax subsidy by increased access to employment-based coverage. Therefore, welfare loss from excess levels of health insurance may be mitigated by welfare gain through expanded access to health insurance and hence to health care for high-risk individuals. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Elimination or reduction of the tax exclusion of health insurance premiums may have the unintended consequences of disproportionately reducing the probability of obtaining coverage in the employment-based market for high-risk individuals.

Adolescent↗