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PubMed2003

Has solidarity survived? A comparative analysis of the effect of social health insurance reform in four European countries.

Social health insurance reform has evolved as an important public policy issue in several European countries. Some of the most important reform programs have been the introduction of managed competition, a shift from full retrospective reimbursement of health insurers to prospective reimbursement, an increase of private payments, and a change in the health benefits of social health insurance. The article investigates the widespread assumption that reform programs have adverse effects on solidarity in social health insurance by looking at the concrete experience of four European countries (Belgium, Germany, The Netherlands, and Switzerland) over the past decade. A distinction is made between risk solidarity and income solidarity, and the scope of solidarity is shown to have two dimensions: entitlements and membership. The analysis consists of three parts: description of the structure of health insurance of each of the four countries in the early 1990s; discussion of health insurance reform; determination of the impact on each dimension of solidarity. The findings are mixed. There are indeed some examples of solidarity having declined as the result of health insurance reform. But, more important, many examples also were found of an increase in solidarity due to health insurance reform. In some cases, reform was explicitly intended to improve solidarity. If a reform program had a negative impact on solidarity (e.g., an increase in private payments), accompanying measures often were taken to keep solidarity intact as much as possible. Thus the assumption of a negative impact as a result of health insurance reform is not confirmed.

Belgium↗
PubMed1997

The effect of insurance status on likelihood of neonatal interhospital transfer.

OBJECTIVE: To determine the effect of insurance status on the likelihood of interhospital transfer for neonates. DESIGN: Population-based retrospective cohort study. SETTING: All general acute care nonpediatric hospitals in the five counties of southeastern Pennsylvania. PATIENTS: Fifty-six thousand, seven hundred eighty-nine infants from 0 to 28 days of age admitted to or born in study hospitals between January 1 and December 31, 1991. INTERVENTION: None. MAINS OUTCOME MEASURE: Transfer to another general or specialty acute care hospital. RESULTS: The incidence (95% confidence interval) of interhospital transfer was 1.69% (1.60, 1.78). Uninsured infants were nearly twice as likely [relative risk (RR) = 1.96 (1.67, 2.31)] to be transferred as commercially insured infants, even when adjusted for the effects of prematurity, severity of illness, and the level of neonatal intensive care unit in the referring hospital. Similarly, infants with Medicaid were more likely to be transferred [RR = 1.20 (1.01, 1.43)] than similar commercially insured neonates. Uninsured and publicly insured infants were also more likely to be born premature [RR 1.49 (1.39, 1. 60)] than privately insured neonates, and were more likely to have both moderate [RR 1.11 (1.04, 1.23)] and high [RR 1.21 (1.11, 1.32)] illness severity on admission to the hospital than privately insured infants. CONCLUSIONS: Neonates with no insurance and those with Medicaid coverage were more likely to be transferred than infants with private insurance. These results are consistent with those of other investigators who have studied financially motivated patient transfers- so-called patient dumping-in nonpediatric populations of patients. Our study may represent the first documentation of this phenomenon in a pediatric population. Our results are also consistent with those of other investigators who have examined the effect of insurance status on maternal interhospital transfer, thus providing further evidence for the existence of financially motivated transfers within regional systems of perinatal care. Future investigation into the effect of economic factors on variation in the utilization of transport services, and on how transfer influences ultimate patient outcome, is needed as managed care health systems become more widespread.

Analysis of Variance↗
PubMed2003

Influence of insurance status and vaccine cost on physicians' administration of pneumococcal conjugate vaccine.

OBJECTIVE: In 2000, heptavalent pneumococcal conjugate vaccine (PCV7) was recommended for children younger than 2 years, but its high cost relative to other universally recommended childhood immunizations and variability in insurance coverage for the vaccine raised concerns. We investigated the influence of PCV7 cost and insurance coverage on physician recommendation of PCV7 to their patients and administration of PCV7 in their practices. METHODS: We conducted a mail survey from April to July 2001 of a random sample of 833 pediatricians and 788 family physicians in 24 states with different vaccine financing strategies (Vaccines for Children [VFC]-only; enhanced VFC; universal purchase). Physicians specified the proportion of children in their practice with insurance coverage for PCV7, where they recommend administering PCV7, and whether they have concerns about the cost of PCV7. RESULTS: The response rate was 60%. Overall, 87% of physicians recommend PCV7 for children younger than 2 years (99% pediatricians; 68% family physicians). Among physicians who recommend PCV7, 98% said that they would administer the vaccine in their own practices for children whose insurance covers the vaccine. However, only 56% of physicians who recommend PCV7 reported that all children in their practices had insurance coverage for the vaccine, whereas 24% of physicians reported 86% to 99% of children with coverage and 20% reported <or=85% of children with coverage. Among physicians in the last group with the lowest PCV7 insurance coverage rates in their practices, only 44% said that they would administer the vaccine in their own practices to children without PCV7 coverage, compared with 62% of physicians who provide care to children with higher rates of PCV7 coverage. Physicians in states with VFC-only vaccine financing strategies for PCV7 are less likely to administer PCV7 in their own practices to children without coverage than physicians in states with enhanced VFC and universal purchase strategies (48% vs 64% vs 74%). Almost one third of physicians who recommend PCV7 are concerned about the cost of PCV7; those with cost concerns are more likely to recommend that children without insurance coverage for PCV7 receive the vaccine at a public health clinic rather than in their own practices (45% vs 29%). Physicians with cost concerns are also more likely to say that they now screen children for insurance coverage more than for previously recommended vaccines (52% vs 21% for physicians without cost concerns). CONCLUSIONS: Nationwide, physician adoption of PCV7 recommendations is high, but where physicians recommend that PCV7 be administered differs significantly by children's variable insurance coverage for the vaccine and by state vaccine financing strategies. Physicians' concerns about the cost of PCV7 may foreshadow their responses to future children's vaccines that may be even more expensive.

Age Distribution↗
PubMed1990

Universal health insurance: lessons of the 1970s, prospects for the 1990s.

In the 1970s, proposals for universal health insurance were not successful. Health care providers, insurers, and others negotiating in the political process foresaw a better future without such legislation. Today, the growth of health insurance coverage has unmistakably reversed. Moral discomfort and self-interest shape the new politics of universal health insurance for the 1990s. Hospitals, physicians, insurers, employers, and tens of millions of individuals would benefit from a universal health insurance plan that was mindful of their concerns and interests. Proposals that require employers to provide insurance for full-time employees and expand public programs to cover to cover other uninsured persons now have the greatest chances for enactment. As leaders, health services and health insurance executives should be in the vanguard of efforts to enact universal health insurance.

Employment↗
PubMedDate not supplied

Alternatives for expanding health insurance coverage.

In March 1990, nearly 14 percent of the U.S. population was without health insurance. This article examines five approaches to increase coverage: tax credits for the purchase of private insurance; changes in the regulation of the private insurance market; additional requirements on employers to provide employment-based insurance; expansion of Medicaid to selected groups; and a universal public health insurance program. Coverage would be most improved under a universal public insurance plan, and least improved by regulatory changes in the private insurance market. Significant but incomplete increases in coverage could be achieved through either new employer mandates or expansion of Medicaid. A tax credit could increase coverage appreciably only if it was substantial relative to the cost of insurance, and even then most of the credits would go to those who would have purchased insurance anyway.

Data Collection↗
PubMed1993

[The relevance of autopsy for insurance carriers].

By means of a retrospective study with an analysis of the data of 12,743 postmortem examinations over a period of 10 years 630 autopsy cases have been ascertained which had a connection to an insurer. Considerable differences in the reaction and behaviour in the event of damage have been found between public and private insurers. In the course of preliminary investigations by professional/trade associations or pension offices in general an immediate and consistent reaction for this group of insured persons--which has been recorded "purely accidentally"--is to be observed through initiating or analysing of postmortem investigations. Quite in contrast to these findings private insurers to only a small percentage made use of their contractual possibilities of a postmortem control and--if at all--mostly delayed, especially in those cases where the costs of such an investigation were to be debited to the insurer's account. In most cases private insurers made use of the results of postmortems by scientific organisations, courts or professional associations. According to the results of an examination following the rules of forensic medicine of postmortem findings an insurance contract conditions, in more than 50 p. c. of the cases the medical preconditions for the performance of the insurance contract had to be denied. A critical comment should follow: in quite a number of undisclosed cases a regulation of accident and life insurance claims is carried through in which unfounded decisions are taken without any postmortem controls.

Adult↗
PubMed1998

Transitions in insurance and employment among people with HIV infection.

This article examines the extent to which people with HIV infection change their insurance and employment status over time and investigates the correlates of such changes. Data come from the AIDS Cost and Services Utilization Survey, which followed 1,949 HIV-infected adults over an 18-month period that began March 1, 1991. In the first interview, overall, 33% of respondents had private insurance; 40% had public coverage (i.e., Medicaid, Medicare, CHAMPUS); and 27% had no insurance. Among the subgroup with AIDS, corresponding figures were 32%, 54%, and 14%. Overall, 65% were unemployed; among those with AIDS, 82% were unemployed. Over the 18-month period, 23% of respondents reported a change in insurance status and 27% reported a change in employment status. Among those who began the study with private insurance, only 15% reported losing this coverage. Transitions from no insurance to public coverage occurred most frequently. Compared to those who began the study with AIDS, those who progressed to AIDS during the study period were more likely to experience a change in insurance (18% vs. 32%). Consistent with prior studies, public insurance plays a major role in financing care for people with HIV infection. Transitions from public coverage to no insurance may disrupt access to care.

Acquired Immunodeficiency Syndrome↗
PubMed1988

The erosion of purchased health insurance.

In this paper, we trace the decline of purchased health insurance and examine the reasons for the rapid growth of self-insurance between 1981 and 1985. Then, using nationally representative data on benefits in larger private sector firms, we examine the changing content of self-insured plans and compare them with fully insured conventional plans from commercial insurers and Blue Cross and Blue Shield Plans. Between 1981 and 1985, the percentage of employees in mid- to large-sized firms covered by self-insurance grew from 21% to 42%. Self-insured plans cost more than purchased plans in 1981, and continued to cost more in 1985. Their higher premiums were not due to richer benefit packages. Indeed, they less often covered "fringe" services and required greater cost sharing via higher deductibles and coinsurance. Upon considering both the efficiency and the equity issues of self-insurance, we sound a cautionary note on this growing trend.

Blue Cross Blue Shield Insurance Plans↗
PubMed1998

Impact of a children's health insurance program on newly enrolled children.

CONTEXT: Although there is considerable interest in decreasing the number of US children who do not have health insurance, there is little information on the effect that health insurance has on children and their families. OBJECTIVE: To determine the impact of children's health insurance programs on access to health care and on other aspects of the lives of the children and their families. DESIGN: A before-after design with a control group. The families of newly enrolled children were interviewed by telephone using an identical survey instrument at baseline, at 6 months, and at 12 months after enrollment into the program. A second group of families of newly enrolled children were interviewed 12 months after the initial interviews to form a comparison sample. SETTING: The 29 counties of western Pennsylvania, an area with a population of 4.1 million people. SUBJECTS: A total of 887 families of newly enrolled children were randomly selected to be interviewed; 88.3% agreed to participate. Of these, 659 (84%) responded to all 3 interviews. The study population consists of 1031 newly enrolled children. The children were further classified into those who were continuously enrolled in the programs. The 330 comparison families had 460 newly enrolled children. MAIN OUTCOME MEASURES: The following access measures were examined: whether the child had a usual source of medical or dental care; the number of physician visits, emergency department visits, and dentist visits; and whether the child had experienced unmet need, delayed care, or both for 6 types of care. Other indicators were restrictions on the child's usual activities and the impact of being insured or uninsured on the families. RESULTS: Access to health care services after enrollment in the program improved: at 12 months after enrollment, 99% of the children had a regular source of medical care, and 85% had a regular dentist, up from 89% and 60%, respectively, at baseline. The proportion of children reporting any unmet need or delayed care in the past 6 months decreased from 57% at baseline to 16% at 12 months. The proportion of children seeing a physician increased from 59% to 64%, while the proportion visiting an emergency department decreased from 22% to 17%. Since the comparison children were similar to the newly enrolled children at enrollment into the insurance programs, these findings can be attributed to the program. Restrictions on childhood activities because of lack of health insurance were eliminated. Parents reported that having health insurance reduced the amount of family stress, enabled children to get the care they needed, and eased family burdens. CONCLUSIONS: Extending health insurance to uninsured children had a major positive impact on children and their families. In western Pennsylvania, health insurance did not lead to excessive utilization but to more appropriate utilization.

Adolescent↗
PubMed1996

Life insurance and inflammatory bowel disease: is there discrimination against patients?

The aims of this study were to compare and contrast the attitude of major insurance companies to patients with inflammatory bowel disease (IBD) and to a Consultant Gastroenterologist (JFM) requesting guidelines for patients with IBD. The experience of patients in Leicester with insurance companies was also investigated. A standard letter requesting information regarding the likelihood of loading on life assurance in connection with a mortgage was sent to 50 major insurance companies from a typical patient. A similar letter was constructed from a consultant gastroenterologist (JFM) to the same 50 insurance companies requesting simple guidelines for patients with IBD when applying for various types of insurance. A questionnaire investigating the experience of patients with IBD when applying for insurance was also sent to 100 patients with IBD selected at random from the Leicestershire data base of patients with Crohn's disease and ulcerative colitis, 39 insurance companies responded to the request for information by a typical patient, (response rate = 78%). 24 were split between those who thought the patient would be accepted at normal rates (n = 7) and those who would request an increased premium (n = 17). Only 27 companies replied to the letter by a consultant gastroenterologist requesting general guidelines, (response rate = 54%). There were only 17 overlapping replies to the two letters. Of these 17 overlapping replies, five companies (30%) informed the patient to expect increased premiums whilst advising the consultant a similar patient could expect normal rates. Six companies conferred (35%), telling both the patient and the consultant to expect normal rates. Either one or both of the remaining six companies (35%) felt unable to comment without either specific details of the patient or a medical examination. 69% of patients responded to the questionnaire. Over half (54%) had applied for an insurance policy. More than a third of patients had required either a medical examination (36%) or a report from their GP (41%) before being accepted for a policy. 39% of patients had received an additional loading on their policies because of IBD including two patients who had been turned down altogether. In conclusion patients with IBD are clearly discriminated against by insurance companies. Life tables should be amended to take account of the low mortality recognised in recent years. Patients should be aware of the difficulties that currently exist.

Adult↗
PubMed1987

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.

Choice Behavior↗
PubMed1995

The impact of health insurance status on adolescents' utilization of school-based clinic services: implications for health care reform.

PURPOSE: 1) To examine variations among students with different health insurance coverage in their use of school-based clinics (SBCs), reasons for not receiving health care when needed, and reasons for using or not using SBCs, and 2) to determine if insurance status is a significant factor in predicting SBC use, after controlling for demographic variables and health status. METHODS: Confidential questionnaires were administered to 2,860 adolescents attending 3 urban high schools with on-site SBCs. Chi-square and multiple logistic regression analyses were used to assess differences among insurance groups in patterns of SBC use and reasons for clinic use/nonuse. RESULTS: Students with private insurance or HMO coverage had the highest rates of SBC utilization (67% & 66%) and students without health insurance and with Medicaid had the lowest (57% & 59%) (p < 0.01). While there was no difference among adolescents according to insurance group membership in their use of SBC medical services, a significantly higher proportion of students with Medicaid coverage used SBC mental health services. Students without health insurance were less likely to receive health care from any source when it was needed. After controlling for demographic variables and health status, no insurance factors remained significant. CONCLUSIONS: SBC users represent a variety of insurance groups. Health care reform efforts need to take into account the special needs of adolescents and the challenges they face in accessing care that go beyond financial barriers to care. SBC have been shown to provide a convenient and acceptable source of care, as well as offering the opportunity to provide preventive and primary care services to at-risk youth. As the country moves to a managed care environment potential partnerships with SBCs represent a unique opportunity to improve the delivery of care to adolescents, assuring increased access to a package of health services that they need.

Adolescent↗
PubMed2001

Are publicly-insured psychiatric outpatients in Japan satisfied?

Japan has a government financed outpatient program for people with mental disorders, called the 'publicly-insured' program. This study was performed to examine whether the target patient population used this publicly-insured program properly and to compare the degree of satisfaction of publicly-insured psychiatric outpatients with generally-insured psychiatric outpatients. The characteristics and satisfaction of 97 (43.9%) publicly-insured psychiatric outpatients and 124 (55.1%) generally-insured outpatients in Japan were studied. Psychiatrists rated sociodemographic and diagnostic information and patients were asked to complete the Japanese version of Client Satisfaction Questionnaire (CSQ-8J). The publicly-insured were longer-term and lower functioning patients and were significantly more dissatisfied with the services they received than the generally-insured patients. The publicly-insured program was successful in that patients with lower functioning (the primary target population of this program) were cared for and because they received treatment for longer periods of time. However, the program does not sufficiently satisfy the consumers of the services, despite its high costs. In this respect, this program needs to focus more on patients' points of view. More information on programs their enrollment procedures for patients may be helpful in educating consumers and citizens, clarifying expectations of services, and in influencing satisfaction.

Adult↗
PubMed2003

Health insurance and child mortality in Costa Rica.

This study uses a natural experiment approach to evaluate the effect of health insurance on infant and child mortality. In the 1970s Costa Rica adopted national health insurance, which expanded children's insurance coverage from 42 percent in 1973 to 73 percent by 1984. Aggregate infant and child mortality rates dropped rapidly during this period, but this trend had begun prior to the insurance expansion, and may be related to other changes during this period. We use county-level vital statistics and census data to isolate the causal insurance effect on mortality using county fixed effects models. We find that insurance increases are strongly related to mortality decreases at the county level before controlling for other time-varying factors. However, after controlling for changes in other correlated maternal, household, and community characteristics, fixed effects models indicate that the insurance expansion could have explained only a small portion of the mortality change. These results question the proposition that health insurance can lead to large improvements in infant and child mortality, and that expanding insurance to the poor can substantially narrow socioeconomic differentials in mortality.

Cause of Death↗
PubMed2006

Use of clinical guidelines for whiplash by insurers.

OBJECTIVE: To describe the opinions of, use of, and compliance with guidelines for whiplash associated disorders (whiplash) by insurance staff after an implementation program. DESIGN: Observational design using questionnaires. SETTING: Insurance offices in New South Wales, Australia. STUDY PARTICIPANTS: 138 insurance staff (60% response rate) working in compulsory third party (CTP) claims for the 8 CTP insurers in NSW. INTERVENTION: Responses were collected after an implementation program that included education workshops provided by an insurance regulator and by insurance staff trained by the regulator. RESULTS: After implementation, 73% were aware of the CTP guidelines for whiplash, 85% had access to them, and compliance with the recommendations was 71%. Awareness of, and compliance with the guidelines was not related to attending the regulator workshop (P = 1.0). Insurance staff found the guidelines to be helpful, with the mean ratings for relevance to work and in managing claims being 7.8/10 and 6.9/10, respectively. CONCLUSION: Awareness of, and compliance with guidelines for whiplash among insurance staff was high after the implementation program, but was not related to attending the regulator workshop. Compliance may be improved by addressing the barriers nominated by the participants. Developing a specific guideline for the insurer market was considered useful.

Clinical Protocols↗
PubMed1997

Long-term determinants of patterns of health insurance coverage in the Medicare population.

Using data from the 1990 Health Supplement to the Panel Study of Income Dynamics, we examine the determinants of patterns of insurance coverage among the elderly. Among those with supplemental insurance through an employment-based source, the primary determinant of having insurance is work history, specifically job tenure and occupation of household heads and their spouses. Among those who do not have employer-provided insurance, wealth is the most important economic factor in the purchase of private insurance. Blacks, persons with less education and women household heads are less likely to purchase supplemental insurance. We find little evidence that persons in prior poor health are more likely to purchase supplemental insurance, and the most important determinant of dental or drug coverage is having employer-based insurance. The current trend toward decreased generosity of post-retirement benefits implies that fewer older Americans will have insurance for these services.

Black or African American↗
PubMed1999

Effects of health insurance and race on early detection of cancer.

BACKGROUND: The presence and type of health insurance may be an important determinant of cancer stage at diagnosis. To determine whether previously observed racial differences in stage of cancer at diagnosis may be explained partly by differences in insurance coverage, we studied all patients with incident cases of melanoma or colorectal, breast, or prostate cancer in Florida in 1994 for whom the stage at diagnosis and insurance status were known. METHODS: The effects of insurance and race on the odds of a late stage (regional or distant) diagnosis were examined by adjusting for an individual's age, sex, marital status, education, income, and comorbidity. All P values are two-sided. RESULTS: Data from 28 237 patients were analyzed. Persons who were uninsured were more likely diagnosed at a late stage (colorectal cancer odds ratio [OR] = 1.67, P =.004; melanoma OR = 2.59, P =.004; breast cancer OR = 1.43, P =.001; prostate cancer OR = 1.47, P =.02) than were persons with commercial indemnity insurance. Patients insured by Medicaid were more likely diagnosed at a late stage of breast cancer (OR = 1.87, P<.001) and melanoma (OR = 4.69, P<.001). Non-Hispanic African-American patients were more likely diagnosed with late stage breast and prostate cancers than were non-Hispanic whites. Hispanic patients were more likely to be diagnosed with late stage breast cancer but less likely to be diagnosed with late stage prostate cancer. CONCLUSIONS: Persons lacking health insurance and persons insured by Medicaid are more likely diagnosed with late stage cancer at diverse sites, and efforts to improve access to cancer-screening services are warranted for these groups. Racial differences in stage at diagnosis are not explained by insurance coverage or socioeconomic status.

Aged↗
PubMed1991

Determinants of health insurance status among young adults.

This study evaluates the determinants of insurance coverage in the 18-24-year-old population using the National Medical Care Utilization and Expenditure Survey. Three specific issues are addressed: 1) the characteristics of the insured versus uninsured, 2) the reason given by the uninsured for not having coverage, and 3) the role of employment status and other variables in determining insurance status. An important consideration is whether age or usual activity is more important in its effect on insurance status. The results show that employment is the strongest predictor of insurance status in all age and usual activity subgroups. Generally, permanent/full-time workers are most likely to be insured. An exception to this trend is found for those attending school who are also permanent/part-time workers. These individuals are more likely to be insured than permanent full-time workers who are in school. Furthermore, young adults with lower incomes, less education, rural residence, not married, hispanic ethnicity, and Western geography are the least likely to be insured. The findings of this analysis can be used by policymakers to identify the mechanisms that can best enhance insurance coverage among young adults.

Adult↗