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The process of determining whether--and how--to limit coverage for certain expensive, experimental medical treatments is complex and involves social, legal and economic considerations. However, employers do have several options for responsibly containing their health plan costs while meeting their employees' basic health care needs.
With the enormous increase in the cost of healthcare, especially for catastrophic illnesses, employers have begun to modify their healthcare insurance plans to limit the amount of coverage an employee can receive for treatment of a particular illness, such as AIDS and its related illnesses. The passage of the Americans with Disabilities Act in 1990, however, prohibits an employer from discriminating against disabled individuals with respect to healthcare benefits even if the employer's healthcare plan is not administered by the employer. Thus, it is important for healthcare providers to actively investigate healthcare claims prior to a patient's admission to a hospital to determine whether adequate coverage exists--and to what extent it exists--for treatment of the patient's illness and how and from whom the hospital will be compensated.
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The Americans with Disabilities Act has been heralded as the Emancipation Proclamation for persons with disabilities. The purpose of the law is to provide nothing less than a "clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities." Precisely how the nondiscrimination principles of the ADA will be applied to an employer's provision of health benefits to its employees has been the subject of much debate since the Act's passage in 1990. Although the statutory language and the legislative history support a limited application of the ADA to benefits issues, recent court decisions and enforcement actions by the Equal Employment Opportunity Commission indicate that the ADA may have a much more profound impact in the area of benefits plan design and administration. Moreover, as benefits administrators take a much more active role in managing health care decisions, the ADA may become a vehicle for legal challenges to those decisions that affect the disabled.
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This document addresses certain issues arising under the group market portability provisions added by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with respect to employees (or their dependents) who, until the effective date of the HIPAA nondiscrimination provisions, were denied coverage under a group health plan, including group health insurance coverage, because of a health status-related factor.
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Market influences are placing many academic health centers (AHCs) in financial distress. Competitive forces threaten the core missions of AHCs, principally because of selective contracting, which has introduced price competition to medical care. This manuscript discusses the issue of adverse selection for AHCs, the probability that patients with higher levels of illness severity seek care at, or are referred to, AHCs. AHCs are particularly vulnerable to adverse selection because of their prominence as referral centers, their specialty composition, research expertise, and the socioeconomic status of patients located proximal to their centers. The adverse selection of AHCs increases the likelihood that health plans will trim their networks to exclude them. Health plans may still contract with AHCs for tertiary care only, but this will only worsen the adverse selection at AHCs.
Managed care prevention techniques can result in better management of the chronically ill--but higher costs for health plans. One physician consultant recommends blending risk management skills of insurers with care management skills of providers to develop the best possible care of these populations.
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How groups insured by fee-for-service health plans react to increased competition from health maintenance organizations (HMOs) is an unresolved question. We investigated whether groups insured by indemnity plans respond to HMO market competition by changing selected health insurance features, such as deductible amounts, stop loss levels, and coinsurance rates, or by adopting utilization management or preferred provider organization (PPO) benefit options. We collected benefit design data for the years 1985 through 1992 from 95 insured groups in 62 US metropolitan statistical areas. Multivariate hazard analysis showed that groups located in markets with higher rates of change in HMO enrollment were less likely to increase deductibles or stop loss levels. Groups located in markets with higher HMO enrollment were more likely to adopt utilization management or PPO benefit options. A group located in a market with an HMO penetration rate of 20% was 65% more likely to have included a PPO option as part of its insurance benefit plan than a group located in a market with an HMO penetration rate of 15% (p < 0.05). Concern about possible adverse selection effects may deter some fee-for-service groups from changing their health insurance coverage. Under some conditions, however, groups insured under fee-for-service plans do respond to managed care competition by changing their insurance benefits to achieve greater cost containment.
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