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PubMed1986

Cost sharing and its effects on hospital utilization. The Blue Cross and Blue Shield of North Carolina experience.

A natural movement away from traditional first-dollar health care benefits to coverage with cost-sharing features was studied among employer groups covered by Blue Cross and Blue Shield of North Carolina. The groups choosing the new benefits were atypical: they had a record of high rates of hospitalization. The new benefits were successful in shifting part of the financial burden away from the employer and, additionally, the groups collectively experienced a decline in inpatient utilization in excess of the decrease noted among controls. Despite the overall decline in utilization, their days/1000 remained in excess of the control groups in the year following the benefit change. Not every group experienced a utilization decline. Participants in counties with traditionally low levels of utilization did not experience a further decline.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Doughnut-hole economics.

Both the recently enacted Medicare prescription drug benefit and a new cohort of consumer-directed health benefit models offer doughnut-shaped insurance coverage with large deductibles that begin around the mean annual spending for enrollees. These policies leave enrollees to bear more risk than policies with equal expected payouts that rely on first-dollar deductibles. This risk to enrollees is substantial, given the skewed distribution of health care spending and the placement of the typical deductible. I consider alternative explanations for this new benefit design trend and conclude that the desire to distribute tangible benefits to the largest number of constituents is most plausible.

Deductibles and Coinsurance↗
PubMed1977

Private industry health insurance plans: type of administration and insurer in 1974.

This report examines the major forms of administration of private health insurance plans. Plans are classified according to whether they are employer-only or joint worker-employer-operated and according to whether they are negotiated or not. A further focus of examination that often reflects industry patterns is whether the plans cover workers of a single employer or involve multi-employer arrangements. These classifications of administration and the method of insuring benefits are examined in terms of proportions of workers with specified plan characteristics and health benefits.

Blue Cross Blue Shield Insurance Plans↗
PubMed1986

Coinsurance effects on dental prices.

For many Americans the cost of dental services represents a barrier to receiving regular dental care and maintaining proper oral health. The recent growth of the dental insurance industry, however, may partly offset this price barrier among insureds. Our purpose is to examine the relationship between coinsurance and dental prices for 16 dental services among a sample of Pennsylvania Blue Shield (PBS) adult insureds. The dependent price measure is the annual average gross price paid for 16 specific preventive, restorative, periodontic, endodontic, prosthodontic, and surgical dental services. Independent variables in the price model include the insured's age, education, coinsurance rates, time costs, market area, non-wage income, oral health status, area dentist-population ratio and usual source of care. Data sources are 1980 PBS claims and coinsurance rate data and a mail survey of sampled insureds. OLS regression analysis reveals that the model's independent variables explain little dental price variation. No variable is consistently significant across services, but market area, coinsurance rates, and time costs alternately dominate across equations. These results suggest that, among adult insureds, coinsurance and time costs influence dental fees in a minority of dental services. Insurance reduces the patient's sensitivity to money price, and non-price factors correspondingly seem to become more important in patient search.

Adolescent↗
PubMed1995

The public cost of expanding coverage.

The 103d Congress considered several health care reform bills that would encourage voluntary expansions of coverage through insurance market reforms, new tax deductions for premiums, and direct premium subsidies for low-income persons. We found that insurance reforms alone will do little to expand coverage. We also found that most of the proposed tax deductions would go to persons who already have insurance and would have little impact on coverage. Premium subsidies for low-income persons would greatly increase coverage. However, coverage would change little for those who would have to pay all or part of the premium.

Costs and Cost Analysis↗
PubMedDate not supplied

Consumer-directed health plans and the RAND Health Insurance Experiment.

Today's consumer-directed health plans, with their high deductibles, bear a strong resemblance to the high-deductible plan of the RAND Health Insurance Experiment (HIE), although they come into a post-managed-care world. The high deductibles and the tools of managed care should complement each other, the former directed primarily at the initiation of care for an episode of illness and the latter at the costliness of episodes, especially ongoing chronic disease episodes. Although the RAND experiment established the effects of varying prices to patients, future experiments with how physicians respond to the various tools of managed care may be useful.

Community Participation↗
PubMed1998

Does competition by health maintenance organizations affect the adoption of cost-containment measures by fee-for-service plans?

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.

Cost Control↗
PubMed1985

Reductions in coverage for mental and nervous illness in the Federal Employees Health Benefits Program, 1980-1984.

After nearly 15 years of nondiscriminatory coverage, the largest plan in the Federal Employees Health Benefits Program cut its coverage of care for mental illness disproportionately to coverage for other health care in 1981 and 1982. "Catastrophic" coverage for inpatient mental illness care was introduced by many of the plans in 1984. The authors review the reductions in coverage from economic and clinical perspectives, highlighting the impact of the disparity between the coverage for mental illness and other medical conditions. The model of catastrophic protection for treatment of mental illness set forth in the Federal Employees Health Benefits Program does not bode well for the patient and family who must cope with such a financial contingency.

Blue Cross Blue Shield Insurance Plans↗
PubMed2005

Effect of a new diagnosis of Barrett's esophagus on insurance status.

BACKGROUND: Barrett's esophagus (BE) is associated with an increased risk of adenocarcinoma of the esophagus. Despite this increased risk, most cohort studies demonstrate that the mean life expectancy of subjects with BE is no different than age-matched controls. The indirect costs associated with a diagnosis of BE are unclear. AIM: To assess the effect of a diagnosis of BE on insurance premiums. METHODS: We assessed twenty national life insurance companies (10 in southern California, 10 in North Carolina) to determine the effect of a diagnosis of BE on life insurance premiums. Our base case in Los Angeles was a 36-yr-old female nonsmoker, and in North Carolina, a 43-yr-old Caucasian male nonsmoker, both in excellent health except for a diagnosis of prevalent BE with no dysplasia. The policy requested was a 20-yr guaranteed term life insurance in the amount of $1,000,000. Companies were asked for their best price exclusive of the BE, and also their best price when considering BE as a preexisting condition. For those companies not offering the "preferred" rates, the insurance representative was subsequently sent a physician's letter explaining BE and providing data substantiating a normal life expectancy in the condition. Companies were also asked for health insurance quotes, including premiums and deductibles, inclusive and exclusive of the diagnosis of BE. RESULTS: Twenty national insurance companies were contacted. For the 43-yr-old man with no BE, the yearly "preferred" premium for life insurance averaged $1,255. The mean cost of the policies offered to the same individual with BE as a preexisting condition was $2,731 (p < 0.001). For the 36-yr-old female the base rate exclusive of BE was $517, with a range of $472-$551. After inclusion of the diagnosis of BE, the mean rate rose by 177%, to $1,434, with a range of $1,144-$1,896. Companies either refused to provide health insurance to the individual with BE or would not provide a quote without review of the medical record. None of the insurance companies changed their quoted rates after receiving the letter written by the physician on behalf of the individual. CONCLUSIONS: Despite the preponderance of data demonstrating a normal life expectancy associated with the condition, a diagnosis of BE more than doubles life insurance premiums, and impacts the availability of health insurance. Further steps to educate insurance companies about the risks associated with BE are warranted, and patients should understand this additional "risk" of endoscopic screening for BE. There are significant indirect costs associated with a diagnosis of BE.

Adult↗