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PubMed1999

Simulating the effects of employer contributions on adverse selection and health plan choice.

OBJECTIVE: To investigate the effect of employer contribution policy and adverse selection on employees' health plan choices. STUDY DESIGN: Microsimulation methods to predict employees' choices between two health plan options and to track changes in those choices over time. The simulation predicts choice given premiums, healthcare spending by enrollees in each plan, and premiums for the next period. DATA SOURCES: The simulation model is based on behavioral relationships originally estimated from the RAND Health Insurance Experiment (HIE). The model has been updated and recalibrated. The data processed in the simulation are from the 1993 Current Population Employee Benefits Supplement sample. PRINCIPAL FINDINGS: A higher fraction of employees choose a high-cost, high-benefit plan if employers contribute a proportional share of the premium or adjust their contribution for risk selection than if employees pay the full cost difference out-of-pocket. When employees pay the full cost difference, the extent of adverse selection can be substantial, which leads to a collapse in the market for the high-cost plan. CONCLUSIONS: Adverse selection can undermine the managed competition strategy, indicating the importance of good risk adjusters. A fixed employer contribution policy can encourage selection of more efficient plans. Ironically, however, it can also further adverse selection in the absence of risk adjusters.

Consumer Behavior↗
PubMed1999

The economics and challenges of breast cancer in a managed care environment. Based on a presentation by Alan H. Heaton, PharmD.

Breast cancer and its population effect are inseparable. One of the challenges managed care organizations (MCOs) face is instilling the idea that patients are part of a population, and in turn, that population is composed of patients. Therefore, there is a need to treat both patients individually and populations as a whole. Because breast cancer, like other major illnesses, involves large-scale expenditures for drugs, pharmaceutical benefit management companies are working with MCOs to look not only at drug costs but at global healthcare expenditures. Whereas treatment of breast cancer has direct costs to a healthcare plan, it is associated with a great deal of comorbidity as well. In dealing with such potential financial exposure, the challenge to health plans is to find individuals at risk, enable them to access the healthcare system, and see that they get proper care. A proactive communications effort involving such media as patient newsletters and a website can educate healthplan members, thereby facilitating the self-assessment of risk factors.

Breast Neoplasms↗
PubMed1999

Employment-based health insurance: a look at tax issues and public opinion.

This Issue Brief provides background information on the employment-based health insurance system and its alternatives. The report discusses the advantages and disadvantages of the current employment-based health insurance system, the current tax treatment of health insurance, and the strength and weaknesses of recent proposals to introduce tax credits. It presents findings from the public opinion survey conducted by the Employee Benefit Research Institute on public attitudes toward health insurance and summarizes recent research on the effects of tax changes on employment-based health benefits and the uninsured. Employment-based health plans are the most common source of health insurance among nonelderly individuals in the United States, providing coverage to nearly two-thirds of this population in 1997. Health insurance is probably the benefit most used and valued by workers and their families. Sixty-four percent of respondents to a recent survey rated employment-based health insurance benefits as the most important benefit. Despite essentially five years of very low health care cost increases and the recent increase in the percentage of Americans with employment-based health insurance coverage, the uninsured population has continued to rise. This has resulted in a new interest among policymakers in finding ways to reverse this trend. One question that continues to be asked is whether the employment-based health insurance system is the appropriate mechanism for expanding health insurance to the uninsured. Employment-based health plans are popular because they offer many advantages over other forms of health insurance and types of delivery systems. However, there are also potential drawbacks to the employment-based system. The advantages include reduced risk of adverse selection, group-purchasing efficiencies, employers acting as a workers' advocate, delivery innovation, and health care quality. The disadvantages include an unfair tax treatment, lack of portability and job lock, little choice of health plans, and lack of universal coverage. The tax credit proposals for health insurance, which come in all shapes and sizes, would either enhance the current employment-based health insurance system or put it at risk. This has potentially enormous public policy implications, since the vast majority of Americans get their health insurance coverage through employers. Such a change may also have political implications, as public opinion currently may not support such a fundamental change in the U.S. health insurance system. A recent public opinion survey conducted by the Employee Benefit Research Institute found that 68 percent of Americans with employment-based health insurance were satisfied with the current mix of benefits and wages. The EBRI survey found that under a changing tax code scenario, there is still strong support for the employment-based system. Strong support for the employment-based system may be the result of respondents' lack of confidence in their ability to choose the best health plan if their employer stopped offering health insurance.

Data Collection↗
PubMed1999

Benefits management beyond the adding machine: using integrated, worker-specific analysis.

Modern employee benefits practices have not taken advantage of modern information technology largely because of an implicit reliance on "adding machine" approaches to health care benefits. This article argues that an integrated, worker-specific approach to benefits management is needed in a modern benefits environment. Quantitative illustrations of the integrated approach are provided in terms of a benefits Pareto analysis. The empirical results presented suggest that human resource/risk management practices can have a significant impact on worker benefits costs.

Actuarial Analysis↗
PubMed2000

Genetic discrimination in health insurance: an overview and analysis of the issues.

The problem of genetic discrimination in health insurance will increase as genetic knowledge expands and the number of genetic tests proliferates. Unless appropriate legislative protections are developed and enforced, a consequence of the genetic revolution may be that more people are put at risk for losing their health insurance. The current situation requires people to make difficult choices about taking tests that could save or prolong their lives. Unless these people believe that they and their families will be adequately protected from discrimination and from the possibility of losing or being denied health insurance, many will choose not to be tested for genetic conditions or predisposition to disease. Solutions to this problem require continuing research and debate and the creation of new policies and laws that protect the people while maintaining the economic viability of insurance companies. This article explores the problem of genetic discrimination as it relates to health insurance in the United States. The goal of this article is to assist nurses and other health care professionals to better understand the important and complex issues and concepts related to genetics, genetic testing, and genetic discrimination in health insurance.

Confidentiality↗
PubMed2000

Principal-agent theory: a framework for improving health care reform in Tennessee.

Using a framework based on principal-agent theory, this study examines problems faced by managed care organizations (MCOs) and major health care providers under the state of Tennessee's current capitation-based managed care programs called TennCare. Based on agency theory, the study proposes a framework to show how an effective collaborative relationship can be forged between the state of Tennessee and participating MCOs which takes into account the major concerns of third-party health care providers. The proposed framework further enhances realization of the state's key health care reform goals which are to control the rising costs of health care delivery and to expand health care coverage to uninsured and underinsured Tennesseans.

Capitation Fee↗
PubMed2000

Health-risk-assessment tools used to predict costs in defined populations.

With the Balanced Budget Act of 1997 mandating that the Health Care Financing Administration (HCFA) implement risk-adjusted payment mechanisms for Medicare managed care plans (Medicare + Choice) by January 2000, risk-adjustment tools will play an important role in future capitated reimbursement. This is because there is growing evidence that healthier-than-average beneficiaries select Medicare + Choice. The risk adjustment that HCFA has adopted is initially based on primary inpatient diagnosis from hospitalizations in the previous year. Other payers are likely to adopt similar payment mechanisms. This article reviews nineteen risk-adjustment research papers, including the tool adopted for Medicare + Choice, some of which are likely to form the basis for subsequent HCFA risk-adjustment methods. In general, claims-based models are more powerful in predicting total costs than survey-based or demographics-based models. Survey-based models, although expensive and not as powerful claims-based models, can be used when claims data are unavailable. One of the most popular survey-based tools, SF-36, is likely to become increasingly important because HCFA will be using it to measure quality outcomes from Medicare + Choice plans and will make the results public. All of the models reviewed have limitations, but can be expected to be building blocks for future risk-based capitated reimbursement.

Aged↗
PubMed2000

Rural beneficiaries with chronic conditions: does prevalence pose a risk to Medicare managed care?

One of several possible barriers to the growth of Medicare managed care in rural areas is the fear of adverse selection (i.e., the perception that rural beneficiaries are less healthy and have pent-up demand for services). Using 1993 Medicare Current Beneficiary Survey data, we conclude that specific chronic conditions common among the elderly are not more prevalent among rural than urban beneficiaries. Medicare reimbursements for beneficiaries with chronic conditions are generally lower in rural counties. However, the difference between actual Medicare reimbursements and projected capitated payments to managed care organizations is similar in magnitude for rural and urban beneficiaries with these conditions.

Aged↗
PubMed2001

[Importance of pharmacogenetics].

Pharmacogenetics deals with the differences in effect of drugs caused by genetic variation. Differences can occur in therapeutic effect and in adverse events. Genetic variation in metabolism may result in high concentrations of drugs and an increased risk of adverse effects in slow metabolizers, which is important when using for example antidepressants or chemotherapy. Genetic variation also occurs in proteins interacting with drugs, which may change the effect of e.g. asthma drugs and antipsychotics. The selection of drugs and their dosages may be improved, and the number of adverse effects reduced by pharmacogenetic investigations. However, it may be important also in case of medical examinations for insurances and job appointments, since some patients may turn out to need expensive drugs or to be susceptible to a certain disease. Therefore, the use of genetic data in these instances has to be regulated.

Drug Interactions↗
PubMed2001

Conducting research on the Medicare market: the need for better data and methods.

OBJECTIVE: To highlight data limitations, the need to improve data collection, the need to develop better analytic methods, and the need to use alternative data sources to conduct research related to the Medicare program. Objectives were achieved by reviewing existing studies on risk selection in Medicare HMOs, examining their data limitations, and introducing a new approach that circumvents many of these shortcomings. DATA SOURCES: Data for years 1995-97 for five states (Arizona, Florida, Massachusetts, New York, and Pennsylvania) from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SIDs), maintained by the Agency for Healthcare Research and Quality; and the Health Care Financing Administration's Medicare Managed Care Market Penetration Data Files and Medicare Provider Analysis and Review Files. STUDY DESIGN: Analysis of hospital utilization rates for Medicare beneficiaries in the traditional fee-for-service (FFS) Medicare and Medicare HMO sectors and examination of the relationship between these rates and the Medicare HMO penetration rates. PRINCIPAL FINDINGS: Medicare HMOs have lower hospital utilization rates than their FFS counterparts, differences in utilization rates vary across states, and HMO penetration rates are inversely related to our rough measure of favorable selection. CONCLUSIONS: Substantial growth in Medicare HMO enrollment and the implementation of a new risk-adjusted payment system have led to an increasing need for research on the Medicare program. Improved data collection, better methods, new creative approaches, and alternative data sources are needed to address these issues in a timely and suitable manner.

Aged↗