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PubMed2000

[Development of second-line occupational health services: toward an integrated network of insurers and care providers].

OBJECTIVE: To describe the development of the second-line Occupational Health Services and the role of private insurance companies in it over the period 1994-1999. DESIGN: Descriptive cross-sectional study. METHOD: Data were collected in 1999 from written documents and supplementary interviews with the five largest private providers of disability insurance, the National Insurance Institute, nine Occupational Health Services of different natures and 24 institutions for second-line occupational health service. RESULTS: After the privatization of the Health Law in 1996 and parts of the Law on disability Insurance, most employers covered the risk of continued payment of wages in case of disability with private insurers. These attempted to keep claims down by active engagement in arbitration, treatment and diagnostics of disabled employees so as to counteract avoidable absenteeism. Under the influence of the insurance companies, a trend developed toward integrated nation-wide chains in which the services provided by insurers, by occupational health services and by implementing institutions are geared for one another. CONCLUSION: Commercial provision of Occupational Health Service is a new, demand-active form of care provision in which the financier plays a key part. This provision of services supplied important innovating impulses for health care in its entirety because of its large scale, strong protocolling of processes and management on the basis of continuous cost-benefit analyses. A lucid and socially acceptable regulation of commercial providers of occupational health services was lacking.

Health Personnel↗
PubMed1975

[Medical insurance estimation of risks].

The purpose of insurance medicine is to make a prognostic estimate of medical risk-factors in persons who apply for life, health, or accident insurance. Established risk-groups with a calculated average mortality and morbidity form the basis for premium rates and insurance terms. In most cases the applicant is accepted for insurance after a self-assessment of his health. Only around one per cent of the applications are refused, but there are cases in which the premium is raised, temporarily or permanently. It is often a matter of rough estimate, since the knowlege of the long-term prognosis for many diseases is incomplete. The insurance companies' rules for estimate of risk are revised at intervals of three or four years. The estimate of risk as regards life insurance has been gradually liberalised, while the medical conditions for health insurance have become stricter owing to an increase in the claims rate.

Coronary Disease↗
PubMed2002

Trends in mental health insurance benefits and out-of-pocket spending.

BACKGROUND: Insurance benefits can have a large effect on whether one is able to access health care services. Mental health and substance abuse (MHSA) insurance coverage has typically been less generous than that of general health services. AIMS OF THE STUDY: This paper examines trends in the generosity of private insurance benefits for mental health (MH) services in the United States from 1987 to 1996. The paper estimates the benefit-induced change in insurance payments for MH services that would have been made by typical health plans between 1987 and 1996 holding constant utilization of individuals at the 1987 level so that the changes in effective benefits could be isolated. METHODS: Trends in mental health benefits were measured using two nationally representative household surveys of the U.S. civilian non-institutionalized population, the 1987 National Medical Expenditure Survey (NMES) and the 1996 Medical Expenditure Panel Survey (MEPS). Data on utilization and expenditures from the NMES/MEPS were used to simulate what the average person would have paid out-of-pocket under typical insurance plans in 1987 and in 1996. RESULTS: The study finds that limits on MH coverage, such as limits on reimbursed days of care, became more prevalent from 1987 to 1996, but that consumer cost-sharing rates declined. The simulations indicate that private insurance would have paid for a lower proportion of total spending in 1996 (60.1 percent) as compared to 1987 (65.8 percent). DISCUSSION: Despite the fact that limits on mental health services became more prevalent over the time-period evaluated, out-of-pocket expenditures did not increase as significantly because there was a corresponding increase in coinsurance covered by health plans. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Trends in plan design negatively affected those with high costs who are likely to surpass their limits and positively affected coverage for those with minimal use due to lower cost-sharing. These trends also indicate that persons in the most need, those with high utilization, particularly of inpatient care, experienced a decline in coverage while those with less intensive needs may have experienced a slight increase. IMPLICATIONS FOR HEALTH POLICIES: Out-of-pocket spending in both years of the study was substantial suggesting that improved health care coverage, such as that mandated in parity legislation, could improve access to care for persons needing mental health treatment. IMPLICATION FOR FURTHER RESEARCH: Additional research is needed to understand how trends in out-of-pocket spending and insurance benefits have influenced access to care.

Adolescent↗
PubMed2006

Insurance coverage and subsequent utilization of complementary and alternative medicine providers.

BACKGROUND: Since 1996, Washington State law has required that private health insurance cover licensed complementary and alternative medicine (CAM) providers. OBJECTIVE: To evaluate how insured people used CAM providers and what role this played in healthcare utilization and expenditures. STUDY DESIGN: Cross-sectional analysis of insurance enrollees from western Washington in 2002. METHODS: Analysis of insurance demographic data, claims files, benefit information, diagnoses, CAM and conventional provider utilization, and healthcare expenditures for 3 large health insurance companies. RESULTS: Among more than 600,000 enrollees, 13.7% made CAM claims. This included 1.3% of enrollees with claims for acupuncture, 1.6% for naturopathy, 2.4% for massage, and 10.9% for chiropractic. Patients enrolled in preferred provider organizations and point-of-service products were notably more likely to use CAM than those with health maintenance organization coverage. The use of CAM was greater among women and among persons 31 to 50 years of age. The use of chiropractic was more frequent in less populous counties. The CAM provider visits usually focused on musculoskeletal complaints except for naturopathic physicians, who treated a broader array of problems. The median per-visit expenditures were 39.00 dollars for CAM care and 74.40 dollars for conventional outpatient care. The total expenditures per enrollee were 2589 dollars, of which 75 dollars(2.9%) was spent on CAM. CONCLUSIONS: The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest. Because the long-term trajectory of CAM cost under third-party payment is unknown, utilization of these services should be followed.

Adolescent↗
PubMed1991

How profitable is medical malpractice insurance?

High medical malpractice insurance premiums charged to physicians have created the perception of a crisis. Some researchers have expressed the concern that medical malpractice insurance companies are making excessive profits. In this paper I compute the actual and allowable normal underwriting profit rates in medical malpractice, as well as in other liability lines, for six large insurance companies. These allowable, normal profit rates are then compared with actual profit rates to evaluate the relative profitability of each line of insurance. Data from 1978 through 1986 show that medical malpractice insurance ranked medium in underwriting profitability compared with other lines of insurance, and during 1985-86 it was the least profitable insurance business.

Actuarial Analysis↗
PubMed1978

Physician participation in health insurance plans: evidence on Blue Shield.

Various health insurance programs, including Blue Shield, have developed arrangements whereby the physician agrees to accept the insurer's reimbursement as payment in full. Incentives facing the physician to accept an arrangement of this type are reviewed in this study. The empirical work uses data on individual physicians from a 1973 survey. The results indicate that physician willingness to accept insurer reimbursement as payment in full is sensitive to the amount the insurer pays for specific procedures and to other insurance program characteristics. Physicians located in high patient income areas and/or with relatively prestigious credentials are less likely to accept insurer payments as payment in full. The empirical findings are used to generate policy implications pertaining to the Medicare and Medicaid programs, to medical care quality-access tradeoffs, and to national health insurance.

Blue Cross Blue Shield Insurance Plans↗
PubMed2000

Health insurance and access to care for symptomatic conditions.

BACKGROUND: The uninsured receive less medical care than the insured. However, it is not known whether the uninsured are less likely to seek medical care for highly "serious" or "morbid" symptoms. METHODS: Participants in the National Access to Care Survey were asked whether they had experienced any of 15 highly serious or morbid symptoms. Those who did were asked whether they received medical care and, if care was not received, whether care was thought to have been necessary. RESULTS: A total of 574 respondents (16.4%) reported 794 new serious or morbid symptoms. Of these, 499 people (86.9%) had health insurance, and they reported 691 new symptoms; 75 (13.1%) lacked health insurance, and they reported 103 symptoms. The uninsured were less likely to have received medical care and more likely to say they did not receive care even though they thought it was needed (P = .001). Medical care was received for 45.4% of symptoms for the insured and 24.3% for the uninsured; care was not thought to have been needed for 41.0% of symptoms for the insured and 45.6% for the uninsured; and care was thought necessary but was not received for 13.6% of symptoms for the insured and 30.1% for the uninsured. In multivariate analysis, the uninsured were much less likely to have received care than the insured (adjusted odds ratio, 0.43; 95% confidence interval, 0.23-0.81). CONCLUSION: Lack of health insurance is a major barrier to receiving medical care, even for highly serious and morbid symptoms.

Adolescent↗
PubMed2003

How does beneficiary knowledge of the Medicare program vary by type of insurance?

BACKGROUND: Prior research found that Medicare beneficiaries' knowledge of the Medicare program varied by the type of supplemental insurance they had. However, none of these studies used both multivariate methods and nationally representative data to examine the issue. OBJECTIVES To measure beneficiary knowledge of the Medicare program and to evaluate how knowledge varies by type of supplemental insurance. RESEARCH DESIGN: A mail survey with telephone follow-up to a nationally representative random sample of Medicare beneficiaries, which had a 76% response rate. The purpose of the study was to evaluate the effects of providing the Medicare & You handbook on beneficiary knowledge, information needs, and health plan decision making. SUBJECTS: A total of 3738 Medicare beneficiaries who completed the survey. MEASURES: A psychometrically validated 22-item index that reflects Medicare-related knowledge in seven different content areas. RESULTS Overall, beneficiaries with a Medicare HMO or non-employer-sponsored supplemental insurance were more knowledgeable about Medicare than those who had Medicare only. In general, beneficiaries tended to be more knowledgeable about issues related to the type of insurance they had (fee-for-service or managed care) than other types of insurance. CONCLUSIONS: Higher levels of knowledge about one's own type of insurance may suggest that beneficiaries learn by experience or they learn more about that type of insurance before enrollment. Further research is needed to better understand how and when beneficiaries learn about insurance and what educational strategies are more effective at increasing knowledge.

Aged↗
PubMed2002

Acute severe asthma: Outcome and Medicaid insurance.

OBJECTIVE: Economically disadvantaged children receive less preventive asthma care and more inpatient care. Studies have not evaluated the association of insurance status on children with severe exacerbations. We evaluated differences in severity of illness, resource use, and outcome associated with Medicaid insurance among children receiving intensive care for asthma. DESIGN: Retrospective cohort study. SETTING: Fourteen American pediatric intensive care units participating in the Pediatric Intensive Care Evaluations database. Methods: Patients with a primary diagnosis of asthma treated from May 1995 to February 2000 were identified. Demographic information and clinical data were evaluated to determine whether there was an association between Medicaid insurance, severity of illness, and length of stay. RESULTS: Twenty-six percent of the children had Medicaid insurance; 22% of children with Medicaid insurance received mechanical ventilation compared with 15% of those with commercial insurance and 16% in a health maintenance organization. After adjustment for severity of illness (Pediatric Risk of Mortality III and use of invasive therapies), Medicaid insurance was significantly associated with increased length of stay in the intensive care unit and hospital. Among children who received mechanical ventilation, patients with Medicaid also received ventilator support significantly longer. CONCLUSIONS: Asthmatic children receiving Medicaid had longer pediatric intensive care unit and hospital stays and an increased risk of mechanical ventilation compared with asthmatic children with commercial or health maintenance organization insurance. Further studies are needed to evaluate differences in outcome and resource utilization for economically disadvantaged asthmatic children.

Journal Article↗
PubMed2006

How does lack of insurance affect use of intensive care? A population-based study.

OBJECTIVE: One in six Americans aged <65 yrs are without health insurance. Although lack of insurance is associated with reduced access to many health services, the relationship between lack of insurance and use of intensive care services is unclear. We sought to compare the use of intensive care by insured and uninsured populations. DESIGN: Retrospective population-based cross-sectional study of five U.S. states (Florida, Massachusetts, New Jersey, New York, and Virginia), analyzing use of hospital and intensive care unit (ICU) services by all residents of these states <65 yrs of age. Data sources included the five 1999 state hospital discharge databases and the 2000 U.S. Census Bureau Current Population Survey. SETTING: Nonfederal hospitals in the five states (all hospitalizations in these during 1999). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 39.3 million and 7.8 million individuals aged 0-64 yrs with and without insurance, respectively, in the five-state sample. The uninsured population was far less likely to be hospitalized (odds ratio [OR], 0.458; 95% confidence interval [CI], 0.456-0.460; p < .001) and to be admitted to the ICU (OR, 0.581, 95% CI: 0.576-0.587, p < .001). Differences persisted irrespective of age, gender, ethnicity, or reason for admission. Among those hospitalized, the uninsured were more likely to receive intensive care (OR, 1.24; 95% CI, 1.22-1.25; p < .01). Hospital mortality rates for patients admitted to the ICU ranged by age from 4.0% to 6.9% for the uninsured and from 2.7% to 5.5% for the insured (OR, 1.12-1.54; p < .01). CONCLUSIONS: Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.

Adolescent↗
PubMed2004

Trust in insurers and access to physicians: associated enrollee behaviors and changes over time.

OBJECTIVE: Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers, and have been cross-sectional rather than longitudinal studies. This study examined associations among trust in a managed care insurer, trust in one's primary physician, and subsequent enrollee behaviors relating to source of care. The study also documents changes in trust in the study population following the disclosure of physician incentives. STUDY SETTING: A medium-sized (300,000 member) HMO, located in the southeastern United States. DATA COLLECTION: One to two years after baseline, we randomly resurveyed a quarter (n = 558) of the initial study population of a large intervention study designed to measure the impact of disclosing HMO financial incentives on patient trust. This follow-up study was also designed to measure the effects of trust on source of care. ANALYSES: Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral, as well as changes in trust since baseline. RESULTS: High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician (OR = 0.55, 95 percent CI: 0.33, 0.91). No long-term effects of prior disclosure of financial incentives were observed. Overall, there was a slight increase in overall trust in the insurer (1.8 percent, p < .05) but no change in trust in one's primary physician. The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey (6.6 percent, p < .01). In multivariate analyses, changing physicians was the most significant predictor of increased insurer trust (OR = 2.17, 95 percent CI: 1.37, 3.43). CONCLUSIONS. Trust in one's insurer seems to change over time more than trust in one's primary physician, and is predictive of enrollee behaviors such as seeking care from other physicians. The ability to change physicians seems to increase trust in the insurer.

Adult↗
PubMed2000

Acute appendicitis risks of complications: age and Medicaid insurance.

OBJECTIVES: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications. DESIGN: Retrospective cohort study. SETTING: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996. METHODS: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation. RESULTS: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days). CONCLUSIONS: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Abdominal Abscess↗
PubMed2004

Health insurance systems in Japan: a neurosurgeon's view.

The health insurance system in Japan is compared to the U.S. system from a neurosurgeon's perspective. The Japanese entire population is enrolled in mandatory health insurance without choice based on employment and residence, called "Health-insurance-for-all." Elderly Health Insurance for senior people aged 70 years or older is set within each health organization. As the relative financial conditions are variable among health insurance organizations, financial adjustment is done. The medical fee is set for all the procedures and products that are paid by health insurance which sets the prices. The same fee schedule applies to both private-practice physicians and hospitals. In the U.S. system, there are numerous fee schedules including both doctor fees and hospital fees. Any extra charges (balance billing) for procedures or materials that are not listed in the fee schedule are strictly prohibited. There is an escape clause that is called the specified medical fee system ("Tokutei Ryoyohi" in Japanese). Some designated items can be exceptionally paid by health insurance fee schedule. Many Japanese neurosurgeons express dissatisfaction with the lack of approval for medical materials which have already been used safely in other countries. The retrospective claim review process includes intermediaries, quasi-public organizations that act as payment makers to providers and claim review boards. Peer-review boards consist of about 8,000 physicians. The billing process itself using the same, uniform fee schedule is very uncomplicated, and has helped to diminish the need for well-trained and well-paid managers, and controlled administrative costs in Japan. Most medical expenses were consumed by a few patients who underwent high-cost medical care. Medical expenditure for the elderly is already taking 1/3 of national health expenditure, and is projected to reach 1/2 of national health expenditure by the year 2025. There is catastrophic coverage for high-cost care or a cap on monthly co-payment spending (High-Priced Medical Fee system: Kogaku Ryoyohi Seido). To maintain reliable and stable medical insurance systems in the aging society with fewer children in the 21st century, it is essential that fundamental reform is introduced across all systems.

Humans↗
PubMed2002

Diabetes in employer-sponsored health insurance.

OBJECTIVE: To examine medical and mental health care expenditures for large numbers of individuals with diabetes enrolled in employment-sponsored insurance plans. RESEARCH DESIGN AND METHODS: Health insurance billing data for approximately 1.3 million individuals enrolled in health insurance plans sponsored by 862 large self-insured employers nationwide were used to examine employer expenditures and consumer out-of-pocket payments for 20,937 people identified with diabetes. These expenditures were compared with expenditures for individuals with other chronic illnesses. Main outcome measures were covered charges, insurance plan reimbursements, and estimated consumer out-of-pocket payments for both medical and mental health services. RESULTS: A total of 1.7% of enrollees were identified as having diabetes and approximately 11% of those used at least one mental health service during 1996. Health care expenditures were three times higher for those with diabetes compared with all health care consumers in these insurance plans, but when compared with individuals with other chronic illnesses such as heart disease, HIV/AIDS, cancer, and asthma, those with diabetes were not more expensive for employers' insurance plans. Diabetes accounts for 6.5% of total health plan expenditures. CONCLUSIONS: Diabetes is not more expensive for either consumers or their employer-sponsored insurance plans than other chronic illnesses.

Age Factors↗
PubMed2003

Support for national health insurance among U.S. physicians: a national survey.

BACKGROUND: Nearly 40 million persons in the United States were without health insurance for all of 2000. National health insurance would remedy this situation, and many believe the success of reform efforts in this direction may depend on physician support. OBJECTIVE: To determine the general attitudes of U.S. physicians toward the financing of national health care. DESIGN: Cross-sectional study. SETTING: National mailed survey. PARTICIPANTS: 3188 randomly sampled physicians from the American Medical Association Physician Masterfile. MEASUREMENTS: Physicians were asked whether they support or oppose 1) governmental legislation to establish national health insurance and 2) a national health insurance plan in which all health care is paid for by the federal government. Weighted multivariate logistic regression analyses were performed to identify factors that independently predicted support for each of these strategies. RESULTS: Sixty percent of eligible participants returned a survey. Forty-nine percent of physicians supported governmental legislation to establish national health insurance, and 40% opposed it. Only 26% of all physicians supported a national health insurance plan in which all health care is paid for by the federal government. In analyses adjusting for differences in personal and practice characteristics, physicians in a primary care specialty, physicians reporting that at least 20% of their patients had Medicaid, and physicians practicing in a nonprivate setting or in an inner-city location were statistically significantly more likely to support governmental legislation to establish national health insurance. CONCLUSIONS: A plurality of U.S. physicians supports governmental legislation to establish national health insurance. This support may be relevant to the success of future efforts to reform national health care.

Attitude of Health Personnel↗
PubMed2001

To offer or not to offer: the role of price in employers' health insurance decisions.

OBJECTIVE: To estimate the effect of changes in price on employers' decisions to offer health insurance. DATA SOURCES/STUDY SETTING: A 1993 survey of 22,347 private employers in ten states was used. STUDY DESIGN: Probit regression was used to estimate the probability of offering insurance as a function of the price and employer characteristics. For employers who did not offer insurance, a price cannot be directly observed. We estimated price for nonofferors using reported quotes received by recent shoppers and a selection model to correct for differences between recent shoppers and nonshoppers. PRINCIPAL FINDINGS: Changes in price affect decisions to offer insurance; however, even a 40 percent reduction in premiums would lead to only a 2 to 3 percentage point increase in the share of employers offering insurance. Employers of low-wage workers are substantially less likely to offer health insurance than other employers. CONCLUSIONS: Policies to reduce the number of uninsured that focus on increasing the supply of employment-based insurance are unlikely to have the intended effect unless coupled with policies to help low-wage workers afford insurance.

Data Collection↗
PubMed2002

A comparison of ambulatory services for patients with managed care and fee-for-service insurance.

OBJECTIVES: To determine whether family physicians provide different ambulatory care to patients with health insurance from managed care organization (MCO) versus fee-for-service (FFS) plans. STUDY DESIGN: Multimethod cross-sectional observational study. PATIENTS AND METHODS: A total of 4454 patients made office visits to 138 family physicians in northeastern Ohio. Direct observation with the Davis Observation Code and a structured checklist were used to assess the process of care. Patient satisfaction was measured with the Medical Outcomes Study 9-Item Visit Rating Form. RESULTS: Among 1588 patients with MCO insurance and 876 with FFS insurance, no differences were noted in the number of visits per year, length of visits, percentage of visits for well care, or the percentage of visits in which medicines were prescribed in analyses controlling for patient mix. Visits by patients with MCO insurance were more likely to involve referrals to another physician than visits by patients with FFS insurance. Patient satisfaction and time use during visits were comparable for the 2 groups. CONCLUSIONS: Managed care insurance appears to increase involvement of the primary care provider in the referral process. However, in a healthcare market with moderate managed care penetration in which the same physicians see patients with different types of insurance, the process of care is affected little by type of insurance coverage.

Adult↗
PubMed1999

The dilemmas of incrementalism: logical and political constraints in the design of health insurance reforms.

Health care reform became a premier issue on the U.S. policy agenda in the 1990s. While the comprehensive proposal put forth by President Clinton failed, states and the federal government successfully pursued a variety of lesser initiatives. This article focuses on a set of reforms intended to make private health insurance more accessible and affordable to individuals and workers in small firms. It outlines the key arguments made by experts to justify stronger regulation of health insurance and the options and difficult tradeoffs that must be considered in policy design. It then examines the scope and strength of legislation adopted by 45 states and the federal government from 1990 to 1996. The substantial variation in state policies demonstrates that even though insurance market reform was the one issue that commanded nearly universal support in the health care debate, few design features were universally accepted by those who crafted the reforms. The article concludes by assessing the pattern of state and federal action. The reforms represent some progress on nominal access to insurance but little progress on the affordability of insurance for individuals and small groups. Few of the reforms present a serious challenge to existing practices and interests of the insurance industry. This pattern of policy design reflects the logical and political constraints of incrementalism. In a system where insurance coverage is voluntary, changes to increase access for one group tend to increase costs and thereby decrease access for another segment of the population. In addition, because incremental reforms will not attract sustained attention and support from the general public, it is politically difficult to impose substantial new regulation on a powerful industry.

Group Purchasing↗