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PubMed1996

[Use of dental services and the percentage of persons possessing private dental insurance in Québec].

The utilization of dental health services and the percentage of adult members of a private health dental insurance plan are generally lower in Quebec than in the other Canadian provinces. In this study, results of a telephone survey of a representative sample of Quebec adults aged 18 and over (N = 8,042) show that 58 per cent of interviewed individuals visited a dentist (53 per cent) or a denturologist (five per cent) during the 12 months preceeding the interview. A multivariate analysis indicates that the most strongly associated factors related to the utilization of dental health services are, in decreasing order, edentulousness, income and level of education. About one third (36 per cent) of those surveyed had dental insurance coverage. Age and income are the most strongly associated factors concerning the membership to a dental health insurance plan. Finally, among those with dental insurance coverage, 71 per cent had visited a dentist or a denturologist during the last 12 months compared to 51 per cent of those not insured.

Adolescent↗
PubMed2005

Feasible economic strategies to improve screening compliance for colorectal cancer in Korea.

AIM: While colorectal cancer (CRC) is an ideal target for population screening, physician and patient attitudes contribute to low levels of screening uptake. This study was carried out to find feasible economic strategies to improve the CRC screening compliance in Korea. METHODS: The natural history of a simulated cohort of 50-year-old Korean in the general population was modeled with CRC screening until the age of 80 years. Cases of positive results were worked up with colonoscopy. After polypectomy, colonoscopy was repeated every 3 years. Baseline screening compliance without insurance coverage by the national health insurance (NHI) was assumed to be 30%. If NHI covered the CRC screening or the reimbursement of screening to physicians increased, the compliance was assumed to increase. We evaluated 16 different CRC screening strategies based on Markov model. RESULTS: When the NHI did not cover the screening and compliance was 30%, non-dominated strategies were colonoscopy every 5 years (COL5) and colonoscopy every 3 years (COL3). In all scenarios of various compliance rates with raised coverage of the NHI and increased reimbursement of colonoscopy, COL10, COL5 and COL3 were non-dominated strategies, and COL10 had lower or minimal incremental medical cost and financial burden on the NHI than the strategy of no screening. These results were stable with sensitivity analyses. CONCLUSION: Economic strategies for promoting screening compliance can be accompanied by expanding insurance coverage by the NHI and by increasing reimbursement for CRC screening to providers. COL10 was a cost-effective and cost saving screening strategy for CRC in Korea.

Aged↗
PubMed2004

Estimating the compensating differential for employer-provided health insurance.

The theory of wage differentials argues that workers must pay for employer-provided group health insurance coverage through lower wages or reductions in other fringe benefits. This paper uses data from the 1988-90 Consumer Expenditure Survey (CEX) to estimate the wage-health insurance trade-off for male workers between the ages of 25 and 55. A fixed-effects model, which takes advantage of the rotating panel design of the CEX, is used to control for unobservable worker characteristics that are positively related with all forms of compensation, including wage earnings and health insurance coverage. I find a compensating differential for health insurance equal to roughly 10 to 11 percent of wages. Some caution is advised here due to the fact that I was unable to control for other fringe benefits, the most important being paid vacation and sick leave.

Adult↗
PubMed1995

Medicare coverage, supplemental insurance, and the use of mammography by older women.

BACKGROUND: On January 1, 1991, the Medicare program began offering reimbursement for screening mammography every two years. This study examined the use of mammography in women covered by Medicare during the first two years that the screening benefit was offered. METHODS: Medicare bills for 1991 and 1992 from a nationally representative sample of 4110 women 65 years of age or older were examined to determine the degree of compliance with recognized guidelines for screening mammography and the extent to which the use of mammography was associated with having supplemental insurance, which shields patients from the out-of-pocket costs associated with using Medicare benefits. RESULTS: A total of 36.9 percent of older U.S. women had mammography during the first two years of the Medicare benefit for screening mammography. Only 14.4 percent of the women lacking supplemental insurance had mammography, as compared with 44.7 percent of those with employer-sponsored supplemental insurance, 40.1 percent of those with self-purchased supplemental insurance, and 23.9 percent of those with Medicaid supplemental insurance. These differences persisted in the stratified and multivariate analyses. As compared with women lacking supplemental insurance, women with employment-based supplemental insurance were more likely to undergo mammography (adjusted odds ratio, 3.03; 95 percent confidence interval, 2.17 to 4.23), as were women with self-purchased supplemental insurance (adjusted odds ratio, 2.97; 95 percent confidence interval, 2.13 to 4.15) and women with Medicaid supplemental insurance (adjusted odds ratio, 1.99; 95 percent confidence interval, 1.30 to 3.07). CONCLUSIONS: The use of mammography was substantially below recommended levels during the first two years of Medicare coverage for screening mammography. Women lacking supplemental health insurance were at particularly high risk of failing to undergo mammography. Requiring copayments for preventive services is an obstacle to the effective mass screening of older women for breast cancer.

Aged↗
PubMedDate not supplied

Are subsidies enough to encourage the uninsured to purchase health insurance? An analysis of underlying behavior.

A growing concern over gaps in health insurance coverage has led to proposals for reform. Some proposals rely on incentives to encourage the purchase of private health insurance, while others rely on mandatory purchase. This paper explores families' demand for private health insurance, with an emphasis on lower income families, in order to understand the factors that affect purchasing decisions. The study uses data from the 1977 National Medical Care Expenditure Survey to show which factors are important in determining whether or not families purchase private health insurance as well as the quantity of insurance purchased. Results indicate that it is the combination of income, price, and substitutes for private health insurance that impact families' decision to purchase private health insurance. As long as a safety net of substitutes exists for low-income families, subsidies may not be enough to encourage more extensive private health insurance coverage.

Costs and Cost Analysis↗
PubMed2006

Summary health statistics for U.S. children: National Health Interview Survey, 2004.

OBJECTIVES: This report presents both age-adjusted and unadjusted statistics from the 2004 National Health Interview Survey (NHIS) on selected health measures for children under 18 years of age, classified by sex, age, race, Hispanic origin, family structure, parent's education, family income, poverty status, health insurance coverage, place of residence, region, and current health status. The topics covered are asthma, allergies, learning disability and Attention Deficit Hyperactivity Disorder (ADHD), prescription medication use, respondent-assessed health status, school-loss days, usual place of health care, time since last contact with a health care professional, selected measures of health care access and utilization, and dental care. SOURCE OF DATA: The NHIS is a multistage probability sample survey conducted annually by interviewers of the U. S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics and is representative of the civilian noninstitutionalized population of the United States. Data are collected for all family members during face-to-face interviews with adults present at the time of interview. Additional information about children is collected for one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child's health. SELECTED HIGHLIGHTS: In 2004, most U.S. children under 18 years of age had excellent or very good health (82%). However, 9% of children had no health insurance coverage, and 5% of children had no usual place of health care. Twelve percent of children had ever been diagnosed with asthma. An estimated 8% of children 3-17 years of age had a learning disability, and an estimated 7% of children had ADHD.

Adolescent↗
PubMed2006

Summary health statistics for U.S. children: National Health Interview Survey, 2005.

OBJECTIVES: This report presents both age-adjusted and unadjusted statistics from the 2005 National Health Interview Survey (NHIS) on selected health measures for children under 18 years of age, classified by sex, age, race, Hispanic origin, family structure, parent education, family income, poverty status, health insurance coverage, place of residence, region, and current health status. The topics covered are asthma, allergies, learning disability, Attention Deficit Hyperactivity Disorder (ADHD), prescription medication use, respondent-assessed health status, school-loss days, usual place of health care, time since last contact with a health care professional, selected measures of health care access and utilization, and dental care. SOURCE OF DATA: NHIS is a multistage probability sample survey conducted annually by interviewers of the U.S. Census Bureau for the Centers for Disease Control and Prevention's National Center for Health Statistics and is representative of the civilian noninstitutionalized population of the United States. Data are collected for all family members during face-to-face interviews with adults present at the time of interview. Additional information about children is collected for one randomly selected child per family in face-to-face interviews with an adult proxy respondent familiar with the child's health. SELECTED HIGHLIGHTS: In 2005, most U.S. children under 18 years of age had excellent or very good health (82%). However, 9% of children had no health insurance coverage, and 5% of children had no usual place of health care. Thirteen percent of children had ever been diagnosed with asthma. An estimated 7% of children 3-17 years of age had a diagnosed learning disability, and an estimated 7% of children had ADHD.

Adolescent↗
PubMed1997

The potential role of risk-equalization mechanisms in health insurance: the case of South Africa.

International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.

Actuarial Analysis↗
PubMed1997

Small group reform in a competitive managed care market: the case of California, 1993 to 1995.

State-level insurance reforms designed to make health insurance more accessible for small businesses and their employees have become common in the 1990s. This study examines the effects of small group reform legislation enacted in California in 1993. Using survey data on health benefits in small firms, we look at changes in health insurance coverage that occurred between spring 1993 (just before reform) and spring 1995. Our results indicate that insurance became slightly more affordable and, among businesses with three to nine employees, employer provision increased more than 10 percentage points. Provision was unchanged among larger-sized businesses, however. Managed care penetration increased considerably. We argue that California's competitive health insurance market, which already was dominated by managed care, represented a favorable environment for small group reform. In this context, the modest growth in insurance provision highlights the limited potential of incremental reforms for expanding insurance coverage.

California↗
PubMed1995

Insurance adjudication favoring prophylactic surgery in hereditary breast-ovarian cancer syndrome.

Insurance payment to cover costs of prophylactic surgery is occasionally denied to patients who may be at inordinately high risk for hereditary cancer. We describe a 43-year-old woman from a hereditary breast-ovarian cancer (HBOC) family which showed linkage to BRCA1 and who was at inordinately high risk for cancer but who was denied insurance coverage for prophylactic oophorectomy, despite strong recommendations by her gynecologist and a cancer geneticist-medical oncologist. The insurance company claimed that the surgery was not medically necessary because the woman's condition (hereditary cancer predisposition) was not an illness. A summary judgment issued by the Douglas County (Nebraska) District Court ruled in favor of the denial decision of Blue Cross/Blue Shield. But on appeal, the Nebraska Supreme Court offered the conclusion that the patient did in fact require this prophylactic surgery and overruled the District Court's decision for denial. The litigation provides the basis for this case report and may provide a precedent for insurance coverage for patients at high risk for hereditary forms of cancer.

Adult↗
PubMed2003

Racial variations in dental procedures: the case of root canal therapy versus tooth extraction.

BACKGROUND: Racial disparities have been widely documented in medical care, but variations in dental care have not been well examined. OBJECTIVES: To determine if there is racial variation in use of root canal therapy versus tooth extraction across different levels of dental insurance coverage and adjusting for other factors known to influence treatment decisions. METHODS: Within 3 different categories of insurance coverage, we examined whether there were racial differences in the provision of the tooth-sparing treatment of root canal therapy (vs. tooth extraction) among 54,423 users of outpatient Veterans Affairs dental care in 1998. Regression analyses adjusted for the severity of tooth- and gum-related disease, age, sex, medical and psychiatric comorbidities, prior use of preventive dental services, tooth extraction and root canal therapy, and clustering by geographic region. RESULTS: In the adjusted regression models, black patients and those with unknown race were less likely overall to receive root canal therapy than whites, whereas Asians were more likely. Among patients with eligibility for continuing and comprehensive dental care, blacks were less likely and Asians more likely to receive root canals than whites. For patients covered only for emergency dental care, Hispanics had a higher likelihood of receiving root canal therapy. Among all other types of coverage, there were no significant racial differences in the care received. CONCLUSION: We observed substantial racial variations in the provision of root canal therapy among patients treated in Department of Veterans Affairs dental clinics. Future research should identify the causes of such variations.

Black or African American↗
PubMedDate not supplied

Direct reimbursement of nurse practitioners in health insurance plans of research universities.

The purpose of this study was to explore the nature of health insurance coverage research universities offer their employees and the extent to which these employers offer options providing for reimbursement of services of independent nurse practitioners. A request for health insurance documents mailed to 77 public research universities resulted in a response rate of 83 per cent. A total of 75 per cent sent usable descriptions of insurance coverage for analysis. Among the respondents, 69 per cent (n = 40) reported offering insurance through Blue Cross/Blue Shield companies. Nursing services reimbursed generally included traditional nursing care such as private duty nursing and home health care. Coverage of nursing services that overlap with traditional medical practice, such as prenatal care and labor and delivery services of nurse midwives, anesthesia services of nurse anesthetists, psychiatric services of nurse specialists, and primary care nursing services of nurse practitioners, was less evident. Findings generally indicated that in spite of the presence of enabling or mandatory state legislation for third-party reimbursement of nursing services, legislation is not being implemented in many states by employers in their purchase of group policies.

Data Collection↗
PubMed2000

Gaining and losing health insurance: strengthening the evidence for effects on access to care and health outcomes.

This study uses longitudinal data to examine the consequences of losing and gaining health insurance coverage for access to care and health. For both Medicaid and privately insured persons, compared with those who remained insured, persons losing coverage over a 2-year period were more likely to lack a usual source of care, encounter difficulty in obtaining medical care, be very dissatisfied with ability to obtain needed care, and report no physician visits in the previous 12 months. Uninsured people who gained coverage showed improvement across all indicators of access, in contrast to those who remained without insurance. The effects of changes in coverage on health were in the same direction as those for access, but did not reach statistical significance. This study strengthens the evidence that health insurance coverage has a substantial impact on ability to gain access to medical care and may affect health status.

Health Services Accessibility↗
PubMed2001

Coverage of smoking cessation treatment by union health and welfare funds.

OBJECTIVES: This study determined the level of insurance coverage for smoking cessation treatment and factors associated with coverage among health and welfare funds affiliated with a large labor union. METHODS: A self-administered written survey was mailed to fund and union officials. Analyses were conducted by chi2 tests. RESULTS: Twenty-nine percent of funds provided coverage for some type of smoking cessation treatment, with the odds of coverage significantly increased among funds whose administrators reported having received members' requests for smoking cessation treatment in the past year (odds ratio = 4.9, P = .05). CONCLUSIONS: Coverage for smoking cessation services is low, comparable to coverage offered by other health insurers. Interventions with union members and fund officials are needed to provide union members with access to affordable and effective smoking cessation treatments.

Administrative Personnel↗
PubMedDate not supplied

Complementary and alternative provider use by insured patients with diabetes in Washington State.

OBJECTIVES: The authors investigated whether insurance coverage for complementary and alternative medicine (CAM) providers is associated with increased medical care use among diabetes patients. Predictors of CAM use and how CAM affects health care use and expenditures under insurance coverage were examined. DESIGN: Claims data from two large insurers in Washington State were obtained for 2002. Types of providers used, comorbid medical conditions, number of visits, and expenditures were calculated for the study sample and compared to a nondiabetic matched group. RESULTS: Of the 20,722 adults with diabetes, 3605 (17.4%) had one or more visits to any licensed CAM provider (mostly chiropractors). This was lower than the 20% CAM use in the comparison group. Diabetes patients who used CAM were more likely to have multiple other medical problems than CAM nonusers. CAM users had a higher average number of annual outpatient visits compared to nonusers (28 versus 16), and higher average annual expenditures (8,736 dollars versus 7,356 dollars); however, after adjustment for disease load and other factors, CAM use was not a significant predictor of expenditures. CAM use was <2% of the overall mean medical expenditures for diabetes patients. Quality of conventional care was similar for CAM users and nonusers. CONCLUSIONS: CAM provider usage when covered by insurance is lower among diabetes patients than in adults without diabetes and represents a small proportion of diabetes care costs. Very few CAM visits were related directly to diabetes care. CAM-using patients often have heavy disease burdens and high total expected resource use compared to those not using CAM.

Adult↗
PubMed2004

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey.

OBJECTIVE: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. DESIGN: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. RESULTS: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. CONCLUSIONS: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.

Data Collection↗
PubMed2000

Uninsured status and out-of-pocket costs at midlife.

OBJECTIVE: To investigate how baseline health insurance coverage affects subsequent out-of-pocket costs and utilization of health services over a two-year period. DATA SOURCE: The first two waves of the Health and Retirement Study, a nationally representative survey of the noninstitutionalized population, ages 51 to 61 at baseline. Interviews were conducted in 1992 and 1994. Our sample consisted of 7,018 respondents who did not report public insurance as their sole source of coverage at baseline. STUDY DESIGN: We compared self-reports of physician visits, hospitalizations, and out-of-pocket health care costs, measured as payments to physicians, hospitals, and nursing homes, by type of insurance coverage at the beginning of the period. We estimated multivariate models of costs and service use to control for individual health, demographic, and economic characteristics and employed instrumental variable techniques to account for the endogeneity of insurance coverage. PRINCIPAL FINDINGS: Controlling for personal characteristics and accounting for the endogeneity of insurance coverage, persons at midlife with job-related health benefits went on to spend only about $50 per year less in out-of-pocket payments for health services than persons who lacked health insurance at the beginning of the period. However, they spent about $650 more per year in insurance premiums than the uninsured. The uninsured used relatively few health services, except when they were seriously ill, in which case they were likely to acquire public insurance. CONCLUSIONS: The medically uninsured appear to avoid substantial out-of-pocket health care costs by using relatively few health services when they are not seriously ill, and then relying upon health care safety nets when they experience medical problems. These results suggest that the main impact of non-insurance at midlife is not to place the locus of responsibility for costly health care upon individuals. Instead, it discourages routine care and transfers the costs of care for severe health events to other payers. Our findings on the high cost of employment-based coverage are consistent with evidence that the proportion of workers accepting health benefits from employers has been declining in recent years.

Age Factors↗
PubMed2000

Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older.

BACKGROUND: This study examined screening utilization at least once and regular adherence to mammography, clinical breast exam, and breast self-exam among older Chinese-American women. METHOD: One hundred women were recruited from senior centers in two metropolitan cities. Participants completed a questionnaire that included sections on demographics, health history, health insurance coverage, breast cancer screening, common and cultural barriers to screening, and acculturation. RESULTS: Logistic regression models found insurance coverage for mammography and acculturation to be significant predictors of having had a mammogram at least once. Low perceived need/lack of physician recommendation and recency of physical examination were significant predictors of having had a mammogram in the past year. Acculturation and modesty were significant predictors of having had a clinical breast exam at least once, while recency of physical examination was a significant predictor of having had a clinical breast exam in the past year. Reliance on medial professionals for screening and forgetting were significant predictors of having performed breast self-exam at least once, and forgetting was a significant predictor of regular performance of breast self-exam. CONCLUSIONS: These findings suggest that both common and cultural barriers play a role in breast cancer screening among older Chinese-American women, with cultural factors being more influential in the initiation of cancer screening behavior.

Acculturation↗