[Insurance law coverage of patients and healthy persons in clinical trials].
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Simple truths about America's uninsured.
Nurses deal with the fallout of a nation with more than 46 million uninsured. Affecting the patients and families they care for, the hospitals and clinics they work in and manage, and the communities they serve, nurses have a credible standing from which to debunk any myths about who the uninsured are, why they are uninsured, and the difference that health insurance makes in their health and well-being. This article on the uninsured and health insurance coverage among low-income Americans outlines key facts about the uninsured and the primary cause of the problem--the affordability of health insurance.
Health Benefit Plans, Employee↗
Who are the uninsured elderly in the United States?
Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.
Activities of Daily Living↗
Effects of health insurance and race on early detection of cancer.
BACKGROUND: The presence and type of health insurance may be an important determinant of cancer stage at diagnosis. To determine whether previously observed racial differences in stage of cancer at diagnosis may be explained partly by differences in insurance coverage, we studied all patients with incident cases of melanoma or colorectal, breast, or prostate cancer in Florida in 1994 for whom the stage at diagnosis and insurance status were known. METHODS: The effects of insurance and race on the odds of a late stage (regional or distant) diagnosis were examined by adjusting for an individual's age, sex, marital status, education, income, and comorbidity. All P values are two-sided. RESULTS: Data from 28 237 patients were analyzed. Persons who were uninsured were more likely diagnosed at a late stage (colorectal cancer odds ratio [OR] = 1.67, P =.004; melanoma OR = 2.59, P =.004; breast cancer OR = 1.43, P =.001; prostate cancer OR = 1.47, P =.02) than were persons with commercial indemnity insurance. Patients insured by Medicaid were more likely diagnosed at a late stage of breast cancer (OR = 1.87, P<.001) and melanoma (OR = 4.69, P<.001). Non-Hispanic African-American patients were more likely diagnosed with late stage breast and prostate cancers than were non-Hispanic whites. Hispanic patients were more likely to be diagnosed with late stage breast cancer but less likely to be diagnosed with late stage prostate cancer. CONCLUSIONS: Persons lacking health insurance and persons insured by Medicaid are more likely diagnosed with late stage cancer at diverse sites, and efforts to improve access to cancer-screening services are warranted for these groups. Racial differences in stage at diagnosis are not explained by insurance coverage or socioeconomic status.
Aged↗
A clinic-based mammography intervention targeting inner-city women.
OBJECTIVE: The objective was to evaluate the effect of a clinic-based intervention program on mammography use by inner-city women. DESIGN: A randomized controlled trial employing firm system methodology was conducted. SETTING: The study setting was a general internal medicine clinic in the university-affiliated county hospital serving metropolitan Seattle. PARTICIPANTS: Women aged 50 to 74 years with at least one routine clinic appointment (when they were due for mammography) during the study period were enrolled in the trial (n = 314). INTERVENTIONS: The intervention program emphasized nursing involvement and included physician education, provider prompts, use of audiovisual and printed patient education materials, transportation assistance in the form of bus passes, preappointment telephone or postcard reminders, and rescheduling assistance. Control firm women received usual care. MEASUREMENTS AND MAIN RESULTS: Mammography completion within 8 weeks of clinic visits was significantly higher among intervention (49%) than control (22%) firm women (p < .001). These effects persisted after adjustment for potential confounding by age, race, medical insurance coverage, and previous mammography experience at the hospital (odds ratio 3.5; 95% confidence interval 1.9, 6.5). The intervention effect was modified by type of insurance coverage as well as prior mammography history. Process evaluation indicated that bus passes and rescheduling efforts did not contribute to the observed increases in screening participation. CONCLUSIONS: A clinic-based program incorporating physician education, provider prompts, patient education materials, and appointment reminders and emphasizing nursing involvement can facilitate adherence to breast cancer screening guidelines among inner-city women.
Adult↗
Physician attitudes toward human growth hormone products.
A national survey of the attitudes of physicians toward the selection of human growth hormone products and factors affecting physicians' prescribing decisions was conducted. A survey was mailed to 800 pediatric endocrinologists. Recipients were asked to rank eight qualities of human growth hormone therapy from a patient's perspective, to rate the importance of each of 15 factors to the prescribing of human growth hormone products, and to respond to a hypothetical clinical situation set up to assess opinions on the interchangeability of human growth hormone products. The physicians were also asked whether they thought all human growth hormone products were clinically equivalent and, if so, whether a formulary should be limited to one brand of product for all indications. The net response rate was 29%. Physicians ranked insurance coverage and out-of-pocket expenses as the most important factors from the patient's perspective and reported efficacy, patient comfort or compliance, insurance coverage, and drug cost as the most important factors to consider when selecting a human growth hormone product; patient preference was reported to be the least important. A total of 209 physicians (92%) considered all human growth hormone products to be clinically equivalent; not quite half of these favored limiting a formulary to one brand of product. Concerning the hypothetical situation, 210 of 226 (93%) respondents indicated that they would not switch all patients receiving one product (product A) to another product (product B) and 192 of 223 (86%) that they would not switch all patients receiving product B to product A. A national sample of pediatric endocrinologists agreed on the clinical equivalence of most human growth hormone products but not on limiting a formulary to one brand of product.
Attitude of Health Personnel↗
Barriers to employment following renal transplantation: implications for the social work professional.
The biopsychosocial model was used to analyze data from an open-ended item in a survey of individuals following kidney transplantation. After sending surveys to kidney transplant recipients at a large, Midwestern teaching hospital, this work analyzed the themes that emerged from an inquiry into factors that affected their ability to return to work or switch jobs. The results revealed that concerns reflecting biological/ psychological factors were most frequently indicated followed by social concerns. That is, the majority of the responses were related to a physical disorder or condition (biological) that appeared to have been directly related to a psychological response to it. This was followed by social concerns primarily related to health insurance. Thus, the researchers involved in this study conclude that social workers in health care must: (1) consistently embrace the assumptions of the biopsychosocial model so that the most inclusive assessments and interventions can be rendered, while (2) remaining knowledgeable regarding legislative changes that impact health insurance coverage for this specific population.
Adult↗
Publicly subsidized health insurance: a typology of state approaches.
Using information from case studies, published documents, and the Current Population Survey, this paper describes and classifies state approaches to providing health insurance to low-income populations (as of 1997). It examines the link between the scope of state efforts and uninsurance rates for low-income populations. Findings indicate that the breadth of state policies contributes to differences in insurance coverage for low-income persons across states.
Eligibility Determination↗
Reimbursement for dental implants: dispelling some popular myths.
BACKGROUND AND OVERVIEW: Dental implants are being placed with increasing regularity. Many dentists do not take advantage of insurance coverages for this treatment because they are under the impression that no aspect of implant therapy is covered. This article discusses a number of insurance benefits that may be available to dental patients but not readily apparent to treating dentists and their staff members. CONCLUSIONS AND PRACTICE IMPLICATIONS: Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not consider implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Knowing that some reimbursement is available may make the difference in the patient's accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they deserve to know their options and to receive appropriate benefits.
Current Procedural Terminology↗
Demographic and social trends affecting the health of children in the United States.
This article provides information on key demographic, social, and economic characteristics of children in the United States that affect the child's health and access to health insurance. The data, drawn principally from the March 1999 supplement to the Current Population Survey (CPS), focus on racial/ethnic groups and generational categories (i.e., immigrants, US natives with foreign-born parents, and US natives with native parents). The article investigates the relationship of socioeconomic status, race/ethnicity, and generation to self-reported health status, health insurance coverage, and use of Medicaid. In general, racial/ethnic minority children and children of immigrants report being in worse health and are less likely to have health insurance than are white, non-Hispanic children and children of US natives. However, much of the difference can be explained by income differences across the racial/ethnic and generation groups. Citizenship of a child's parents is also a key factor in health insurance coverage. The article closes with a discussion of how likely demographic trends over the next 10-25 years may affect these factors, especially noting the competing demands of children and the elderly on the future working-age population.
Adolescent↗
The financing and regulation of medical devices in the United States.
This paper focuses on two major areas of US federal policy that relate to medical devices, regulations regarding premarketing approval and arrangements for financing the use of devices. Other relevant areas, such as patents, liability, and taxation, are discussed more briefly. In 1976 legislation authorized the federal Food and Drug Administration (FDA) to require manufacturers of medical devices to show that their products meet acceptable levels of safety and effectiveness. FDA has classified each device into one of three classes according to the extent of regulation needed to ensure safety and effectiveness. Although all devices must conform to general manufacturing controls and some to premarketing approval, no performance standards have yet been developed. About two-thirds of all expenditures for medical care in the United States are paid by private or public insurers. Although procedures vary for institutional and individual providers, payment is usually made after the medical care has been provided and covers the provider's costs or charges. Prevailing insurance coverage and payment methods contain incentives for the innovation and use of medical devices that are part of mainstream medical care. At the same time, these financial arrangements discourage preventive and rehabilitative devices, which are generally excluded from insurance coverage.
Cost Control↗
ACOG Committee Opinion No. 308. The uninsured.
The United States is one of the.few industrialized nations in the world that does not guarantee access to health care for its population. Access to health care for all women is a paramount concern of obstetrician-gynecologists and the American College of Obstetricians and Gynecologists. Lack of health care coverage creates access issues that affect women, practitioners, and the health care system as a whole. The number of women in the United States without health care coverage grew 3 times faster than the number of men without such coverage during the late 1990s and early 2000s. A change in our currently fragmented health care system is warranted because the lack of coverage clearly matters to the millions of uninsured Americans. Pregnant women and infants are among the most vulnerable populations in the country and the American College of Obstetricians and Gynecologists believes that providing them with fill insurance coverage must be a primary step in the process of providing coverage for all Americans. However, it is only the first step; it is critical to expand coverage for all Americans. Health professionals can play a pivotal role in improving access to needed health care by helping society understand the importance of broadening health insurance coverage.
Female↗
Access to health care for children and adolescents in working poor families: recent findings from California.
BACKGROUND: Children in working poor families are among the most disadvantaged, yet little is known about barriers to care for these children. OBJECTIVES: We sought to compare health care access and use by children from working poor families with other poor and nonpoor children and consider the extent to which expansions in public health insurance have contributed to increased access in California. METHODS: This was cross-sectional study using data from the 2001 California Health Interview Survey, a representative telephone survey. Using this survey, we were able to include 16,528 children younger than the age of 18 in our analysis. We measured financial and nonfinancial access to health care and service use. RESULTS: Children in working poor families had higher odds of being uninsured (adjusted odds ratio 2.9, 95% confidence interval 2.0, 4.1; adjusted odds ratio 3.7, 95% confidence interval 2.9, 4.8, respectively) compared with children in nonworking poor/TANF and nonpoor families. Disparities in nonfinancial access and use between the working poor and nonworking poor narrowed considerably when controlling for insurance and other covariates. Compared with nonpoor children, disparities in access were wider. The largest disparities in use were in dental care. After controlling for insurance and other covariates, disparities remained. CONCLUSIONS: Despite public insurance expansions, particularly through Healthy Families, disparities in insurance coverage between the working poor and other poor and nonpoor children remain, placing children of the working poor at a disadvantage for access and use. Insurance coverage expansions must be protected and coupled with continued efforts to narrow nonfinancial barriers to care.
Adolescent↗
Smoking cessation services offered by health insurance plans for Wisconsin state employees.
Health insurance plans for state of Wisconsin employees were surveyed regarding the smoking cessation benefits offered to their members. Seven of the 25 plans (28%) cover some form of cessation treatment. Those plans that cover smoking cessation services differ substantially in the scope of benefits, and some have limitations and exclusions. These results suggest that smokers in Wisconsin are offered only limited insurance coverage for effective smoking cessation treatments.
Humans↗
Injuries among older Americans with and without Medicare.
OBJECTIVES: We evaluated the generalizability of Medicare fee-for-service data for patients hospitalized with injuries. METHODS: We used 1998-2000 Medicare hospitalization data and National Hospital Discharge Survey (NHDS) data to analyze patients aged 65 years and older with principal injury diagnoses. RESULTS: Demographics and injury patterns were similar in Medicare data and NHDS Medicare data. Injured patients without Medicare or health maintenance organization coverage were younger, less likely to have hip fractures, and more likely to have head or chest injuries. Mortality and discharge to long-term care were not significantly affected by insurance coverage, after we controlled for injury type and severity, age, gender, and comorbidity. Medicare patients had slightly longer hospital lengths of stay. CONCLUSIONS: Hospital outcomes are generally similar among older patients with a given anatomic injury, regardless of insurance coverage.
Age Factors↗
Aid to people with disabilities: Medicaid's growing role.
Medicaid is the nation's largest health care program providing assistance with health and long-term care services for millions of low-income Americans, including people with chronic illness and severe disabilities. This article traces the evolution of Medicaid's now-substantial role for people with disabilities; assesses Medicaid's contributions over the last four decades to improving health insurance coverage, access to care, and the delivery of care; and examines the program's future challenges as a source of assistance to children and adults with disabilities. Medicaid has shown that it is an important source of health insurance coverage for this population, people for whom private coverage is often unavailable or unaffordable, substantially expanding coverage and helping to reduce the disparities in access to care between the low-income population and the privately insured.
Adult↗
Substitution of physicians and other providers in outpatient mental health care.
This paper evaluates the extent to which patients may substitute physician and non-physician outpatient mental health services in response to insurance coverage which differs by provider type. Using data from the National Medical Expenditure Survey, a semi-flexible two-stage demand specification is used to estimate substitution elasticities. Our results indicate that insurance coverage significantly affects the choice of provider from whom care is sought and, for individuals who seek care from both provider types, that physician and non-physician services are substitutes. Our elasticity estimates provide a welfare economic argument supporting coverage parity of physician and non-physician mental health services.
Adult↗
[Private health expenditures and income distribution in Brazil].
BACKGROUND: This paper analyses the share of the family private health expenditures in the Brazilian GDP and in personal income; and the distribution of the family private health expenditures among social groups. METHODS: The research utilized the 1998 Brazilian Home Sample Survey (Pesquisa Nacional por Amostra de Domicilios) with the division of the population into four social groups according to the family income per capita; and the distribution of the family private health expenditures among health insurance, physicians, other health professionals, medical tests, drugs, orthopedic and other medical durables, vision products, dental services, hospital care, nursing home care and other health spending. RESULTS: In 1998, only 7.2% of the population with family income per capita up to 1 minimum wage had health insurance and the health expenditures of this group, that represented 52.5% of the population, was US$ 4.62 per capita. For the people with 9 and more minimum wages per capita the health insurance coverage was 83.2% and the health expenditures was US$ 114.66 per capita. CONCLUSIONS: The implementation of the Brazilian public universal health care system in 1988 denominated "Sistema Unico de Saude" was followed by an expressive expansion of private insurance coverage in the 1990's. Even if all public health expenditures had been exclusively directed to the population without any private insurance, these people's health expenditures would only reach 43% of the health expenditures of those with private insurance.
Brazil↗