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PubMed2001

[Implementation of health insurance reform].

Authors expose in the first part of this article practical modes to implement the health insurance reform under the angle of the mastery of care expenses, at the micro and the macroeconomic levels. Thus they pass in review the different possibilities to master expenses, at the supply and the demand sides, by identifying advantages and risks of each of they and by specifying orientations of the health insurance reform in this area: the moderating ticket, contractual payment methods of hospitals and health professionals, the path of care, the refund of care expenses, the rationalization of consumption of medicines and complementary examinations and the harmonious development of care supply by a better public and private mix. A particular accent is put on preliminaries and implementation conditions of the prospective payment of providers and organizational conditions of care provision, from general practitioner that would become the main entry of the care system. In a second part, authors pass in review organization and management conditions of social security bodies, needed for the health insurance reform implementation. On the basis of decentralization and a three levels organization (local, regional and central), social security bodies will put in place the most appropriate organization to insure a steady efficient implementation of the health insurance reform, in dialogue with stakeholders. Consultative committees at regional and central levels, regrouping all the intervening in the health insurance, will be instituted. The sought-after objective through this organization is to administer the health insurance, at the strategic, decisional and operational levels, with suppleness, as a changing and dynamic project, in function of flexibility imperatives necessary for the reform implementation.

Cost Control↗

PubMedDate not supplied

Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis.

OBJECTIVE: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services into managed care. DATA SOURCES: A literature review and information search were conducted to determine which new insurers had special policies for CAM from 1999 to 2000. Telephone interviews were conducted with a sample of 6 new managed care organizations (MCOs) or insurers identified in 2000 and a nonrepresentative cohort of 4 of the original 18 MCOs and insurers who responded both to the original survey in 1997 and again in 1998 to determine trends. STUDY SELECTION: This study constitutes the results of the third year of an ongoing annual survey. For the year 2000, a total of 14 new companies were identified as offering some CAM coverage. Survey results were analyzed for 6 of these who responded to the current survey as well as the results of the cohort mentioned above. DATA EXTRACTION AND SYNTHESIS: Most of the insurers interviewed offer some coverage for the following: nutrition counseling, biofeedback psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. All new companies indicated that market demand was a primary motivator for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness, consumer interest, and demonstrable clinical efficacy. Among the most common obstacles listed for incorporating CAM into mainstream healthcare were lack of research on clinical or cost-effectiveness, economics, ignorance about CAM, provider competition, and lack of standards of practice. CONCLUSION: Consumer demand for CAM is motivating more MCOs and insurance companies to assess the clinical and cost benefits of incorporating CAM. Outcomes studies for both conventional and CAM therapies are needed to help create a healthcare system based on treatments that work, whether they are conventional, complementary, alternative, or integrative medicine.

Complementary Therapies↗

PubMed2002

[Competence center for insurance sciences].

The insurance companies located in Hannover have launched an initiative for a "Compentence Center for Insurance Sciences" whose participants include the Hannover Medical School (MHH/HMS), the University of Göttingen and the University of Hannover. A chair of insurance medicine has been established at the MHH/HMS, a professorship for insurance mathematics in Hannover and a professorship for insurance law in Göttingen. In cooperation with the chair of insurance economics, the above-mentioned participants are preparing to open a competence center that will operate as a limited liability company (GmbH), coordinating activities with economic relevance and providing information to encourage interdisciplinary cooperation among the university institutes and the insurance industry.

Curriculum↗

PubMed2003

Funding long-term care by applying the trade-off principle to public and private insurance.

The uncertain need for long-term care (LTC) services is a risk that is best protected by insurance. However, current LTC funding in the United States relies heavily on personal payment and public welfare and only lightly on social insurance and private insurance. This method is akin to sitting on a two-legged stool, which is likely to be unstable. This brief describes a "three-legged" funding model where social insurance would provide basic LTC protection that would be supplemented by private insurance and personal payment. The model would mobilize public and private resources more effectively by linking LTC insurance to social security, private life insurance, and other financial products.

Aging↗

PubMed2004

Improving health insurance coverage for Latino children: a review of barriers, challenges and State strategies.

OBJECTIVES: To summarize key findings on disparities in health insurance coverage for latino children, to present selected socioeconomic and healthcare access indicators for the nine states with latino populations over 500,000, and to recommend state strategies to increase public health insurance coverage for latino children. METHODS: Literature review performed on latino children and health insurance coverage, key informant interviews with frontline service providers, review of outreach sections of eight state 1115 waiver requests approved by the Secretary of the U.S. Department of Health and Human Services, and national and state data compiled on sociodemographic and healthcare access indicators for nine states with the largest latino populations. RESULTS: Eligibility and enrollment into Medicaid and State Children's Health Insurance Program (SCHIP) are hindered by financial, nonfinancial, and social policy barriers. Disparities in insurance and access indicators show that lack of parental employment-linked benefits, procedural barriers to enrollment, and lack of clarification on eligibility for children of noncitizen parents are associated with low levels of insurance coverage among latino children. CONCLUSION: To state strategies consistent with the overarching goal of Healthy People 2010 to eliminate health disparities can increase health insurance coverage for children of low-wage latino workers.

Child↗

PubMed2004

[Hospital risk management from the viewpoint of insurers].

The present article deals with the significance of risk management in hospitals from the viewpoint of liability insurers. From the perspective of insurance companies, the liability risk of a hospital and its personnel has considerably increased during the past 25 years. The present risk situation is characterized by a growing number of reported liability cases, as well as by an enormous increase of average compensation claims. This development has led some insurance companies to financial deficits in the segment of hospital liability. While some insurers have withdrawn their activities from this market segment, others have reacted by raising their premiums. Since in Germany the premiums usually depend on the number of beds held by a hospital, the problem of rising premiums is exacerbated by the general increase of the number of clinical cases in the face of a parallel reduction of the number of beds. In the process of finding new criteria or methods for adequate premium calculation, a key role will be played by the individual future risk development of a hospital and by the evaluation of this risk by its insurance company. An extensive system of clinical quality management supported by elements of risk management will have persistent positive effects on the development of individual insurance premiums and on the insurability of clinical liability. Risk management is defined as the totality of measures taken by a company to identify risks that could lead to reduced success. Clinical risk management must be regarded in the context of a general trend that is not limited to the field of health service. In this process, the handling of errors and their causes plays a central role. Further variants of hospital risk management are the technical and economic risk management, both of which are increasingly important and are in part implemented in the German legislation. Clinical risk management has originated from the U.S., where as early as in the nineteen-seventies instruments and methods have been developed to avoid errors. Important application fields are anesthetics, surgery, orthopedics, and obstetrics. Risk management is primarily a task of the internal personnel of a hospital. The support by external consultants promises additional benefits for the hospital. Measures of classical risk management usually are essential elements of any quality management system; as such, they are therefore certifiable. Certification alone, however, does not prove the sustained efficiency of a risk-prevention system.

Humans↗

PubMed2005

Influences of health insurance status on clinical treatments and outcomes for 4,714 patients after acute myocardial infarction in 14 Chinese general hospitals.

BACKGROUND: It is unknown whether insurance status influences care provided and patients' prognosis, in China. METHODS: This retrospective cohort study included medical records of 4,714 patients with acute myocardial infarction aged 20 and older, discharged consecutively from 14 Chinese hospitals between January 2000 and February 2003. Uni-variate analysis, multivariate logistic regression and linear regression were used to compare differences in patients' characteristics, care provided and prognosis between insured patients and the uninsured. RESULTS: The uninsured were more likely to be older, female, have transfer admissions, and less likely to be hospitalized to institutions with cardiac interventional facilities, intensive care units or coronary care units. The uninsured were also less likely to undergo diagnostic procedures, interventions and to receive medications, and stayed shorter in hospital and consumed less health care resources. In-hospital mortality in the uninsured, the non-government insured and the government insured was 10.5%, 12.2% and 8.4% respectively. After adjusting for potential confounders, odd ratio in hospital mortality was 1.079 (95% CI, 0.836-1.392) and 0.763 (95% CI, 0.559-1.041) for the non-government insured and the government insured, compared to the uninsured. At significant level of 0.05, we could not assert insurance status is a significant factor to in-hospital mortality.

Adult↗

PubMed1991

The health insurance coverage of working-age persons with physical disabilities.

In this article, we examine the health insurance status of working-age, physically disabled persons, and particularly the question of whether the public sector insures a disproportionate share of the highest-risk disabled population. We use descriptive statistics to develop an insurance profile of respondents with severe physical disabilities, and multivariate procedures to model differences between privately and publicly insured, disabled persons. Results of logistic regression procedures indicate that respondents with private insurance alone are more likely to have a high functional level, a positive perception of their health, and to be married, than are those with public (or a combination of public and private) insurance. Specific type of disability, age, and wheelchair use were also found to predict the type of insurance, their effects largely mediated by employment status and income.

Adult↗

PubMed1991

Liability insurance for moonlighting by family practice residents.

BACKGROUND: Moonlighting is a widespread practice among residents in family practice programs. It is thought that many residents fail to appreciate the problems that moonlighting may pose with respect to liability insurance. METHODS: A survey regarding liability insurance instruction and moonlighting insurance was sent to the chief resident of each family practice residency program (380) in the United States. An overall response rate of 78.7% was achieved. RESULTS: Chief residents appear to have limited knowledge about liability insurance, believe that education about liability insurance in the residency program is inadequate, and are not well informed regarding liability insurance issues related to moonlighting. CONCLUSIONS: Information regarding professional liability insurance and its implications for the resident who chooses to moonlight should be a part of the practice management curriculum of every residency program.

Awareness↗

PubMed1979

[Dental insurance systems in light of present-day prevention potentials].

The situation of public dental insurance systems of several countries in Western Europe was examined in the light of the fact that caries and periodontitis may be prevented. Available epidemiological data were discussed as to their relevance. In Switzerland, dental insurance systems are of minor importance. In voluntary insurance plans for adults, prevention is scarcely included. On the other hand, the communities provide subsidies for dental care of schoolchildren, and prevention is an integral part of this system. In the German Federal Republic, dental insurance costs have quadrupled during the period 1970-1977. Preventive measures are not subsidized, and in recent years, more than half of the insurance payments were used for prosthetic dentistry. The few dental statistics available show that dental treatment of children is unsatisfactory. In Sweden, preventive measures are refunded at 75%. Since the introduction of the public insurance system in 1974 prosthetic dental work has increased at the expense of conservative treatment. In France, the social security system pays for about three quarters of conservative and simple prosthetic work. Prevention has so far not been included. Despite liberal refunding of restorative work markedly higher prevalence of tooth loss was found in lower social levels as compared to higher levels. In Great Britain, the National Health Service was introduced in 1948. As in France, tooth loss is most frequent in lower social levels. The findings are discussed with respect to cost developments and oral health prospects in Switzerland. Attention is focused upon the observation that the insurance systems were conceived at a time when realistic preventive programs were unavailable and their success had not yet been demonstrated in large groups.

Dental Health Services↗

PubMed1988

Impact of private medical insurance on the demand for child consultations with general practitioners.

Data were collected on over 4000 consultations with general practitioners for childhood complaints. Almost half of these consultations (46%) were covered by private medical insurance. A larger proportion of consultations for respiratory conditions were covered by insurance (50%) compared to those for nonrespiratory conditions (42% insured). Amongst those with respiratory conditions larger proportions of consultations for upper respiratory tract infections were insured (50%) than was the case for the potentially more serious conditions of asthma or otitis media (46% insured). The delay in seeking consultation for respiratory conditions was examined. In consultations for followup or persisting problems there was less delay among the insured (8.7 days) than amongst the noninsured (11 days). Those consultations initiated by the patient (or parent) were more likely to be covered by insurance (50%) than those which had been initiated by the doctor or other agency (44%). The findings are discussed in terms of the implications for equity and efficiency in health care.

Adolescent↗

PubMed1995

Explaining trends in health insurance coverage between 1988 and 1991.

This paper uses regression-based decompositions to examine the downward trend in insurance coverage between 1988 and 1991. I find that falling family incomes account for much of the decline in overall insurance coverage, while a secular decline in insurance coverage across all industries, firm sizes, employment statuses, income levels, and demographic groups accounts for most of the decline in employer-sponsored insurance among workers. Rising unemployment and changing patterns of industrial employment explain little of the decline in coverage across the entire population. Taken together, these results suggest that fewer employers are offering health coverage, workers are finding it difficult to pay their share of the premiums, and those without access to employer-sponsored plans are finding it harder to purchase nongroup insurance. Thus, it appears that the rising cost of health insurance coupled with falling incomes and profits during the recession account for the fall in health insurance coverage between 1988 and 1991.

Family↗

PubMed1994

[Medical insurance problems of professional athletes].

Like every working person employed in Switzerland, sports professionals are also required to be insured under the Accident Insurance Law--the mandatory social accident insurance in Switzerland. They can also take out supplementary private insurance contracts for cases in which the mandatory accident insurance does not cover the total injury claim. Often the limitations imposed by law on accident insurance do not meet the demanding individual requirements of sports professionals, or more precisely, those of their employers. A survey of private insurance companies showed some difficulties encountered with the regulations regarding the damages of sports professionals. The main differences concern the interpretation of the legal terms of the notions of accident, of lesions assimilated to an accident and of occupational disease, questions of causality, problems of economy of treatment, excesses of rehabilitation, discrepancy between the ability for any working and the ability for sport, certain career constraints, and finally, problems with the termination of the career brought about by an accumulation of a series of chronic injuries.

Adult↗

PubMed1994

Health insurance and preventive care sources of children at public immunization clinics.

BACKGROUND: Recent proposals to reform immunization financing aim to help more children receive vaccines at their sources of primary care. Under the current system, referrals of children from the private sector may strain public immunization clinics, but scant information exists on what proportions of public clinic patients actually have insurance or primary care sources. OBJECTIVE: To describe the health insurance, usual sources of health care, and referral patterns of children at low-cost public immunization clinics. DESIGN: Cross-sectional study based on face-to-face, structured interviews. SETTING: Public immunization clinics at three sites in Contra Costa County. PARTICIPANTS: Five hundred thirty-eight parents of children awaiting immunizations. RESULTS: Thirty-four percent of families at these public immunization clinics had Medicaid alone, whereas 24% had private insurance. Of those with private insurance, almost one third had at least partial coverage for vaccines. Sixty-two percent of families had sources of preventive care other than the immunization clinic, and most would have preferred to receive their vaccines at these sources. Most in this group named cost as the main barrier to immunizations at primary care sources; but one third of this group, including almost all the families insured by health maintenance organizations, named the wait for appointments at their usual source of care as the main barrier to receiving vaccines there. Two thirds of Medicaid patients and at least one third of privately insured patients were either uninformed or mistaken about whether their insurance covered vaccines. CONCLUSIONS: Financing reform may improve immunization delivery and reduce the load on public clinics. However, legislation to improve immunization financing will not achieve optimal results unless parent education is improved and organizational barriers are also removed.

California↗

PubMed1993

Insurance status and access to health services among poor persons.

OBJECTIVE: We examine the relationship between health insurance status and access to care among low-income persons 65 years of age and under, taking into account their social demographic characteristics and health care needs. DATA SOURCES AND STUDY SETTING: Study groups consist of the subsamples of persons with incomes between 100 and 150 percent of the federal poverty level and those below the federal poverty level interviewed in the 1983, 1984, and 1986 Health Interview Surveys (HIS) of the National Center for Health Statistics. Sample sizes range from about 6,000 to 11,000 depending on the proportion of each study group administered the insurance supplement. STUDY DESIGN: Annual visits and whether hospitalized during a year are used as measures of access to medical care. The analysis consists of identifying predictors of use of services (i.e., health status and social characteristics) and, taking them into account, examining the relationship of insurance status to access to care. This was first undertaken on the 1983 survey; the models obtained then are replicated on the other two years of data. DATA COLLECTION/EXTRACTION METHODS: The HIS utilizes in-person interviews to gather health and medical history information from a stratified random sample of the U.S. population. Data were obtained through public use tapes distributed by the National Center for Health Statistics. PRINCIPAL FINDINGS: Results are consistent for all three years among persons in poverty. Being covered by Medicaid, in contrast to having private insurance or being without health insurance, is related to use of both ambulatory care and hospital care. The access differences for persons in poverty, regardless of their vulnerability or "risk" of requiring medical care, are marked and generally statistically significant. Among the near-poor the same findings occur, although the differences are less sharp and less often statistically significant. CONCLUSIONS: The most obvious explanation is that the poor, and to a considerable extent the near-poor, have limited access because of copayments and deductibles that are typically part of private insurance coverage. The findings raise policy questions regarding the utility of either "play or pay" employer-provided insurance or income tax deductions to increase access.

Data Collection↗

PubMed1993

Physician utilization disparities between the uninsured and insured. Comparisons of the chronically ill, acutely ill, and well nonelderly populations.

BACKGROUND: This study examines the associations between lack of health insurance coverage and physician utilization for the chronically ill, acutely ill, and well nonelderly populations in the United States. METHODS: Cross-sectional data from the 1989 National Health Interview Survey, conducted by the National Center for Health Statistics, were analyzed for the nonelderly population using a correlational, two-group design (N = 102,055). Analytic models, using multiple logistic regression, were tested to predict the odds and likelihood of physician utilization for the uninsured and insured in the three subpopulations (ie, chronically ill, acutely ill, and well), controlling for health status, number of conditions, and geographic, sociodemographic, and economic factors. Disparities in utilization were then calculated between the uninsured and insured for each subpopulation. RESULTS: The nonelderly uninsured were consistently less likely than the insured to have received any health care within 12 months. Moreover, there were differential effects of being uninsured on utilization depending on whether an individual was chronically ill, acutely ill, or well. Whereas chronically ill and well uninsured persons were half as likely to have seen a physician as their insured counterparts (odds ratio, 0.50), acutely ill uninsured persons were almost two thirds as likely to receive physician care (odds ratio, 0.62). Thus, the disparity in physician utilization between the uninsured and insured was larger for the chronically ill and well than for the acutely ill; uninsured acutely ill were less likely to go without care. Of the three populations, those in the well population had average disparities with the largest magnitude (40%), compared with disparities of the chronically ill (20%) and acutely ill (10%). CONCLUSIONS: These disparities represent large inequities in utilization of care by the uninsured, particularly for the chronically ill and well. Whether these disparities result from lower access or individual choice cannot be determined from this study. When viewed in light of other studies examining the impact of utilization on health status, these results provide support for the development of comprehensive health insurance packages with universal coverage and better inclusion of chronic and preventive care models in benefit packages.

Acute Disease↗

PubMed1997

Referrals of adult patients from primary care: demographic disparities and their relationship to HMO insurance.

BACKGROUND: Increasing enrollment in managed care organizations and dissatisfaction with policies to restrict direct access to specialists have intensified interest in referrals from primary care physicians to specialists. We examined the associations of demographic factors and insurance with referrals of adult patients by primary care physicians. METHODS: Office visits of adult patients to primary care physicians (general practitioners, family physicians, and internists) reported in the National Ambulatory Care Survey for the years 1985 through 1992 were used to examine referrals by primary care physicians. Regression analyses were adjusted for patient factors (age, sex, race, insurance, case mix, diagnostic category, new problem or not, new patient or not, and visit length), physician factors (age, sex, specialty, and degree of specialization), and practice factors (proportion of HMO patients, rural location, region, and study year). RESULTS: Overall, 4.5% of patients were referred compared with 7.5% of patients with HMO insurance. After adjustment, an increased likelihood of referral was associated with being a male patient, having fewer medications prescribed, not being seen before for the presenting problem, a longer visit, less physician specialization, seeing a female physician, seeing an internist, and seeing a physician with a greater proportion of patients with HMO insurance. Among patients with HMO insurance, no gender disparity in referral rate was observed, and patients who also had Medicaid or Medicare insurance were more likely to be referred. CONCLUSIONS: Male patients are more likely to be referred. HMO insurance may reduce this gender disparity and increase the access of patients with Medicaid and Medicare to specialty care.

Adult↗

PubMedDate not supplied

The effect of health insurance coverage on the appropriate use of recommended clinical preventive services.

INTRODUCTION: Lack of health insurance coverage has been shown to reduce use of some preventive services. However, even when care is free or fully covered by insurance, clinical preventive services are not used at recommended levels. This study investigates the impact of different levels of health insurance coverage (ranging from none, some, most, and all preventive services covered) on the use of recommended clinical preventive services for adult men and women. METHODS: Logistic regression was used to estimate the effect of different levels of health insurance coverage for preventive care on the probability of receiving six different clinical preventive services including periodic health exam, blood pressure screening, cholesterol screening, Pap smear, clinical breast exam, and screening mammography, as well as all recommended services for a given age and gender group. The study sample of adults ages 18 to 64 is from the Centers for Disease Control's 1991 Behavioral Risk Factor Surveillance System (BRFSS) (n = 53,981). RESULTS: The results demonstrate a positive and statistically significant dose-response relationship between level of health insurance coverage for preventive care and receipt of recommended preventive services in adult men and women. The odds ratios (ORs) of men who had full coverage for preventive care receiving recommended preventive services compared to men with no coverage for preventive care ranged from 1.8 to 2.8. For women the ORs were 1.2 to 2.0. The ORs for men with "most" preventive services covered compared to none covered ranged from 1.3 to 2.1, and for women from 1.2 to 2.0. CONCLUSIONS: The level of health insurance coverage for preventive care is one of the most important determinants of receipt of recommended preventive services for adult men and women 18-64 years of age. These results suggest that comprehensive health insurance coverage for clinical preventive care may significantly increase receipt of recommended preventive services for this population.

Adolescent↗