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PubMed1998

Parity for mental health and substance abuse care under managed care.

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.

Journal Article↗
PubMedDate not supplied

Socioeconomic differences in Medicare supplemental coverage.

In this study we compare the beneficiaries with various types of Medicare supplemental insurance coverage to examine the impact of socioeconomic characteristics on such coverage. We found that those who are more disadvantaged are less likely to have any coverage, and those who have it are less likely to have it subsidized by a former employer. These findings have direct implications for the fairness of proposed programs to provide prescription drug coverage to Medicare beneficiaries, and for the advisability of various proposals for reforming Medicare, including "premium-support" programs.

Drug Prescriptions↗
PubMed2003

[Cost analysis of acute therapy of polytrauma patients].

The rising costs of the Swiss health care system are currently a source of discussion. Precise facts about the treatment costs in Switzerland are not available. The aim of this paper is to assess the price of the acute therapy of multiple trauma patients at the University Hospital of Zurich. We analysed the exact treatment costs of 16 patients with an average Injury Severity Score (ISS) of 33.9. All these cases had a private or a supplementary insurance coverage, were foreigners or were otherwise invoiced according to the so-called hospital tariff (Spitalleistungskatalog/SLK). We developed a concept to measure the expenditure not covered by the insurance of those with a basic insurance, who entail the largest percent of all hospitalized patients. The average amount invoiced was 128,135 Swiss Francs (31,266-310,358 CHF). After subtracting the profit, gained on cases charged according to the SLK, the remaining deficit per ordinary insured was 42-65% or 33,703-138,829 CHF The range of this amount depends on the insurance status of the afflicted person. If hospitals are required to work with a balanced budget, then these losses can no longer be neglected. New forms of invoicing multiply trauma patients must be found in Switzerland.

Adolescent↗
PubMed2006

Comparison between two orthodontic skeletal anchorage devices: osseointegrated implants and miniscrews - Medical-Legal Considerations.

The object of this article is to describe potential medical-legal problems concerning the use of miniscrews as orthodontic skeletal anchorage. The miniscrews, which are already used in rigid fixation, do not need either a healing period before loading, or complete osseo-integration as do implants. Their particular shape allows high primary stability and they can be placed in the sub-periosteal region. The dimensions of these miniscrews are minute, with dimensions of only 4-5 mm in length. They penetrate only slightly deeper than the cortical layer and therefore notably reduce the risk of lesions to roots, nerves, or maxillary sinus, when compared to other skeletal anchorage systems such as implants. The use of the miniscrew in oral surgery or periodontology does not need specific insurance coverage in contrast to the insertion of implants. Accordingly, orthodontic therapy completed by the dentist with orthopaedic microscrews as anchorage could also be included in a general civil insurance policy for orthodontics.

Bone Screws↗
PubMed2000

Screening trauma patients for alcohol problems: are insurance companies barriers?

BACKGROUND: Impairment caused by alcohol is the leading risk factor for trauma. However, many physicians do not screen for alcohol use because of concerns about confidentiality and denial of insurance coverage. The purpose of this study was to examine objectively the confidentiality issues and insurance statutes affecting alcohol screening in trauma centers. METHODS: We conducted a survey of insurance commissioners in all 50 states to determine the prevalence of statutes allowing denial of coverage for injuries sustained while impaired due to alcohol, reviewed state insurance laws, and reviewed federal regulations protecting the confidentiality of alcohol information in patients seeking alcohol treatment. RESULTS: Special federal regulations protecting confidentiality of alcohol screening data depend on how such information is acquired and do not routinely cover trauma patients. Concerns about screening on insurance coverage are valid in 38 states. CONCLUSION: Segregating information about alcohol use in the medical record and assigning designated chemical dependency counselors to screen all trauma patients would provide confidentiality of alcohol information under current federal regulations, allowing denial of release of such information, except under subpoena.

Alcoholism↗
PubMed1983

The INSURE Project on Lifecycle Preventive Health Services: cost containment issues.

The INSURE Project on Lifecycle Preventive Health Services (LPHS) is a three-year feasibility study to determine whether preventive health services can be implemented in the primary medical care setting as a covered health insurance benefit and what the short-term behavioral effects will be on physicians and their patients. Thus far, the negotiated reasonable and customary fees that have been paid are lower than anticipated. Patients have expressed a willingness to pay extra for preventive care insurance coverage if it were available. The positive reactions of providers and consumers and the reasonable cost of LPHS may prove to be more crucial than broader cost containment issues in determining the extent of health insurance coverage for preventive care in the future.

Cost Control↗
PubMed2001

Quality improvement in pediatric well care with an electronic record.

For the past 4 years the pediatric office of Children's Health Specialists has used an electronic medical record (EMR). The EMR has forms for the routine well child visits recommended by the American Academy of Pediatrics (AAP) [1] and instruction sheets with key information on development and safety as recommended by "Bright Futures" [2]. In this study the completeness of well visits, instruction distribution, immunizations and lead testing were examined for all children in our practice with birthdays in 1998. When children did get to the office they did get their instruction sheets on child development and safety and were well immunized. Children who had insurance coverage to pay for in-office lead testing were 42.6 times more likely to have blood lead testing done: Risk Ratio 42.6, lower limit 10.6, upper limit 171.3. Insurance coverage and regulatory changes would likely increase lead screening markedly in high risk populations. Our implementation of our EMR has helped us to deliver high quality pediatric well child care but external obstacles limit the completeness of the care.

Ambulatory Care↗
PubMed1997

On becoming 65 in Ontario. Effects of drug plan eligibility on use of prescription medicines.

OBJECTIVES: The authors assess (1) the effects of first-dollar prescription drug insurance coverage provided by the Ontario Drug Benefit plan at age 65 on prescription drug use by seniors, and (2) the differential effects of this coverage on prescription drug use by seniors with varying levels of health status. METHODS: The authors modeled self-reported prescription drug use contained in the 1990 Ontario Health Survey as a function of eligibility for coverage, controlling for health status and other factors. The two-part model was used and was estimated by maximum likelihood. RESULTS: The provision of first-dollar prescription drug insurance coverage at age 65 is associated with an increase in drug use. Increases in drug use are, however, concentrated primarily among individuals with lower levels of health status. Most of the increased use occurs among individuals already under physician supervision, ie, an increase in the level of use among drug users rather than an increase in the probability of use. CONCLUSIONS: As Ontarians turn age 65 and become eligible for publicly subsidized prescription drugs, their use increases but the effect appears to be restricted mainly to persons with lower levels of health status. Given a growing trend toward reduction of public subsidy and increased reliance on patient cost sharing, more research is needed to quantify the use and health effects of such initiatives.

Age Factors↗
PubMed2004

Disputes over coverage of emergency department services: a study of two health maintenance organizations.

STUDY OBJECTIVE: We describe the characteristics and outcomes of enrollee-health plan disputes over insurance coverage for emergency department (ED) services at 2 large health maintenance organizations (HMOs) that apply the prudent layperson standard. METHODS: We abstracted information from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs (hereafter referred to as Plan 1 and Plan 2). We describe appeals involving ED services in terms of the timing of visits, patient age, costs of services, primary reason the patient sought care, and appeal outcome. RESULTS: Disputes over ED services accounted for approximately one half (52%) of postservice appeals at Plan 1 and one third (34%) at Plan 2. Nearly one half (46%) of ED appeals involved weekend, nighttime, or holiday visits to the ED; 22% were children's visits. The average cost of services in dispute was US$1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64%), injuries (22%), and services related to disease (8%). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6%); earaches or ear infections (3.4%); and lacerations/cuts (2.9%). Enrollees won more than 90% of appeals. CONCLUSION: The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard.

Adult↗
PubMed2000

Utilization of preventive medical services in the United States: a comparison between rural and urban populations.

Differences between rural and urban residents in their utilization of three clinical preventive services--Papanicolaou screening tests (Pap smears) for women aged 18 to 65, mammograms for women aged 50 to 69 and flu shots for people aged 65 or older--were examined using a nationally representative sample from the 1994 U.S. National Health Interview Survey. Eighty-two percent of urban women and 79 percent of rural women (P = 0.11) had Pap smears. Sixty-eight percent of urban women and 61 percent of rural women (P = 0.01) had mammograms. Flu shots were received by 55 percent of urban and 58 percent of rural elderly residents (P = 0.11). Of women aged 50 to 69 who had a high school education or whose annual household income was between $15,000 and $34,999, significantly fewer rural than urban women had mammograms (P < 0.01). However, the proportion of rural women receiving mammograms was not significantly different from that of urban women after adjusting for their education, household income and health insurance status. Education level, house-hold income and health insurance coverage were positively associated with utilizing mammograms. These results suggest that differences in the utilization of preventive services between rural and urban women vary by services. Improving socioeconomic status and health insurance coverage of rural women may reduce the disparity in mammogram use between rural and urban women. Mechanisms of how a woman's socioeconomic status affects her utilization of mammograms needs further study.

Adult↗
PubMed1994

A study of factors affecting dental expenditures in Quebec: 1962-1991.

The issue of dental manpower planning has received considerable attention in Quebec in recent years. Quebec dentists agree that there is a need for detailed information regarding the impact of economic factors on the supply of and demand for dental care in the province. This study examines the impact of economic factors on dental care expenditures in Quebec between 1962 and 1991. The functional form of the econometric model used by the authors is similar to the one used in a study of the growth of the U.S. dental sector between 1950 and 1989. The dependent variable is per capita dental expenditure, and the three independent variables are: dentist/population ratio, per capita personal disposable income; and percentage of the population with dental insurance coverage. All data come from secondary sources. The findings indicate that per capita dental expenditure has grown substantially in Quebec over the past three decades, with the rate of growth slowing dramatically during the 1980s. Dental insurance coverage, the number of dentists in the community and the disposable income of the population all have a positive impact on dental expenditure in Quebec. However, it is clear that the incomes of Quebec dentists may decrease in the future if: no restrictions are placed on the number of new dental graduates entering the profession; dental insurance programs are curtailed; or dental disease levels continue to fall.

Dentistry↗
PubMed1979

Psychiatric manpower ratios. A beguiling numbers game?

Many characteristics of California's counties that correlate with physician-population ratios also correlate with psychiatrist-population ratios, with their changes through time and with rural counties' ability to attract psychiatrists. These same county characteristics seem to influence the uneven distribution of lawyers throughout the state, a fact that should help physicians help legislators understand problems in attempting to equalize manpower distribution. California's relatively high psychiatrist-population ratio and the presence of counties that are statistically anomalous should preclude the application of these findings to other states. Despite government interest in psychiatrist-population ratios as a device to estimate manpower needs, these ratios are a poor measure of access to services. Barriers to care such as lack of private insurance coverage and Medicaid and Medicare restrictions appear more powerful than uneven manpower distribution. Proposals for influencing psychiatrists' distribution should be compared with other methods of decreasing mental illness morbidity, such as mandating insurance coverage and increasing funds for preventive services and research.

Adult↗
PubMed2001

State medicaid coverage for tobacco-dependence treatments--United States, 1998 and 2000.

The Guide to Community Preventive Services recommends reducing the cost of tobacco-dependence treatments because these interventions increase both the use of treatment by smokers during attempts to stop smoking and the number of smokers who actually stop. The Public Health Service (PHS) Clinical Practice Guideline supports insurance coverage for tobacco-dependence treatment (i.e., individual, group, and telephone counseling, and Food and Drug Administration-approved pharmacotherapy. One of the 2010 national health objectives is to provide coverage in the 50 states and District of Columbia (DC) for nicotine-dependence treatment by Medicaid (objective 27.8b). In 2000, approximately 32 million low-income persons in the United States received their health insurance coverage through the federal-state Medicaid program; approximately 11.5 million (36%) of these persons smoked (CDC, unpublished data, 2000). Medicaid recipients have approximately 50% greater smoking prevalence than the overall U.S. population. To assess the amount and type of coverage for tobacco dependence offered by Medicaid, the Center for Health and Public Policy Studies at the University of California, Berkeley, conducted state surveys in 1998 and 2000. In 1998, 24 states and DC offered some coverage for tobacco-dependence treatment; in 2000, nine started offering some coverage. In 1998 and 2000, one state offered coverage for all the counseling and pharmacotherapy treatments recommended by PHS. These findings indicate that states can reduce smoking prevalence among Medicaid recipients by implementing more extensive Medicaid coverage for treatment of tobacco dependence.

Bupropion↗
PubMed1996

Income, social stratification, class, and private health insurance: a study of the Baltimore metropolitan area.

Most studies of inequalities and access to health care have used income as the sole indicator of social stratification. Despite the significance of social theory in health insurance research, there are no empirical studies comparing the ability of different models of social stratification to predict health insurance coverage. The aim of this study is to provide a comparative analysis using a variety of theory-driven indicators of social stratification and assess the relative strength of the association between these indicators and private health insurance. Data were collected in a 1993 telephone interview of a random digit dialing sample of the white population in the Baltimore Metropolitan Statistical Area. Indicators of social stratification included employment status, full-time work, education, occupation, industry, household income, firm size, and three types of assets: ownership, organizational, and skill/credential. The association between social stratification and private health insurance was strongest for those having higher household incomes, having attained at least a bachelor's degree, and working in a firm with more than 50 employees, followed by being an owner or manager, and by being employed. The addition of education and firm size improved the prediction of the household income model. The authors conclude that studies of inequalities in health insurance coverage can benefit from the inclusion of theory-driven indicators of social stratification such as human capital, labor market segmentation, and control over productive assets.

Adult↗
PubMedDate not supplied

Removing barriers to care among persons with psychiatric symptoms.

Many persons with serious psychiatric conditions who could benefit from available treatments do not receive care, and the barriers are generally understood to be limited knowledge, inadequacies in insurance coverage, and stigma. Sophisticated approaches are needed to realistically eliminate these and other barriers. Public policy should focus on criteria for need for care and encourage interventions that facilitate treatment when it can be helpful. Appropriate insurance coverage is indispensable, and achieving mental health parity will require careful management of care. Policymakers must help to create a trustworthy management structure that is inclusive, that develops and disseminates models of best practice, that encourages evidence-based decision processes, and that ensures continuing dialogue and procedural fairness in managed care decision making.

Health Education↗
PubMed2004

Service quality and attrition: an examination of a pediatric obesity program.

OBJECTIVE: To examine the demographic, illness, and quality of care determinants of service attrition in a pediatric obesity program, and to elucidate factors that may promote families' return to care. DESIGN: Cross-sectional survey with semi-structured interviews. SETTING: A regional children's hospital in the United States. STUDY PARTICIPANTS: Caregivers of 163 patients, consecutively enrolled in a pediatric obesity treatment program between January 1998 and September 2000, were contacted by telephone and offered participation in a survey of clinical care experiences. A total of 120 (74%) families participated. MAIN OUTCOME MEASURES: Service attrition as defined as premature discontinuation of treatment before completing phase I of a multi-phase treatment program. RESULTS: Multivariate results indicated that service attrition was associated with both insurance status and perceived quality of care. Patients with government-subsidized insurance were more likely to defect from services than those with commercial insurance. Perceived quality of care was highly associated with attrition after controlling for demographic and health parameters. Caregiver-reported reasons for service attrition included difficulty with adequate insurance coverage (53%), the child's desire to leave the program (50%), and the program taking too much time (32%). The most frequent suggestions to facilitate families' return to the program were: (i) assistance with insurance coverage; (ii) following up with families; and (iii) increasing engagement with the child. CONCLUSIONS: This study found few demographic differences between patients completing the program and those defecting from services. Both families completing the program and those discontinuing prematurely rated the overall quality of the program as high. However, lower quality of care was related to increased service attrition even after controlling for the effects of demographic and health parameters. Although a considerable number of patients discontinued services, very few reported that they would not return to the program. The results provide further support for ongoing audit and examination of families' care perceptions in preventing attrition and promoting service recovery.

Adolescent↗
PubMed2003

Insured versus uninsured patients in the emergency room: is there a difference?

OBJECTIVE: To define the differences in emergency room usage patterns between patients with and without medical insurance coverage. METHODS: A retrospective analysis of the database of 34 642 consecutive patient visits to an urban hospital emergency room over a period of 509 days. Arrival times and admission rates were compared for insured and uninsured patients. RESULTS: A total of 46.8% of insured patients arrived at night or during the weekend versus 51.7% of the uninsured. Slightly more insured patients were admitted (18.6 versus 15.4%), both after their visit during the daytime (20.6 versus 17.1%) and outside daytime hours (16.3 versus 13.8%). The uninsured population was younger. CONCLUSION: Uninsured patients arrived more frequently during weekends and at night than insured patients. They were on average less likely to be admitted to the hospital. Demographic differences between both groups seemed to play an important role in the admission rate. Despite differences in emergency room usage patterns, it cannot be concluded that either group used the emergency room in excess of the other.

Adolescent↗