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PubMed1975

Copayments for ambulatory care: penny-wise and pound-foolish.

The California "copayment experiment" imposed a charge of $1 on certain Medicaid beneficiaries for the first two visits to a doctor and 50 cents for the first two drug prescriptions each month, effective January 1, 1972. Data on utilization rates were gathered for six months before this date and for 12 months after it. While other administrative requirements, like prior authorization of certain services, doubtless also played a part, it was found that, following the start of copayment, utilization of ambulatory doctor's office visits and other services associated with them showed a decline, relative to that of the non-copayment cohort. After a brief lag, however, hospitalization rates in the copay cohort rose to levels higher than those of the non-copayment cohort-more than offsetting the savings to the state from the reduction of ambulatory service use rates. Due presumably to the neglect of early medical care because of the inhibiting effect of the copayments, these higher use rates of costly hospitalizations suggest that financial deterrents on access to ambulatory service by poor people are penny-wise and pound-foolish, not to mention their effects on health and well-being.

Aid to Families with Dependent Children↗
PubMed1976

Health care financing in China.

Today's China, still a developing country with per capita health expenditure of 50 cents to one dollar (U.S.), has established a complex network of health facilities and well-distributed health personnel through the efforts of the existing political structure. The curative health services are decentralized and provide care through a variety of plans which combine capitation prepayment and modified fee-for service. Each plan is striving for the goal of making health care accessible to all at low cost, and hence, efforts of cost containment for self-sufficiency are widely practiced. The responsibility of the preventive health services (such as health education, screening, family planning, food distribution, etc.) are assumed by the central government and they are provided without charge to encourage maximal utilization. Other features of the Chinese system discussed include self-reliance, self-sufficiency, mass orientation, regionalization and innovative utilization of existing facilities, and personnel.

Allied Health Personnel↗
PubMed1981

Out-of-plan use under two prepaid plans.

This analysis of out-of-plan use of physician and paramedical services under a Kaiser plan and under a prepaid option offered by a predominantly fee-for-service group practice (Clinic plan) deals primarily with services that members could have obtained from plan providers ("covered services"). The extent and pattern of out-of-plan use were found to be similar. While 16-20 per cent of plan members used some out-of-plan covered services and the mean number of such services was about one half visit per member per year, most out-of-plan user were occasional user, 10-12 per cent of user (or 2 per cent of plan members) accounting for 50 per cent of all out-of-plan covered services. The principal members characteristics associated with out-of-plan use were dissatisfaction, health status and having other insurance. The literature on out-of-plan use is also reviewed.

Adolescent↗
PubMed1989

The use, cost, and economic burden of nursing-home care in 1985.

Nursing-home expenses constitute one of the greatest financial risks for elderly Americans. This study, based largely on the 1985 National Nursing-Home Survey, examines the economic burden posed by nursing-home care during 1985. The results indicate that nursing-home expenses constitute by far the largest out-of-pocket burden of all health care services. It was found that nursing-home care expenses constituted 82.5% of the out-of-pocket expenditures among the elderly who incurred $3,000 or more in such expenditures during 1985. Surprisingly, though, it was found that the frequency in which those in nursing homes "spend-down" their assets and income, thus becoming eligible for Medicaid, is much lower than others have calculated. This may be due in part to the fact that a large proportion of the elderly are already eligible for Medicaid when they begin their nursing-home stays.

Aged↗
PubMed1994

The willingness to pay for in vitro fertilization: a pilot study using contingent valuation.

The use of in vitro fertilization (IVF) has increased rapidly in recent years and debate has focused on whether health insurance should cover the procedure. We developed and disseminated a contingent valuation survey to investigate how individuals value IVF treatment. Couples pursuing in vitro fertilization can be viewed as purchasing an increased probability of conceiving and bearing a child. In our survey, respondents were asked if they would pay stated amounts for IVF, under various assumptions about the probability of success. The survey explores the ex post perspective, (respondents' willingness to pay (WTP) for IVF in the event that they are infertile), the ex ante perspective, (WTP for IVF insurance, assuming respondents do not know their infertility status), WTP for a public IVF program, and how respondents value IVF relative to mortality risk reduction. Among 150 respondents who were potential childbearers, average WTP was $17,730 for a 10% chance at having a child through IVF in the event of infertility. Average WTP was $865 for a lifetime insurance benefit providing access to a 10% chance. Among 231 respondents of all ages, average WTP was $32 per year in taxes for a public program giving 1,200 couples per year in Massachusetts a 10% chance. The estimated implied ex post WTP per statistical baby was $177,730, while ex ante WTP per statistical baby was $1.8 million. The results of regression analyses were consistent with theoretical predictions, (e.g., increasing WTP with household income). The contingent valuation method is a potentially useful tool in understanding how people value the benefits of IVF. Further research is needed to test the validity of this methodology.

Adult↗
PubMed1994

Health plan choice in the Twin Cities Medicare market.

This paper examines the relationship between characteristics of Medicare beneficiaries and their choice of health plan in the Twin Cities during 1988. This analysis provides the first comparison of beneficiaries in the basic fee-for-service (FFS) Medicare sector (without a supplementary policy) to beneficiaries in the FFS sector with a supplementary policy, enrollees in independent practice associations (IPAs), and network health maintenance organizations (HMOs). The site and time period are important because there were five large, mature HMOs with TEFRA-risk contracts operating at that time, enrolling 50% of Medicare beneficiaries in the market area. We find that the oldest, poorest and, to a lesser extent, the sickest Medicare beneficiaries were most likely to have basic FFS Medicare coverage without supplementary insurance. The youngest enrollees are found in network HMOs. The availability of group coverage and premium subsidies are positively associated with choice of FFS with a supplementary policy. Government policy concerning Medicare HMO premiums appears to contribute to the poorest beneficiaries facing the highest out-of-pocket costs.

Age Factors↗
PubMed1996

Individual choice in spending accounts. Can we rely on employees to choose well?

Flexible spending accounts (FSA) represent a current health care financing tool that may become an important component of incremental health care reform. Because FSAs require employees to make financial contributions based on anticipated health care needs, contribution decisions are likely to be subject to many of the errors made in other insurance decisions. The authors analyzed the benefits selections, benefits forms completion, and FSA contribution levels of approximately 9,500 employees of the University of Pennsylvania from 1987 to 1992. Default and repeat choice trends characterize the completion of benefits forms and the reselection of health insurance options by employees. Despite the economic benefits of contributing to an FSA, only 14% of employees contributed in any one year and 73% never made a contribution. Multivariate models of these contributions fail to demonstrate the importance of what ought to be relevant influences in contribution decisions (for example, age, income, family status, or underlying health insurance). Whereas most FSA decisions are characterized by default contributions of $0, employees who contribute in one year are most likely to contribute exactly the same amount the next year, even when other circumstances change. The pervasiveness of these patterns raises concerns that health care reform plans that rely on financial incentives at the consumer level--for example, proposed medical saving accounts--will be inefficient.

Choice Behavior↗
PubMed1996

The impact of implementing a more restrictive prescription limit on Medicaid recipients. Effects on cost, therapy, and out-of-pocket expenditures.

On November 1, 1991, the Georgia Department of Medical Assistance reduced the maximum number of monthly reimbursable prescriptions from six to five. This policy change provided a natural experiment to investigate the recipient responses to a decrease in an existing prescription limit. The research design was a quasiexperimental, retrospective, 12-month interrupted time-series analysis of a cohort. The cohort consisted of 743 ambulatory recipients who were high prescription users. Complete Medicaid claims data were obtained, in addition to pharmacy-generated computer profiles for all cohort recipients to determine Medicaid and out-of-pocket prescriptions expenditures. Interrupted time-series analyses were performed to model the effect of the five-prescription limit on total, Medicaid-reimbursed, out-of-pocket, and prescription use across eight therapeutic categories. After the implementation of the five-prescription limit, total prescription use fell 6.6%, prescriptions reimbursed by Medicaid fell 9.9%, and prescriptions paid for out-of-pocket increased 9.7%. Abrupt, permanent decreases were observed for cardiovascular, miscellaneous, pulmonary, and palliative therapeutic drug categories (alpha = 0.05), whereas gastrointestinal, chemotherapy, hormone (insulin), and central nervous system prescription use remained constant. The implementation of a more restrictive prescription limit alters prescription regimens potentially predisposing elderly Medicaid recipients to clinical consequences. Further examination of the health outcomes of these recipients is necessary.

Adult↗
PubMed1999

Assessing the performance of utility techniques in the absence of a gold standard.

BACKGROUND: Utility techniques are the most commonly used means to assess patient preferences for health outcomes. However, whether utility techniques produce valid measures of preference has been difficult to determine in the absence of a gold standard. OBJECTIVE: To introduce and demonstrate two methods that can be used to evaluate how well utility techniques measure patients' preferences. SUBJECTS AND DESIGN: Patients treated for advanced prostate cancer (n = 57) first ranked eight health states in order of preference. Four utility techniques were then used to elicit patients' utilities for each health state. MEASURES: The rating scale, standard gamble, time trade-off, and a modified version of willingness-to-pay techniques were used to elicit patients' utilities. Technique performance was assessed by computing a differentiation and inconsistency score for each technique. RESULTS: Differentiation scores indicated the rating scale permitted respondents to assign unique utility values to about 70% of the health states that should have received unique values. When the other techniques were used, about 40% or less of the health states that should have received unique utility scores actually did receive unique utility scores. Inconsistency scores, which indicate how often participants assign utility scores that contradict how they value health states, indicated that the willingness-to-pay technique produced the lowest rate of inconsistency (10%). However, this technique did not differ significantly from the rating scale or standard gamble on this dimension. CONCLUSIONS: Differentiation and inconsistency offer a means to evaluate the performance of utility techniques, thereby allowing investigators to determine the extent to which utilities they have elicited for a given decision problem are valid. In the current investigation, the differentiation and inconsistency methods indicated that all four techniques performed at sub-optimal levels, though the rating scale out-performed the standard gamble, time trade-off, and willingness-to-pay techniques.

Aged↗
PubMed2001

Medicare beneficiaries' management of capped prescription benefits.

BACKGROUND: Having annual dollar limits in prescription coverage is a type of benefit design unique to Medicare beneficiaries. This type of coverage is found predominantly within private Medigap policies and Medicare+Choice plans offering prescription coverage. OBJECTIVES: The purpose of this study was to determine the impact of capped prescription benefits on efforts to reduce out-of-pocket prescription expenses by beneficiaries at risk for reaching their cap. RESEARCH DESIGN: This design was quasi-experimental, with data obtained from self-administered questionnaires mailed to 600 Medicare HMO risk enrollees with capped prescription benefits. RESULTS: Data were collected on 378 Medicare enrollees for a 63% response rate. Approximately half of all respondents participated in > or =1 strategy to reduce their out-of-pocket prescription expenses. Participation in selected strategies included obtaining samples from physicians (39.2%), taking less than prescribed amounts (23.6%), and discontinuing prescribed medications (16.3%). Additionally, 15% of respondents indicated going without necessities, and 12% indicated borrowing money to pay for their prescriptions. Those who reached their prescription cap were more likely to participant in any one behavior (odds ratio [OR], 2.18), more likely to take less medication than prescribed (OR, 2.83), more likely to discontinue a medication (OR, 3.36), and more likely to obtain samples from their physician (OR, 2.02) compared with those who had not reached their prescription cap. CONCLUSIONS: Beneficiaries at risk for reaching their prescription cap are taking steps to reduce their out-of-pocket prescription costs. Although some behaviors would be considered prudent, other behaviors may be placing beneficiaries at risk for drug-related morbidity and mortality.

Aged↗
PubMed2001

Who uses flexible spending accounts: effects of employee characteristics and employer strategies.

BACKGROUND: Many large employers offer flexible spending accounts (FSAs) to shelter their employees' out-of-pocket medical expenses from taxes and thereby to encourage the purchase of health insurance policies with higher cost sharing. However, very little empirical research has examined the individual employee's decision to contribute to an FSA. OBJECTIVES: To estimate equations for the probability that single employees with no dependents and employees with family health insurance coverage will contribute to FSAs, and the amounts contributed by those with FSAs. RESEARCH DESIGN: An observational study of randomly-selected employees in 15 Minnesota firms matched with information on the strategies those firms use to promote FSAs. Measures of FSA participation were regressed on expected health care spending, employee socio-demographics, and employer strategies. SUBJECTS: 779 single employees with no dependents and 679 employees with family coverage. RESULTS: Education beyond high school increases the probability that both types of subjects will contribute to FSAs, with marginal effects ranging from 16 to 48 percent. The FSA contribution rate for families doubles when the family's marginal federal income tax rate increases from 15 to 28 percent. Employer strategies to encourage participation are also effective in promoting FSAs. CONCLUSIONS: FSAs are used mainly by high-income and highly-educated workers. We question whether this is an equitable use of the income tax code.

Choice Behavior↗
PubMedDate not supplied

Education financing.

Explore the source record for details and available documents.

Education, Nursing, Baccalaureate↗