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PubMed2001

Health status of African Americans.

The health status of African Americans identifies a higher prevalence of cardiovascular diseases, cancer, hypertension, diabetes, obesity, and sexually transmitted infections when compared with Whites. However, more research is needed to identify socioeconomic variables and to establish needed health programs. The vestiges of early 20th century traditions of substandard housing and inadequate nutrition for African Americans are still apparent in many communities today. Most health care professionals are not educated and trained to be culturally sensitive. The struggle against the prevalence of diseases in African Americans must incorporate cultural sensitivity, community organization and empowerment. The need for a universal system of health insurance coverage is of utmost importance. The elimination of health disparities among African Americans requires a national effort, the involvement of public and private sectors, individuals and communities.

Black or African American↗
PubMed1996

The Australian health care system.

Medicare is Australia's universal system of health insurance, which is based on the principles of equity. It provides free accommodation and treatment in public hospitals and entitlement to medical services. Laboratories receive reimbursement from Medicare if they are accredited. Hospital funding may be directly funded, whereas in some States the funding is through structures such as Health Areas. There are increasing moves to determine the hospital share of funding based on the number and types of hospital cases. To lower the cost of Medicare, the Federal Government is considering reforms including those which will allow private health insurers to negotiate with doctors and hospitals. Some of the major issues facing the health care system are: (1) how best to deliver care to Aboriginal Australians, (2) overspending, particularly in high-technology medicine, and (3) provision of health care for the small but significant number of Australians who do not live in major metropolitan centers.

Australia↗
PubMed2003

[Changes in the surgical health care system and future aspect of surgery].

Since universal coverage of health insurance of Japan was introduced in 1961. Japan's health care system has become one of the few comprehensive systems from the perspective of national welfare. In 2002, as the gross national medical expenditure (GNME) increased to 30 trillion yen, the Japanese Government employed a policy of medical cost containment. In Japan, the ratio of GNME to the gross national product (GNP) is not so high in the world, and it ranks 6th among developed countries (OECD-Health Data, 2002). During the past 38 years from the scientific viewpoint the Joint Committee of Social Insurance established by the Multidisciplinary Group of Surgical Associations has evaluated the rationalization of surgical fee (include doctor's fee). If our system is employed, more fair surgical care may be provided in the future.

Forecasting↗
PubMed1998

Radiotherapy for breast cancer in Ontario: rate variation associated with region, age and income.

OBJECTIVE: To describe the variation in the use of radiotherapy (RT) in women in Ontario within 1 year of diagnosis of breast cancer, from 1982 to 1991, and to identify factors associated with these variations. DESIGN: Retrospective, population-based cohort study. SETTING: Ontario. POPULATION: All women registered by the Ontario Cancer Registry (OCR) with a diagnosis of invasive breast cancer between Jan. 1, 1982, and Dec. 31, 1991. INTERVENTIONS: RT to any anatomic site within 1 year of the diagnosis of breast cancer. OUTCOME MEASURES: Odds of receiving RT within 1 year of diagnosis (from RT files from all radiotherapy departments in Ontario) associated with year and with geographic, age-related and socioeconomic factors. RESULTS: Use of RT within 1 year of diagnosis increased from 21.1% (95% confidence interval [CI] 19.8-22.4) in 1982 to 44.7% (95% CI 43.4-46.0) in 1991 (p < 0.0001). Among the regions of Ontario, the use of RT varied from 24.5% (95% CI 23.5-25.6) to 44.4% (95% CI 43.0-45.9) (p < 0.0001). Increasing age was associated with decreasing likelihood of receiving RT (test for trend p < 0.0001), as was decreasing income (test for trend p < 0.0001). CONCLUSIONS: The use of RT within 1 year of the diagnosis of breast cancer in women in Ontario varies by region, age and income. Despite universal and comprehensive health insurance coverage, women with breast cancer in some populous regions of Ontario were less likely to receive RT within 1 year of their diagnosis than women in other populous regions.

Age Factors↗
PubMed1991

Managed-care plans. Their future under national health insurance.

The nation's health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation's physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.

Health Maintenance Organizations↗
PubMed2005

National healthcare spending in the U.S. and Japan: national economic policy and implications for neurosurgery.

Growth of national healthcare spending is a problem confronting national governments of all industrially advanced countries. Healthcare spending in the U.S. reached 13.9% of the Gross Domestic Product (GDP) in 2003, compared to only 8% in Japan. In the U.S., health insurance is voluntary, with 15% of the population uninsured. In Japan, health insurance is mandatory and virtually universal, with growth in national health costs about half the rate of growth in the U.S. U.S. healthcare costs are projected to reach 18.4% of GDP 2013. The predicted growth in health care costs is expected to cause strain on the federal budget and a growing inability of employers and employees to pay for private insurance. Different national policies are the reason for different national health care costs in the U.S. and Japan. The U.S. has higher healthcare prices for salaries, equipment, supplies, and pharmaceuticals as compared to Japan. Higher prices, higher service intensity and volume during hospitalization create higher total cost in the U.S. Price controls in Japan kept medical inflation low at 0.46%/yr from 1980-2000. Market-pricing mechanisms in the U.S. have proven ineffective in controlling national healthcare costs, while Japan's national fee and price control policies have kept national costs among the lowest within the Organization for Economic Cooperation and Development. To guide insurance coverage policy, neurosurgery and other highly technical specialties should better define the comparative health benefit of high price technical services by prospective outcome studies.

Health Care Costs↗
PubMed1991

The adequacy of college health insurance coverage.

This analysis of private health insurance plans offered in 100 four-year colleges and universities in 1988 indicates a tremendous diversity in plan options, benefits covered, cost-sharing requirements, and catastrophic protections. Consistent with relatively low premium prices, most student health insurance plans offer limited benefits and expose students to significant out-of-pocket medical cost liabilities. Only a minority of schools use financial incentives, such as preferred provider arrangements, to integrate their health insurance plans with their university health service system. We conclude that universities should carefully reexamine the adequacy of their health insurance plans and their relationship to student health centers. As more students rely on student health insurance as their only source of coverage, the quality of these plans assumes an even greater importance.

Adolescent↗
PubMed1997

[Special therapeutic practices from the viewpoint of naturopathy].

Naturopathy being orientated towards natural science and conventional medicine does not lead to basically different judgements about unconventional treatments nor about special therapies such as homeopathy, phytotherapy or anthroposophic medicine. It may, however, be more open-minded towards new ideas and theoretical even philosophical concepts and it is more likely used to question the 'state of the art' of actual medical knowledge. It is only for a relatively small part of unconventional treatments, that naturopathy recognizes a certain plausibility, which causes scientific investigation of the method to be meaningful. Naturopathy sometimes proposes traditional anthropologies and nosologies to be used for the election of suitable indications. A variety of psychologic effects of different methods of naturopathy may not be excluded by protocols used for clinical studies. As far as the majority of unconventional and paramedical treatments is concerned, naturopathy raises ethical beside scientific objections. Beyond a probable success of the treatment, it insists on a certain rationale and intellectual honesty. A differentiation between the more pragmatic interests of a health insurance and the scientific obligations of university medicine is given. An important and decisive criterium for the health insurances results from the demand for economics.

Complementary Therapies↗
PubMed1998

Performance measurement in pneumonia care: beyond report cards.

OBJECTIVE: To compare the medical management of bacteremic pneumococcal pneumonia at a university-based and a community-based teaching hospital and evaluate strategies for performance measurement and subsequent improvement. DESIGN: We conducted a retrospective cohort study involving a 450-bed university hospital in the inner city and a 400-bed private hospital in a rural community. MATERIAL AND METHODS: The medical records of all adults with bacteremic pneumococcal pneumonia admitted to a university and a community hospital during a 5-year period were reviewed. Information about patient age, sex, underlying medical condition, severity of disease, health-care insurance, management, and outcome was collected and analyzed. RESULTS: Patients at the two hospitals were similar in underlying illnesses and severity of disease. In comparison with the community hospital, resource expenditure was greater at the university hospital, where all 11 identified diagnostic measures and treatment resources were used more often. This difference was statistically significant for sputum cultures, all cultures, and lumbar punctures. Despite the greater intensity of care, in-hospital mortality was higher at the university hospital (26%) than at the community hospital (12%) (P>0.1). CONCLUSION: The outcome of bacteremic pneumococcal pneumonia did not differ significantly at a university hospital in comparison with a community teaching hospital, even though resource expenditure at the university hospital was greater. Our findings suggest that hospital "report cards" based solely on outcome comparisons provide inadequate information. In contrast, examination of variations in profiles of resource utilization can detect important differences in hospitals and can be used to guide continuous quality improvement efforts and ultimately improve hospital care.

APACHE↗
PubMed2003

Proposal of the Physicians' Working Group for Single-Payer National Health Insurance.

The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care--the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least 200 billion dollars annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage.

Cost Control↗
PubMedDate not supplied

National health insurance and its impact on group practice. Part one.

In the last decade, medical group practices have readily adapted to the prospective payment system and managed care environment. In this article, Thomas Weil, Ph.D., speculates on the possibility and impact of equal access and universal coverage, i.e., national health insurance.

Forecasting↗
PubMed1998

Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan.

STUDY OBJECTIVES: To assess whether the introduction of "managed care" (capitated budget and utilisation control by general practitioners) in a Swiss health insurance plan caused a selective disenrolment of plan members, and whether it achieved its goal of reducing health care expenditures. DESIGN: Controlled before-after analysis of health insurance claims. SETTING: Health insurance plan of the University of Geneva, Switzerland, which introduced managed care at the end of 1992, and comparison plan, which reimbursed health care expenditures without setting a budget or controlling access. PARTICIPANTS: Analysis of self selection: university plan members who accepted (3993) or refused (659) transfer to managed care. Analysis of change in expenditures: cohorts of persons continuously enrolled in the university (1575) and comparison (3384) plans in 1992 and 1993. MAIN RESULTS: During 1992, the year before the transformation of the university plan, persons who refused managed care had generated 35% higher expenditures than those who accepted managed care (p < 0.001). Between 1992 and 1993, expenditures per member decreased by 9% in the university cohort and increased by 11% in the comparison cohort (p = 0.004). Technical procedures (laboratory tests, physical therapy, drugs) decreased most in the university plan. No impact on hospital admissions was detected. CONCLUSIONS: Introduction of gatekeeping and budget management by physicians caused a favourable self selection process for the university plan. In addition, the managed care plan achieved a substantial decrease in overall health care expenditures in its first year of operation, chiefly by reducing outlays for technical procedures.

Adult↗
PubMed2004

Billing and reimbursement for pediatric surgical services: a unique assessment of a complex process.

BACKGROUND/PURPOSE: Billing and reimbursement for pediatric surgical services is a complicated process that has not been rigorously evaluated. This study evaluates pediatric surgery billing and reimbursement and compares the process between third party payors. METHODS: The authors tracked all noncapitated bills from submission to final payment for all cases performed during 1 month. Data included operation, insurance type, amount billed, and amount collected. If payments were denied, the reasons were ascertained and the appropriateness verified. Chi-square and Student's t tests were used for comparisons. RESULTS: The billing process for all noncapitated pediatric surgical cases during May 2000, was reviewed (n = 136). The majority of bills (79%) were paid outright. Of the rejected bills, 76% were denied inappropriately. Inappropriate denial of payment was most frequent among patients insured by Medicaid. Mean time to complete payment was longest among patients insured by managed care groups. Percent of total charges reimbursed for surgical services was significantly lower for patients insured by Medicaid and Health Maintenance Organizations (HMO). CONCLUSIONS: A significant number of bills for pediatric surgical services are rejected inappropriately. Careful analysis of one's rejected bills can recoup up to 20% of revenue. HMO's and Medicaid are more likely to deny payment inappropriately, take longer to make payments, and reimburse less for pediatric surgical services.

Costs and Cost Analysis↗
PubMed1991

Canada's universal-comprehensive healthcare system.

The Canadian healthcare system consists of provincial- and territorial-based health insurance plans that provide universal-comprehensive coverage for medically necessary hospital and physician services, the public funding of healthcare with no financial-access barriers, and the private delivery of care. A profile of the Canadian system and its expenditures fosters some noteworthy comparisons between Canadian and U.S. healthcare.

Canada↗
PubMed2002

A cross-sectional audit of student health insurance waiver forms: an assessment of reliability and compliance.

To assess the reliability of using a waiver process to ensure compliance with health insurance requirements established by a university, the author conducted a cross-sectional verification and compliance audit of insurance waiver forms received for the 1999/2000 academic year. This study revealed that a waiver form process could not be relied upon to enforce compliance.

Adolescent↗
PubMed1997

Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system.

As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas.

Adolescent↗
PubMed1998

Collaborative approaches to purchasing and managing oncology services for a prepaid population.

BACKGROUND: Change created by managed care plans is producing tensions among oncology care providers, health plans, patients, and employers. Managed care plans, which now are dominant, are engendering concern among some patients and providers because those plans limit provider choice and reimbursement, as well as inject themselves in clinical decision-making. Collaborative approaches to purchasing and managing oncology service for a prepaid population should help reduce these tensions. METHODS: This article provides a case history of how Harvard University Health Services, a managed care delivery and insurance program serving the university collaborates with contracted oncology providers. The described approach defines mutually beneficial payment and shared responsibility for care in the context of patient centered values. As a part of this collaborative effort, liberal experimental treatment coverage is offered. RESULTS: Patient care is improved because the flow of clinical information among caregivers is improved. When communication is more open, nurse case managers who work for the managed care plan also can arrange for covered services in a more expeditious manner. CONCLUSIONS: Collaboration among health plans, oncologists, and other health care providers to provide patients with high quality, cost-effective care on a fully informed basis is challenging, but not impossible. The key is to define common ground and commitment to the needs of patients among health plans and providers.

Cooperative Behavior↗