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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↗
PubMed2004

Prescription patterns of hypertension--National Health Insurance in Taiwan.

BACKGROUND: Hypertension is a universal disease. Treatment patterns of hypertension provide valuable information for clinicians. Therefore, we present the patterns of antihypertensive medications in Taiwan by their pharmacological classifications, breaking down by patients' ages and genders. METHODS: A descriptive and cross-sectional analysis was performed. Claims from the National Health Insurance of Taiwan were used and included all ambulatory cares of 21 million people from July 1, 1997 to June 30, 1998. A total of 9,717,960 visits with 16,595,030 matched records of antihypertensive medications were obtained. Hypertensive medications were divided into 5 main categories; monotherapy and multiple therapy were defined and discussed separately. Frequency and proportion of utilization of antihypertensive medication were charted and figured. RESULTS: The most frequently prescribed antihypertensive medications were: calcium antagonists: 5,332,527 records (54.9% of enrolled visits); beta-blockers: 4,230,843 records (43.5%); angiotensin converting enzyme inhibitors (ACEIs): 3,057,009 records (31.5%); diuretics: 2,255,838 records (23.2%); and "others": 1,647,100 records (16.9%). Regardless of gender, the top 2 prescription patterns were calcium antagonists and beta-blockers for monotherapy, beta-blockers + calcium antagonists and ACEIs + calcium antagonists for multiple therapy. CONCLUSIONS: Although Taiwan is a country with National Health Insurance, patterns of pharmacologic treatment of hypertension in Taiwan are close to those in the US, not to those of countries in Europe. Also, these treatments were tailored to the conditions of the patients.

Adolescent↗
PubMed1990

Choosing among health insurance options: a study of new employees.

This study examines how 296 new university employees selected among alternative health care options. Those selecting a traditional Blue Cross and Blue Shield (BC&BS) plan attributed greater importance to freedom of choice of physician, while those selecting an HMO were more likely to give priority to cost considerations in seeing a doctor and to having services at a single location. Better educated respondents and those with more recent experience with the medical care system were more accurate in objectively appraising alternative choices. Respondents, whether choosing a BC&BS plan or an HMO, tended to deny the gatekeeper roles of physicians in HMOs, although the BC&BS plan enrollees were somewhat better informed.

Attitude↗
PubMed2006

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia.

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.

Armenia↗
PubMed1995

The health insurance system in Korea and its implications.

The national health insurance system was introduced in Korea in 1977 and achieved universal coverage in July 1989. This article briefly describes the general features of the insurance scheme: coverage, management, benefit package, financing provision of medical services and method of reimbursement. Generally speaking, the system mirrors that of the German and Japanese experiences. Although the Korean health insurance system achieved universal coverage during a remarkably short time-span, there is much room for improvement. In this regard, the article also highlights the problems related to Korea's health insurance system and the attempts to improve equity and efficiency in both financing and provision of services.

Cost-Benefit Analysis↗
PubMed2002

Association of medical insurance and other factors with receipt of antiretroviral therapy.

OBJECTIVES: This study was designed to assess sociodemographic and medical insurer factors associated with receipt of highly active antiretroviral therapy (HAART). METHODS: Patients included (n = 959) were enrolled in the Johns Hopkins HIV Clinic after April 1, 1996, received > or = 90 days of care, and had a CD4 count > or = 500 cells/mm3 or HIV-1 RNA > 20 000 copies/mL. We assessed the associations of sociodemographic factors and medical insurance with receipt of HAART, stratified by 2 time periods (April 1996 through March 1997 versus April 1997 through March 1999). RESULTS: HAART was more likely to be used in patients who were > 39 years, White, had CD4 counts < 350 cells/mm3, had fewer missed clinic visits, and did not have intravenous drug use as their risk factor for HIV transmission. In period 1 (April 1996 through March 1997), HAART was more likely to be used in patients who were commercially insured than in other payer groups; differences between payers narrowed in period 2 (April 1997 through March 1999), however, as did differences by race. CONCLUSIONS: Differences in use of HAART on the basis of payer have narrowed since 1996. This encouraging finding may demonstrate the importance of programs that lower economic barriers to medical care.

Adolescent↗
PubMed2005

[Community financing for health care in Africa: mutual health insurance].

Health care in sub-Saharan Africa is increasingly financed by direct payments from the population. Mutual health insurance plans are developing to ensure better risk sharing. However mutual health insurance cannot fully resolve all equity issues. The low resources available for contribution and the limited availability of care services especially in the public sector cannot guarantee the quality of care necessary for the development of mutual health insurance. National governments must not forget their responsibility especially for defining and ensuring basic services that must be accessible to all. Will mutual health insurance plans be a stepping-stone to universal health care coverage and can these plans be successfully implemented in the context of an informal economy?

Africa South of the Sahara↗
PubMed2003

Probabilistic linkage in household survey on hospital care usage.

OBJECTIVE: To evaluate the potential advantages and limitations of the use of the Brazilian hospital admission authorization forms database and the probabilistic record linkage methodology for the validation of reported utilization of hospital care services in household surveys. METHODS: A total of 2,288 households interviews were conducted in the county of Duque de Caxias, Brazil. Information on the occurrence of at least one hospital admission in the year preceding the interview was obtained from a total of 10,733 household members. The 130 records of household members who reported at least one hospital admission in a public hospital were linked to a hospital database with 801,587 records, using an automatic probabilistic approach combined with an extensive clerical review. RESULTS: Seventy-four (57%) of the 130 household members were identified in the hospital database. Yet only 60 subjects (46%) showed a record of hospitalization in the hospital database in the study period. Hospital admissions due to a surgery procedure were significantly more likely to have been identified in the hospital database. The low level of concordance seen in the study can be explained by the following factors: errors in the linkage process; a telescoping effect; and an incomplete record in the hospital database. CONCLUSIONS: The use of hospital administrative databases and probabilistic linkage methodology may represent a methodological alternative for the validation of reported utilization of health care services, but some strategies should be employed in order to minimize the problems related to the use of this methodology in non-ideal conditions. Ideally, a single identifier, such as a personal health insurance number, and the universal coverage of the database would be desirable.

Adolescent↗
PubMed2006

The effect of crowding on access and quality in an academic ED.

BACKGROUND: Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality. METHODS: This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction. RESULTS: During data collection periods, 11743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (kappa = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times. CONCLUSIONS: We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.

Adult↗
PubMed1997

Introducing managed care in Switzerland: impact on use of health services.

The objectives of this study were to assess changes in the self-reported use of health care services after gatekeeping by general practitioners and a global budget were introduced in the health insurance plan for students at the University of Geneva, Switzerland, in October 1992. A random sample of 336 members of the University plan answered questions about their use of health care services during the year before (1992) and the year after (1993) the introduction of managed care. Similar data were collected among a random sample of 300 members of a comparison plan. All participants were 18-44 y old in 1992, spoke French and lived in Geneva. The proportion of insurees who visited specialists decreased by 10% in the University plan between 1992 and 1993 and remained unchanged in the comparison group. The proportion of insurees who visited general practitioners increased by 12% in the University plan and remained unchanged in the comparison group. No effects on the total number of health care visits, on hospitalisations or on use of medications were detected. The introduction of gatekeeping and of a global budget managed by physicians was associated with a transfer of patient visits from specialists to general practitioners.

Adolescent↗
PubMedDate not supplied

Denial of emergency department authorization of potentially high-risk patients by managed care.

This study was designed to evaluate patients presenting to a large urban university emergency department (ED) who were subsequently denied authorization for reimbursed care by their managed care provider and to characterize the denial as potentially safe or unsafe based on published triage criteria. A consecutive case surveillance was performed from October 1, 1994 to September 30, 1995 at a university-based ED (30,000 visits per year) for adult patients in inner-city Chicago. Cases were comprised of adult managed care participants whose providers refused by telephone to authorize payment for ED services and who then left the ED without treatment. Chief complaints and vital signs were used to categorize patients as high-risk or nonemergent based on previously published criteria. A total of 2,965 adult managed care patients presented to the ED during the study period, representing 11.1% of the total ED census. Of these patients, 244 (8.2%) were denied authorization for payment of their care. By previously established criteria, 115 (47.1%) were identified as potentially unstable, 61 (53%) due to abnormal vital signs and 54 (47%) with other high-risk indications such as severe pain, chest pain, or abdominal pain. These potentially high-risk patients may subsequently suffer adverse outcomes. Current guidelines used for telephone triage by managed care to divert patients from our ED do not meet previously published safe triage criteria.

Adult↗
PubMed2004

Influence of health insurance status on inclusion of HER-2/neu testing in the diagnostic workup of breast cancer patients.

OBJECTIVE: . To assess the prevalence of HER-2/neu testing in a community-based health care system shortly after the approval of several laboratory kits for HER-2/neu testing for diagnostic purposes by the US Food and Drug Administration and to discern the best discriminating variables for inclusion of the test in the diagnostic workup of breast cancer patients. DESIGN: A retrospective cross-sectional study was designed to analyze data for the period beginning 1 January 1999 and ending 31 December 2000. SETTING: Henry Ford Health System, the largest health care system in southeastern Michigan, is a comprehensive, self-contained system. STUDY PARTICIPANTS: Four hundred and fifty-one women diagnosed with primary invasive breast cancers were consecutively sampled from the tumor registry of the Henry Ford Health System. RESULTS: The proportion of women tested for HER-2/neu increased by 2-fold during year 2 of the observation. Absence of estrogen receptors (OR = 1.96, 95% CI 1.15-3.21), physicians with specialty in surgery (OR = 6.21, 95% CI 2.88-13.33, P = 0.0001), and having a capitated insurance (OR = 1.59, 95% CI 1.06-2.44, P = 0.027) were associated with HER-2/neu testing. CONCLUSION: Absence of estrogen receptors was the only pathological characteristic associated with HER-2/neu testing. The effect of specialization in surgery on the increased likelihood of HER-2/neu testing can be explained mostly by the 'patient volume effect'. The observed disparity in the delivery of innovative diagnostic approaches to cancer patients was influenced by the type of health insurance. Implementation of institutional policies can improve in providing universal quality of care for all patients regardless of their health insurance.

Biomarkers, Tumor↗
PubMed1997

Dilemmas of anonymous predictive testing for Huntington disease: privacy vs. optimal care.

Some persons at risk for Huntington disease (HD) seek predictive testing under the protection of anonymity to reduce the risk of insurance discrimination for themselves and their families. While Canadian and European health care systems seem to limit insurance discrimination to life and disability insurance, U.S. residents do not have national health insurance and are concerned about health insurance discrimination. Two persons residing outside Canada requested predictive testing anonymously. Their primary reason for doing so was to avoid the risks of medical insurance discrimination. After a detailed preparatory session and agreement to counselling and to receipt of results in person, we agreed to provide anonymous testing to these persons. One participant, whose psychological assessment was unremarkable, coped well with the predictive testing process and did not have the CAG expansion. The other participant had considerable emotional problems prior to testing, which necesitated postponement of discussion of results and referral for psychiatric assessment and support. Both participants had difficulty maintaining anonymity. The provision of anonymous predictive testing raises several problems. With anonymous testing, clinicians cooperate with participants to exclude insurance companies from information. This may invalidate the contract with insurance companies. A policy response by insurance companies or a universal health care system to protect individuals is preferable. Individuals who request anonymous testing may be precisely those most vulnerable and in need of additional support and counselling. However, the preservation of anonymity is a burden to participants and may frustrate the clinicians' ability to establish rapport in counselling and to provide appropriate follow-up typically available through genetic counselling in predictive testing programs.

Adult↗
PubMed2007

[Project "Partnership"--university surgical departments and hospitals for basic and regular medical care. Directing cooperation for the future].

Over the last 20 years, urgently needed changes in the German health care system have forced hospitals to make a flexible adjustment to rising costs and the single handed, almost unmanageable dynamics of technical innovation in medicine. The partnership between the Salem Hospital and the Heidelberg University Hospital represents a pioneering management concept for the future. The alliance between a university surgical department with a basic peripheral hospital provides large advantages to patients, staff, hospitals and cost carriers.

Cost Allocation↗