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PubMedDate not supplied

[The structure of old age insurance carriers and the principle of subsidies].

This paper reports on the organizational structure of public and non-public welfare institutions for the aid to the aged. The latter ("charitable non-profit associations") constitute the most important social institutions based on voluntary rather statutory provision of social services in the Federal Republic of Germany. The first section is devoted to a description of the legel provisions regarding goals, institutions, type and means of service provision of different institutions aiding the aged in relation to each other. In conclusion, the hierarchical structure of the institutions is discussed in relation to the observance of the principle of subsidiarity. In the framework of a critical discussion of the concept of neocorporationalism, it is pointed out that in any analysis of the institutional structure of the aid to the aged it is necessary to take into consideration the behavior of those concerned.

Aged↗
PubMed1998

[Target agreements between insurance carriers and hospitals as instrument for modifying hospital length of stay].

In 1995 the statutory sickness fund (AOK) in Magdeburg arranged target agreements with 10 of 23 acute care hospitals in its district to exercise an influence on the development of the average length of hospital stay. With the aim of decreasing the length of stay as well as the administrative cost and effort, these agreements set upper limits on the average length of stay which were hospital-specific and period-specific. In return, with only a few exceptions, the AOK Magdeburg refrained from limiting the coverage of individual cases. Hospital cases discharged from 1994 and 1996 were analysed to determine whether the development of the length of stay in the ten hospitals with target agreements differed from that in the other 13 hospitals. Only some of the hospitals were successful in reaching their target agreements. The average length of stay dropped by 4.2% in the hospitals with target agreements and by 7.9% in those without target agreements. This must be considered in the context of the development of the case load and number of available hospital beds. For instance, in spite of a target agreement, one hospital showed a (compensatory) increase in the average length of stay in association with an increase in the number of authorized beds and a concurrent decrease in the number of cases. The number of days billed by AOK patients per authorized bed (as an indicator of hospital productivity) showed a more favourable development in the group of hospitals with target agreements than in the other group. This was not a controlled trial as far as the selection of the hospitals is concerned. The results suggest that there is no harm in incentives that induce hospitals to manage primarily on their own the average length of stay. The use of routine aggregate data in monitoring this development, rather than the current more expensive individual case approach, also seems reasonable. Well planned studies that further test the "tool" of target agreements can be recommended.

Cost Control↗
PubMed1982

Dental insurance plans--boon or bane to the dental practitioner?

The dentist who participates in reimbursement pursuant to a dental insurance plan establishes a legal relationship to the insurance carrier, which is governed by third-party beneficiary concepts in law. The terms of the dental plan provide specific links to the provider of dental services, which include the right to review the quality of dental services rendered, the right to determine what are reasonable charges for the services rendered, and the right, through subrogation and indemnification, to recover what the insurance carrier determines to be improper payments to the insured and the dentist. The enforcement of those rights against the dentist can affect the manner in which he practices his profession. The failure of the dental practitioner to properly protect his interests when challenged by the insurance carrier under the plan can have adverse and far-reaching consequences upon his practice and upon his very license. It therefore behooves the dental practitioner to be fully knowledgeable of the potential pitfalls to his participation in dental insurance plan reimbursement programs. Unfortunately, the touting of the benefits accruing to the dental practitioner by participation in such plans tends to mask their dangers. It is hoped that this article will have shown that it is incumbent upon the dentist to ensure that his professional record with the insurance carrier and any dental review board accurately reflects proper professional judgement by him in participating in a dental insurance plan.

Adolescent↗
PubMed2004

Exploratory evidence on the market for effective depression care in Pittsburgh.

OBJECTIVE: Despite the existence of effective and relatively cost-effective depression treatments, many depressed patients do not receive appropriate care. The authors assessed opportunities for increasing the rate of effective depression treatment by investigating the market for such treatment in the Pittsburgh area. METHODS: A conceptual framework was developed to evaluate the market for effective depression care. On the basis of the conceptual framework, interviews were conducted with representatives from seven large employers, two medical health insurance carriers, two behavioral health insurance carriers, four primary care providers, and four behavioral health care providers. Respondents were asked to assess the barriers to and opportunities for increasing the rates of depression treatment from their perspectives. RESULTS: The findings suggest that there is currently little demand among purchasers for improving depression care and little interest among insurers and providers for improving care in the absence of purchaser demand. Even stakeholders who identified depression as an important problem could not come to a consensus about who should be responsible for addressing the problem. Employers reported that they look primarily to their vendors to initiate quality improvement efforts, whereas insurers reported that such improvement efforts were more likely to occur if they were initiated by employers who purchase their health plans; providers, in turn, reported feeling powerless to initiate change. CONCLUSIONS: The absence of a clear locus of responsibility for improving depression care lends considerable inertia to the status quo. Because the currently low treatment rates are likely to be socially inefficient, researchers and policy makers should consider strategies to help overcome this inertia.

Catchment Area, Health↗
PubMed1958

Analysis of your professional liability insurance policy.

The most important lessons for the physician to learn in regard to his professional liability insurance coverage are the following:1. The physician should carefully read his professional liability policy and should secure the educated aid of his attorney and his insurance broker, if they are conversant with this field.2. He should particularly read the definition of coverage and carefully survey the exclusion clauses which may deny him coverage under certain circumstances.3. If the physician is in partnership or in a group, he should be certain that he has contingent partnership coverage.4. The physician should accept coverage only from an insurance carrier of sufficient size and stability that he can be sure his coverage will be guaranteed for "latent liability" claims as the years go along-certainly for his lifetime.5. The insurance carrier offering the professional liability policy should be prepared to offer coverages up to at least $100,000/$300,000.6. The physician should be assured that the insurance carrier has claims-handling personnel and legal counsel who are experienced and expert in the professional liability field and who are locally available for service.7. The physician is best protected by a local or state group program, next best by a national group program, and last, by individual coverage.8. The physician should look with suspicion on a cancellation clause in which his policy may be summarily cancelled on brief notice.9. The physician should not buy professional liability insurance on the basis of price alone; adequacy of coverage and service and a good insurance company for his protection should be the deciding factors.

Insurance↗
PubMed1983

Psychiatric benefits and insurance regulation in Massachusetts: a national model?

The Massachusetts Mandatory Mental Health Insurance Act requires all health insurance plans in the state to cover mental illness. Because of their concerns that this law might be taken as a national model, the authors describe the problems encountered in implementing it and the conflicts between the insurance carriers and psychiatry. The authors attribute the problems to some insurance carriers' failure to deal directly with organized psychiatry in obtaining screening guidelines, the absence of psychiatrists on the carriers' central committees, and psychiatrists' generally indifferent and hostile attitudes toward the carriers. The authors describe recent improvements and recommendations based on 10 years of experience.

Attitude of Health Personnel↗
PubMed1991

[Meaning of the "scientific validity clause" of private hospital insurance (section 5/1 f MB/KK 76). With reference to recent verdicts].

As per Section 5/1 f of the classic conditions 1976 of the "Association of private health insurance carriers" (Verband der privaten Krankenversicherung), benefits won't be paid for methods of examination or treatment and remedies which are from the scientific point of view generally not recognized. Basic reflections have led to the fact that today the term "scientifically recognized methods" and the term "traditional medicine" will be treated as equivalent. Contrary verdicts, according to which treatments on the basis of anthroposophic medicine or by means of electro-acupuncture by Voll would be considered as generally recognized medicine from the scientific point of view and would have to be paid by the private health insurance carriers, are consequently not comprehensible. Supposing that the trend continues that private health insurers have to pay more and more expenses incurred for all kind of outsider-methods, this would lead not only to a great drain on the purse of the private health insurance carriers, but have also unpleasant consequences for the whole medicine, because the uniformity of the medicine is endangered. To take steps against has not only to be the task of the private health insurance carriers, but it is also in the interest of the physicians and, at last, of the patients, too.

Complementary Therapies↗
PubMed2006

Determining the limits of orthodontic treatment of overbite, overjet, and transverse discrepancy: a pilot study.

INTRODUCTION: Because of the severity of some malocclusions, it is not always possible to treat them without a combination of orthodontics and orthognathic surgery. However, many insurance carriers have difficulty in deciding whether such treatment should be covered. The purpose of this study was to develop a simple method that can be used by insurance carriers to determine when a malocclusion is not correctable by orthodontics alone. METHODS: Twenty-eight orthodontists independently evaluated 30 sets of pretreatment dental models (10 with overjet from -6 to 12 mm, 10 with overbite from 60% to 100%, and 10 with transverse discrepancies from single tooth to total arch crossbite) to determine whether the conditions were orthodontically treatable. They were instructed to assume that growth was complete and that the treatment would not seriously compromise facial esthetics. RESULTS: It was the opinion of the orthodontists that a positive overjet greater than 8 mm, a negative overjet of -4 mm or greater, and a transverse discrepancy greater than 3 mm were not orthodontically treatable. However, most orthodontists believed that they could treat all overbite patients without surgery. CONCLUSIONS: These data can serve as a simple guideline for helping insurance carriers determine the need for orthognathic surgery.

Feasibility Studies↗
PubMed1988

Outpatient treatment for an adult with traumatic brain injury.

In this case, occupational therapy was invaluable for continuity of care and facilitating the earliest possible successful return to work. The major goal of rehabilitation was for Aaron to prepare to go back to work by relearning or refining all the necessary physical, cognitive, emotional, and perceptual skills. This specialized occupational therapy plan meant that unnecessary services, and therefore unnecessary expenditures, were avoided. Occupational therapy intervention allowed for open communication between the family, the employer, the insurance carrier, and the physician. Throughout treatment, the insurance carrier received regular monthly reports supplemented with periodic telephone updates. The carrier commented favorably on the initial evaluation, believing the information to be comprehensive and relevant. The occupational therapist provided the family with medical information to decrease confusion over medical terminology, provided support as appropriate within the context of treatment, and demonstrated ways that the family could become more involved in Aaron's rehabilitation. Through the weekly treatment sessions and direct observation, Marie was able to more fully understand the scope of her husband's disability. It is interesting to contrast the hospital findings and the findings of the private therapist. Aaron had been diagnosed as having severe visual-spatial deficits on the standardized, clinical tests; however, he showed only limited deficits when tested in functional situations in the familiar home environment 2 weeks later. This contrast demonstrates occupational therapy's unique role in the home setting, where the therapist is able to use relevant and meaningful activities directly related to the client's roles, hobbies, interests, and cultural experiences. The flexibility possible at home should enhance cooperation and success.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidents, Occupational↗
PubMed1990

Evaluation of the cost-effectiveness of home monitoring of uterine contractions.

In 1988, the major health insurance carrier in the state of Hawaii initiated a prospective study to determine the cost-effectiveness of ambulatory uterine activity monitoring. At the end of the study, 79 patients had completed 3189 days on the monitor. Thirty-six patients (45.6%) did not have preterm labor; the daily monitoring resulted in an average loss to the insurance carrier of $3300 per patient, or $118,800. Forty-three patients (54.4%) experienced preterm labor and were found to have benefited from the monitoring system. Earlier detection of preterm labor and better management of oral tocolysis in this group resulted in earlier initiation of maternal tocolytic therapy, which ultimately decreased the preterm birth rate and hospitalization days in the neonatal intensive care unit. Cost analysis of this group demonstrated an average savings of $24,000 per patient, or an overall savings of $1,032,000. The total group of high-risk patients (79) resulted in a net savings to the insurance carrier of $913,200, or $11,500 per patient, suggesting that use of the ambulatory uterine activity monitoring system significantly reduced the cost associated with preterm labor and early delivery.

Adult↗
PubMed1980

How self-insurance can offer more for the money.

The author examines the three services that conventional liability insurance carriers offer to hospitals and shows how self-insurance combined with a good risk management program may provide these services better and more cost-effectively.

Financial Management↗