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PubMed2001

Disability, chronic illness, and risk selection.

As high-cost users of health care, people with disabilities or chronic conditions are particularly vulnerable to risk selection. Preferred risk selection, in which insurers avoid enrolling high-risk people, threatens their access to coverage. Adverse selection, in which high-risk people enroll in the most generous plans, compromises the financial viability of plans that are most responsive to their specific needs. The Americans with Disabilities Act prohibits some forms of risk selection, but does not prevent all disability-based distinctions in insurance practices. From a disability perspective, risk selection must be addressed in a manner that: (1) adequately reflects the health care costs of such individuals; (2) eliminates their need to engage in adverse selection; (3) does not stigmatize them; (4) preserves confidentiality of information; (5) uses substantial outcome measures to ensure quality; and (6) creates market conditions that discourage disability-based discrimination. A risk adjuster based on prior use/expenditures or on a diagnostic indicator sensitive to disability issues may be effective. Failure of reform to address risk selection may threaten the viability of a market-based health care system.

Chronic Disease↗
PubMed2002

Policy change and private health insurance: did the cheapest policy do the trick?

From the introduction of Australia's national health insurance scheme (Medicare) in 1984 until recently, the proportion of the population covered by private health insurance declined steadily. Following an Industry Commission inquiry into the private health insurance industry in 1997, a number of policy changes were effected in an attempt to reverse this trend. The main policy changes were of two types: "carrots and sticks" financial incentives that provided subsidies for purchasing, or tax penalties for not purchasing, private health insurance; and lifetime community rating, which aimed to revise the community rating regulations governing private health insurance in Australia. This paper argues that the membership uptake that has occurred recently is largely attributable to the introduction of lifetime community rating which goes some way towards addressing the adverse selection associated with the previous community rating regulations. This policy change had virtually no cost to government. However, it was introduced after subsidies for private health insurance were already in place. The chronological sequencing of these policies has resulted in substantial increases in government expenditure on private health insurance subsidies, with such increases not being a cause but rather an effect of increased demand for private health insurance. The paper also considers whether the decline in membership that has occurred since the implementation of lifetime community rating presages the re-emergence of an adverse selection problem in private health insurance. Much of the decline to date may be attributable to failure on the part of some members to honour premium payments when they first fell due. However, the changing age composition of the insured pool since September 2000, resulting in an increasing average age of those insured, suggests the possible reappearance of an adverse selection dynamic. Thus the 'trick' delivered by lifetime community ratings may not be maintained in the longer term.

Australia↗
PubMed2002

Conflicting interests in private hospital care.

This article looks at key changes impacting on private hospital care: the increasing corporate ownership of private hospitals; the Commonwealth Government's support for private health; the significant increase in health fund membership; and the contracting arrangements between health funds and private hospitals. The changes highlight the often conflicting interests of hospitals, doctors, Government, health funds and patients in the provision of private hospital care. These conflicts surfaced in the debate around allegations of 'cherry picking' by private hospitals of more profitable patients. This is also a good illustration of the increasing entanglement of the Government in the fortunes of the private health industry.

Australia↗
PubMed1995

Malpractice coverage for health professionals with physical, mental, or substance-abuse impairments. How do insurance companies make their decisions?

How do insurance companies decide whether or not to provide malpractice insurance to health professionals? What information do they gather on applicants and renewing policyholders? Who has the responsibility to determine if health professionals are suffering from physical, mental, or substance-abuse impairments that make them unfit to care for patients? The authors conducted a survey to find the answers to these questions.

Data Collection↗
PubMed2004

Investigating genetic discrimination in Australia: opportunities and challenges in the early stages.

Genetic discrimination, defined as the differential treatment of individuals or their relatives on the basis of actual or presumed genetic differences, is an emerging issue of interest in academic, clinical, social and legal contexts. While its potential significance has been discussed widely, verified empirical data are scarce. Genetic discrimination is a complex phenomenon to describe and investigate, as evidenced by the recent Australian Law Reform Commission inquiry in Australia. The authors research project, which commenced in 2002, aims to document the multiple perspectives and experiences regarding genetic discrimination in Australia and inform future policy development and law reform. Data are being collected from consumers, employers, insurers and the legal system. Attempted verification of alleged accounts of genetic discrimination will be a novel feature of the research. This paper overviews the early stages of the research, including conceptual challenges and their methodological implications.

Australia↗
PubMed2005

'Genetics is not the issue': insurers on genetics and life insurance.

This article offers an analysis of the way private insurers deal with the issue of genetics and insurance. Drawing on specific written insurance sources, a reconstruction is made of internal debates on genetics and insurance within the private insurance world in Europe and the United States. The article starts by analyzing the way insurers initially framed the issue of genetics. It proceeds by showing how ideas with respect to this issue developed beyond public policy debates in the nineties. Although not a strictly linear development, a trend towards a change in perspective can be demonstrated: at the beginning most insurance companies took another stance than they do nowadays. The article concludes by questioning the effect of these changes within the insurance world for the definition of the problem with respect to genetics and insurance. Does taking into account the public concerns around genetics also include taking genetics as a public problem?

Actuarial Analysis↗
PubMed2001

Risk-adjusted capitation. The Israeli experience.

As in a number of countries during the 1990s, Israel's health system has been undergoing structural reform based on public contracting and regulated markets. The main element of the reform was the enactment of the National Health Insurance Law (NHI), which went into effect on 1 January 1995. According to the Law, the sick funds receive risk-adjusted capitation payments, which place them fully at risk for the cost of supplying a legally mandated basket of health benefits. The paper analyses the effects of the NHI on the Israeli competitive health insurance market and discusses the major policy issues facing the Israeli system.

Capitation Fee↗
PubMed1993

New perspectives on the affordability of long-term care insurance and potential market size.

A study of over 6,000 elderly long-term care insurance purchasers shows that the typical policy sold costs $102 per month, covers 5 years of nursing home care and pays $69 per day in benefits. Close to one-third of the purchasers have incomes less than $20,000, most (63%) use some savings to pay for premiums, 37% spend more than 5% of income on policies. Most nonpurchasers cited reasons unrelated to policy cost to explain why they did not buy a policy.

Age Factors↗
PubMed2002

Outpatient encounter data for risk adjustment--a view from Europe: comments on Welch.

This article comments from a European perspective on W. Pete Welch's article, which examines the use of outpatient encounter data for risk adjustment. Although diverse, Western European health care systems all seek to provide a comprehensive package of care, financed by premiums unrelated to health status. Some form of risk adjustment is therefore required as a basis for funding insurers in all systems. Two objectives have dominated: to secure equity between patients covered by different insurers and to ensure that (where implemented) competitive insurer markets operate efficiently. The commentary concludes that, although risk adjustment research of this type is important, the most fundamental requirement is to develop a more active purchasing function on the part of insurers.

Ambulatory Care↗
PubMed1997

Insurability of children with congenital urological anomalies.

PURPOSE: We sought to determine life insurance underwriting practices for children diagnosed with multicystic dysplastic kidney or unilateral neonatal hydronephrosis, and evaluate whether management options (observation versus operative intervention) have an influence on such practices. MATERIALS AND METHODS: A questionnaire and history of 1 child with multicystic dysplastic kidney and 1 with unilateral neonatal hydronephrosis were distributed to 348 insurance companies licensed to issue life insurance policies in New Jersey. The medical director of each insurance company was requested to indicate the current underwriting practices for life insurance policies based on these 2 case scenarios, and asked whether observation or operative intervention influenced such decisions. RESULTS: Of the 348 insurance companies licensed to issue life insurance 130 (37.4%) responded, including 5 (3.8%) that did not choose to participate in the study, 56 (43.1%) that did not issue life insurance to children and 69 (53.1%) that completed the questionnaire based on current life insurance underwriting practices. For a child with multicystic dysplastic kidney 10 companies (14.5%) would issue life insurance if treatment involved observation only, while 49 (71%) would do so after nephrectomy. For a child with unilateral neonatal hydronephrosis 19 (27.5%) companies would issue life insurance if treatment involved observation only, while 46 (66.7%) would do so after pyeloplasty. CONCLUSIONS: Despite limited long-term data on and uncertainty about the natural course of multicystic dysplastic kidney and unilateral neonatal hydronephrosis, treatment options offered a child with a congenital urological anomaly may have a significant impact on the ability to obtain life insurance. Children with multicystic dysplastic kidney and unilateral neonatal hydronephrosis can usually obtain life insurance after early operative intervention (nephrectomy and pyeloplasty, respectively), although sometimes at higher cost.

Child↗