Health care vouchers--a proposal for universal coverage.
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Government Regulation↗
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Results for “Universal Health Insurance”
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Why requiring employers to provide health insurance is a bad idea.
There is mounting pressure at the federal (and state) level to require employers to provide health insurance to their employees. However, two quite different groups of workers could be affected by such a mandate. In addition, there are at least five major problems with requiring employers to provide health insurance. Chief among these is the further fracturing of the insurance market, so that the spreading of risk will be reduced, and only the young and healthy will be offered insurance at relatively low premiums. We should be designing a health insurance system that has both universal coverage and a cost-containment structure. Toward this end, we need to tackle issues that transcend alternative methods of financing health care in the U.S.
Evaluation Studies as Topic↗
A critical review of the arguments for insurance coverage for smoking-cessation therapies.
This article elucidates the reasons most insurance companies do not cover smoking-cessation therapies despite their obvious benefits. It critically reviews the arguments for and against using a universal mandate as a strategy to increase use of smoking-cessation programs to realize the associated health benefits and cost-savings. While convincing arguments exist to mandate insurance coverage for self-destructive health behaviors, their merit is tempered by several valid counter arguments. For example, insurance coverage for small, routine, and predictable events, such as smoking-cessation treatment, violates the "first principles" of what ought to be covered when considered from the traditional insurance perspective. An insurance solution to risky behaviors may be to make undesirable behaviors more undesirable to individuals by raising premiums rather than to make them less undesirable with subsidies.
Cost Savings↗
Cancer risk in patients with inflammatory bowel disease: a population-based study.
BACKGROUND: The objective of the current study was to determine the incidence of cancer among persons with inflammatory bowel disease (IBD) and to compare these incidence rates with those of the non-IBD population using population-based data from the administrative claims data of Manitoba's universal provincial insurance plan (Manitoba Health). METHODS: IBD patients were matched 1:10 to randomly selected members of the population without IBD based on year, age, gender, and postal area of residence. The incidence of cancer was determined by linking records from the IBD and non-IBD cohorts with the comprehensive Cancer Care Manitoba registry. Incidence rates and rate ratios (IRR) were calculated based on person-years of follow-up (Crohn's disease = 21,340 person-years and ulcerative colitis [UC] = 19,665 person-years) for 1984-1997. RESULTS: There was an increased IRR of colon carcinoma for both Crohn disease patients (2.64; 95% confidence interval [95% CI], 1.69-4.12) and UC patients (2.75; 95% CI, 1.91-3.97). There was an increased IRR of rectal carcinoma only among patients with UC (1.90; 95% CI, 1.05-3.43) and an increased IRR of carcinoma of the small intestine only in Crohn disease patients (17.4; 95% CI, 4.16-72.9). An increased IRR of extraintestinal tumors was observed only for the liver and biliary tract in both Crohn disease patients (5.22; 95% CI, 0.96-28.5) and UC patients (3.96; 95% CI, 1.05-14.9). There was an increased IRR of lymphoma for males with Crohn disease only (3.63; 95% CI, 1.53-8.62), and this finding did not appear to be related to use of immunomodulatory therapy. Compared with controls, Crohn's disease was associated with an increased risk of cancer overall, but UC was not. CONCLUSIONS: There appear to be similar increased risks for developing colon carcinoma and hepatobiliary carcinoma among patients with Crohn disease and UC. There is an increased risk of developing rectal carcinoma in UC patients, an increased risk of developing carcinoma of the small bowel in Crohn disease patients, and an increased risk of developing lymphoma among males with Crohn disease.
Adult↗
Economic effects of beta-blocker therapy in patients with heart failure.
PURPOSE: Studies suggest that beta-blockers improve outcomes in heart failure patients and may be cost saving to society. However, many heart failure patients are not treated with beta-blockers. Economic incentives facing hospitals, physicians, payers, and patients may not encourage treatment adoption. We assessed the economic effects of beta-blocker therapy from various perspectives: societal, Medicare, hospital, physician, and patient. METHODS: A Markov model of heart failure progression over 5 years was developed. Transition probabilities and the effect of beta-blockers on mortality and hospitalization were based on clinical trial data. Estimates of hospital costs and reimbursement were obtained from the Duke University Medical Center. Physician fees were based on the Medicare fee schedule. RESULTS: Beta-blocker therapy increased survival by 0.3 years per patient and reduced societal costs by US dollars 3959 per patient over 5 years. Medicare costs declined by US dollars 6064 per patient, due primarily to lower hospitalization rates. Unless heart failure admissions could be replaced with other hospitalizations that generated an equal or greater revenue above variable cost, hospital revenue would be negatively affected. Physician revenue from treating heart failure patients would also decline. Patient costs increased with beta-blocker use (US dollars 2113 over 5 years). CONCLUSION: Beta-blocker therapy improves the clinical outcomes of heart failure patients and is cost saving to society and Medicare. However, hospitals and physicians have no clear financial incentives to support increased beta-blocker use. Changes in practice patterns could be encouraged by linking reimbursement with evidence-based care and covering patients' medication costs.
Adrenergic beta-Antagonists↗
Are we expecting too much from print media? An analysis of newspaper coverage of the 2002 Canadian healthcare reform debate.
News media effects on their audiences are complex. Four commonly cited effects are: informing audiences; agenda-setting; framing; and persuading. The release in autumn 2002 of two reports on options for reforming Canada's healthcare system attracted widespread media attention. We explored the potential for each of the four media effects by examining Canadian newspaper representation of this healthcare policy debate. Clippings were gathered from regional and national newspapers. Two data collection methodologies were employed: the first involved two staggered "constructed weeks" designed to capture thematic news framing styles; the second collected "intensive" or episodic coverage immediately following the report releases. Health reform articles with a financing and/or delivery focus were included. Using a codebook, articles were coded to track article characteristics, tone, healthcare sector and reform themes, and key actors. A greater quantity of episodic (n=341 clippings) versus thematic coverage (n=77) was documented. Coverage type did not vary significantly by newspaper, reporting source (e.g., staff reporter versus staff editorialist) or article type (e.g., news versus letter). Thematic articles were significantly shorter in length compared to episodic clippings. Episodic coverage tended to have a positive tone, while thematic coverage ranged in tone. Most coverage was general in scope. Sector-specific coverage favoured physician and hospital care--the two providers accorded privileged financing arrangements under Canada's universal, provincially administered health-insurance plans. Coverage of healthcare financing arrangements favoured broad discussions of publicly financed healthcare, federal-provincial governmental relations, and the Canada Health Act that governs provincial plans. Governmental actors and the political institutions that they represent were the dominant actors. Professional associations were also visible, but played a less dominant role. Given its non-specific scope, it is unclear how informative this coverage was. The large quantity and short duration of the episodic coverage, and the preponderance of governmental actors, suggests these newspapers acted as conduits for the policy agenda. Differences in framing styles were observed by coverage type, newspaper, reporting source, article length and type of article. Finally, the dominance of governmental actors provided these actors with numerous opportunities to persuade the public.
Bibliometrics↗
The changing epidemiology of chickenpox in Alberta.
BACKGROUND: Varicella vaccine was licensed in Canada in 1998. The province of Alberta introduced a universal publicly funded varicella vaccination program in 2001. PURPOSE: To describe the epidemiology of non-fatal cases of chickenpox for which publicly funded health services were utilized for the period 1986-2002. METHODS: We used the records of Alberta's universal, publicly funded health care insurance system to identify cases of chickenpox for the period 1986-2002. The earliest dated utilization of a health service for which there was an ICD9-CM code of 052.xx or an IC10-CA code of B01.xx was used as the date of illness onset. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Registry. Age-specific rates were estimated for each year. RESULTS: The crude incidence of chickenpox significantly declined over the period 1994-2002, most steeply after the year 2000. The incidence of chickenpox varied by age group and year and there was evidence of age-group-year interaction. Among those aged 5-19 years, chickenpox incidence began to decline prior to vaccine licensure in Canada. Among those aged less than one year and those aged 1-4 years, the incidence increased until 1999 when a decline began. Over the period 0.8% of cases were hospitalized. CONCLUSION: Chickenpox rates began to decline prior to the introduction of the publicly funded vaccination program; however the declines in rates among the youngest age-groups are consistent with a vaccination program effect.
Adolescent↗
Rates of successful vaginal delivery after cesarean for patients with private versus public insurance.
OBJECTIVE: To examine the effect of insurance status on method of delivery while controlling for clinical and sociodemographic characteristics of women delivering at a single medical center. STUDY DESIGN: Sociodemographic and clinical characteristics of 878 women, who delivered their infants between 1985 and 1991 at a university hospital, were analyzed. Women were included if their previous infant was delivered by cesarean section and if the current pregnancy was > or = 37 weeks' gestation at nonemergent delivery with insurance status clearly specified. The outcome of interest was the rate of successful vaginal births after cesarean (VBAC) delivery by insurance status. RESULTS: The trial of labor rate for the cohort, defined as the rate of VBAC or cesarean deliveries following labor, was 55%; 61% were vaginal deliveries. Significant differences with regard to insurance status and several maternal factors were noted between trial of labor and cesarean section--no labor groups. After controlling for potentially confounding variables, the Medicaid/indigent group was more likely than the privately insured group to undergo a trial of labor (odds ratio, 1.5; 95% confidence interval, 1.1 to 2.4). Of women who underwent a trial of labor, after controlling for other characteristics, the Medicaid/indigent group was more likely than the privately insured group to deliver vaginally (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2). CONCLUSION: After controlling for other covariables, women with a history of a prior cesarean section with Medicaid/indigent insurance were more likely than privately insured women to attempt a trial of labor, and subsequently, to deliver vaginally, given that a trial of labor was attempted.
Adult↗
Waiting times for knee-replacement surgery in the United States and Ontario.
BACKGROUND: Canada, which has universal single-payer health insurance, is often criticized for waiting times for surgery that are longer than those in the United States. We compared waiting times for orthopedic consultations and knee-replacement surgery and patients' acceptance of them in the United States and in the province of Ontario, Canada. METHODS: A stratified random sample of 1486 Medicare recipients (629 from the U.S. national sample, 428 from Indiana, and 429 from western Pennsylvania) and 516 people from Ontario who had been hospitalized for knee replacement between 1985 and 1989 were surveyed by mail in 1992. Patients were asked how long they had waited to see an orthopedic surgeon and to have surgery, the acceptability of these waiting times, and their overall satisfaction with surgery. RESULTS: About 80 percent of the questionnaires were returned, but not all the respondents answered all the questions. The rate of response to specific questions was about 60 to 65 percent in both countries. The median waiting time for an initial orthopedic consultation was two weeks in the United States and four weeks in Ontario. The median waiting time for knee replacement after the operation had been planned was three weeks in the United States and eight weeks in Canada. In the United States, 95 percent of patients in the national sample considered their waiting time for surgery acceptable, as compared with 85.1 percent in Ontario. Overall satisfaction with surgery ("very or somewhat satisfied") was 85.3 percent for all U.S. respondents and 83.5 percent for Canadian respondents. CONCLUSIONS: Waiting times for initial orthopedic consultation and for knee-replacement surgery were longer in Ontario than in the United States, but overall satisfaction with surgery was similar.
Aged↗
Current hospital costs and medicare reimbursement for endovascular abdominal aortic aneurysm repair.
OBJECTIVE: The purpose of this study was to analyze the current inpatient hospital cost and Medicare reimbursement of endovascular abdominal aortic aneurysm repair (EVAR) at different hospitals. METHODS: The cost of EVAR from October 2000 to October 2001 with two commercially available endografts (Ancure, Guidant Endovascular Solutions, Menlo Park, Calif; and AneuRx, Medtronic AVE, Santa Rosa, Calif) was retrospectively analyzed at seven hospitals. Three university (n = 111) and four community hospitals (n = 110) from different regions of the country participated in the survey. Consecutive cases with complete financial records were included. Hospital finance departments provided their best estimates of hospital costs, including overhead for operating room, endograft, medical supply, bed, radiology, laboratory, and pharmacy services and reimbursement on the basis of hospital-specific Diagnostic Related Groups (DRG) 110 or 111. Detailed hospital charges and International Clinical Diagnosis codes also were reviewed from Universal Billing-92 forms submitted to Medicare. An additional cost analysis was performed by the authors to validate the estimates of the hospital financial departments. Outliers of more than three standard deviations from the mean were excluded. RESULTS: The mean total hospital cost was $22,999, and mean reimbursement, weighted by case mix, was $20,837, resulting in a net loss of $2162. The majority of EVAR cost was from the device (57%) and other medical supplies (16%). EVAR was reimbursed on the basis of DRG 110 in 78% of cases and of DRG 111 in 22%. Reimbursement varied widely by hospital and location (mean, $20,837; range, $14,818 to $35,343; standard deviation, $5450). With the exclusion of one hospital where reimbursement was not based on the DRG, cases reimbursed with DRG 110 resulted in an average loss of $2200, while the average loss was $9198 with DRG 111. The mean net loss for hospitals reimbursed with the DRG system was $3898. CONCLUSION: EVAR reimbursement is presently inadequate to cover hospital expenses. Substantial financial losses occurred at four of the participating centers. University hospitals fared surprisingly better because of higher reimbursement.
Aortic Aneurysm, Abdominal↗
Reducing financial barriers enhances the return rate of stool Hemoccult packets.
Patient compliance in returning fecal-hemoccult card packets has been studied in recent years but no specific interventions have been shown consistently to improve the return rate. It was wondered whether removing a small financial barrier for indigent patients would positively affect compliance. Therefore, the effect of prepaid postage on the rate of return was studied. Pre-prepared packets containing hemoccult cards with return envelopes were distributed in a randomized fashion to indigent and private insurance patients in outpatient clinics. On half of the return envelopes return postage was applied. The main outcome measure was the rate of return of stamped and unstamped packets stratified between indigent and private insurance patients. The overall rates of return were 117 of 159 (74%) for the stamped packets and 102 of 166 (61%) for unstamped packets (p < 0.02). After stratification, in the indigent patients (n = 177), 73 of 95 (77%) stamped packets were returned compared to 46 of 82 (56%) unstamped packets (p < 0.006). In the private insurance patients (N = 148), 44 of 64 stamped packets (69%) and 52 of 84 unstamped packets (62%) were returned (p > 0.10). Removing even small financial barriers (eg, providing a postage stamp) can enhance compliance for indigent patients.
Aged↗
Charges by residents and faculty physicians in a university hospital pediatric practice.
The impact of pediatric residents on total patient charges generated in the outpatient pediatric practice of a university hospital was evaluated. Data were collected on 450 consecutive visits covered by two types of third-party category payers, Medicaid and private insurance. Charges were tabulated for visit charges, office-based procedures, and hospital laboratory and radiology tests. Average charges generated for visits to residents were greater than for visits to faculty pediatricians. The difference was attributable to the higher number of hospital laboratory and radiology tests ordered by residents. Patients' age, economic status, and diagnosis did not explain the more frequent use of these tests. These results emphasize that teaching hospitals need to develop specific methods to decrease unnecessary laboratory and radiology tests in pediatrics residency programs. The methodology used in this study provides a means for estimating the economic impact of resident education on the patients they serve.
Faculty, Medical↗
The role of laparoscopy in abdominal trauma.
Thirty-nine hemodynamically stable trauma patients were evaluated prospectively by laparoscopy before planned celiotomy. Laparoscopy was performed using a forward-viewing laparoscope connected to two high-resolution video monitors. The mechanism of injury was blunt trauma in eight, stab wounds (SWs) in 16, and gunshot wounds (GSWs) in 15. Laparoscopy correctly identified the presence of an intraperitoneal injury in 26 patients. Six other patients had retroperitoneal injuries, five of which were seen on laparoscopy. The remaining seven patients had no demonstrable intraperitoneal or retroperitoneal injuries, did not undergo celiotomy, and were observed without morbidity. In comparison with findings at surgery, laparoscopy identified injuries to the liver in eight of ten, to the diaphragm in three of three, to the colon in two of three, to the stomach in three of three, to the kidney in one of one, to the spleen in none of three, and to the small bowel in none of four patients. Visualization of the spleen was achieved in only one patient. The extent of the hemoperitoneum was underestimated from the laparoscopic examination in all nine patients with greater than 750 mL of peritoneal blood, four of whom had undetected active bleeding. Laparoscopy was performed easily in all patients and there were no complications associated with its use. In conclusion, the absence of an intra-abdominal injury was correctly identified with laparoscopy in 11 patients and laparoscopy may decrease the need for celiotomy in selected patients. However, the inability to "run the small bowel," visualize the spleen, and evaluate hemorrhage limits the utility of laparoscopy in determining which patients with laparoscopically visualized injuries will require celiotomy.
Abdominal Injuries↗
An end to a consensus on health care in the Federal Republic of Germany?
Over the past fifteen years the national government in the Federal Republic of Germany has animated the political debate about rising health care expenditures. However, it has only provided health policy leadership by shifting the burden of financing health and medical care to others. This paper presents three cases that illustrate the political and institutional constraints inherent in the German policy process that limit the proposal and implementation of appropriate policy solutions to rising health care costs. Cost controls have been inhibited because of the near-universal entitlement of national health insurance, the access all social groups have to advanced medical care, and policies targeted at providers rather than users of health services. The paper also underscores the past and future importance of regional policy coalitions in shaping national health policy.
Economics, Medical↗
Marketing of health insurance services.
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Health Benefit Plans, Employee↗
Pattern of non-ICU inpatient supplemental oxygen utilization in a university hospital.
Random assessments of SaO2 were performed via pulse oximetry in 274 hospitalized non-ICU patients prescribed supplemental O2 in a large tertiary care university hospital. In 507 assessments performed in patients inspiring the prescribed O2, 426 were receiving excessive amounts of O2 to maintain a SaO2 > or = 92 percent. In 233 of these assessments, SaO2 was > or = 92 percent while breathing ambient air. In an additional 193 assessments, the concentration of inspired supplemental O2 was excessive to maintain a SaO2 > or = 92 percent. However, in 81 assessments performed in patients inspiring O2, the prescribed amount was insufficient to maintain SaO2 > or = 92 percent. These results indicate that O2 prescription in hospitalized non-ICU patients is excessive or not required in the majority of cases. Furthermore, routine use of pulse oximetry in hospitalized patients prescribed O2 may be useful in determining the continued need for supplemental O2 and adjusting the proper concentration needed to avoid hypoxemia.
Baltimore↗
Patients' perceptions of maternity nurse practitioners.
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California↗
The competitive solution and the health care problems of today.
Mark Pauly claims that a "competitive" health care system will solve the health care cost crisis. This article examines how well the competitive solution deals with the five central problems of the health care system: (1) almost universal lack of adequate health insurance for nursing homes and home care; (2) Medicaid's penurious approach to payment for health services for the poor; (3) the emergence of a dual health care system, especially for children; (4) the entrenched waste and inefficiency of the health care system; and (5) consumers' inability to judge the quality of health care. The competitive solution does not eliminate any of these problems--and may not even improve some of them.
Economic Competition↗