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PubMed2003

Insurance expenditures on bipolar disorder: clinical and parity implications.

OBJECTIVE: This study assessed treatment rates and expenditures for behavioral health care by employers and behavioral health care patients in a large national database of employer-sponsored health insurance claims. METHOD: Insurance claims from 1996 from approximately 1.66 million individuals were examined. Average annual charges per person and payments for behavioral health care were calculated along with patient out-of-pocket expenses and inpatient hospital admission rates. Behavioral health care expenditures for bipolar disorder were compared to expenditures for other behavioral health care diagnoses in these same insurance plans. RESULTS: A total of 7.5% of all covered individuals filed a behavioral health care claim. Of those, 3.0% were identified as having bipolar disorder, but they accounted for 12.4% of total plan expenditures. Patients with bipolar disorder incurred annual out-of-pocket expenses of $568, more than double the $232 out-of-pocket expenses incurred by all claimants. The inpatient hospital admission rate for patients with bipolar disorder was also higher (39.1%) compared to 4.5% for all other behavioral health care claimants. Furthermore, annual insurance payments were higher for covered medical services for individuals with bipolar disorder than for patients with other behavioral health care diagnoses. CONCLUSIONS: Bipolar disorder is the most expensive behavioral health care diagnosis, both for patients with bipolar disorder and for their insurance plans. For every behavioral health care dollar spent on outpatient care for patients with bipolar disorder, $1.80 is spent on inpatient care, suggesting that better prevention management could decrease the financial burden of bipolar disorder.

Adult↗

PubMed1998

The insurance refund request: a legal analysis.

When an insurance payment is made erroneously to a healthcare provider and no contract between the insurer and provider addresses the issue of refunding such payments, the law relating to restitution generally applies. Restitution does not apply, however, to three exceptions that the courts have used to refuse claims by insurers for refunds of overpayments: the innocent third-party creditor exception, whereby the healthcare provider cannot be unjustly enriched by the overpayment, cannot have induced the mistaken payment, and cannot have known beforehand that the insurer was not obligated to pay; the material change in position exception, whereby the healthcare provider in good faith accepts an overpayment and so does not pursue other means of payment; and the assumption of the risk exception, which occurs when the insurer pays a claim without having complete information about it.

Financial Management↗

PubMedDate not supplied

The structure and enforcement of health insurance rating reforms.

Requiring health insurers to cover everyone who applies regardless of health status--an approach called "guaranteed issue"--is severely hampered without accompanying rating restrictions that keep insurance affordable for higher-risk people. The degree of rating flexibility also determines how much insurers can continue to compete based on their skills at risk selection, and how well they can counter adverse selection. Therefore, the structure and enforcement of rating reforms are essential to how insurance market reforms function. Based on an in-depth qualitative study in seven states with insurers, agents, and regulators, this article explains the factors that determine the stringency of rating reforms, and details how various aspects of rating restrictions can be used strategically to engage in greater risk segmentation than first appears possible. The article concludes by reflecting on the appropriate degree of complexity in rating rules, and it offers recommendations for crafting rating reforms that avoid unintended consequences.

Actuarial Analysis↗

PubMed2003

Tensions in private health insurance regulation.

This article provides an analysis of the regulatory framework of Australian private health insurance linked to four major implicit regulatory objectives: promoting access to health insurance for consumers; promoting financial solvency and industry viability of registered health benefits organisations; promoting competition between registered health benefits organisations; and promoting accountability to consumers. Through an analysis of regulatory changes, case law and policy documents on the performance of the health insurance industry, it is argued that existing health insurance regulation exhibits inevitable tensions due to shifting and often conflicting government objectives about the role of private health insurance.

Australia↗

PubMed1992

The practice and ethics of risk-rated health insurance.

Health insurance in the United States is driven by competitive risk rating and is promoted as the best way to give policyholders optimal value for their money and to be fair to those with lower risks. In practice, however, competitive risk rating costs more than noncompetitive, universal systems of health insurance, and it erodes the basic function of insurance to spread infrequent large losses over a wide base. This article describes not only how risk rating covers least those with the greatest medical bills, but also how it has spawned a labyrinth of complex manipulations by insurance companies to charge more or pay less than actuarially fair risk rating would justify. The final section shows that even if risk rating were done fairly, it contradicts moral fairness. Many of the leading proposals for national health insurance do not address these practical and ethical issues. The medical profession and policymakers need to discuss them and take a stand on them.

Actuarial Analysis↗

PubMed1989

The role of physician-owned insurance companies in the detection and deterrence of negligence.

This study presents evidence that physician-owned insurance companies and their physician members play an important role in the detection and deterrence of negligent behavior. A survey of physician-owned companies indicates that 94% involve their physicians in one or more aspects of the underwriting process. About 60% involve their members in assessing the competence of physicians who have been sued and in advising the underwriters on decisions concerning both continued insurability and the conditions of insurance. During 1985, a total of 0.66% of the physicians in physician-owned companies had their insurance terminated or were forced to give up their coverage because of negligence-prone behavior. An additional 0.7% of active policyholders were subject to restrictions on practice or other medical sanctions and 1.8% to surcharges and deductibles. Thus, disciplinary actions were in place against 3.2% of insured physicians whose performance was viewed as in some way substandard. The findings indicate that the physician-owned companies are effective agents in identifying negligence-prone behavior, and suggest that these companies also play an important role in deterring substandard performance.

Clinical Competence↗

PubMed1998

Interactions between use of and insurance for specialty ambulatory mental health services.

BACKGROUND: There is continuing interest in the effects of coinsurance rates on the use of ambulatory mental health services. Persons who expect to use mental health services may choose coverage with more generous mental health benefits, as such treatment may be expected to be a recurring activity. However, it may also be the case that if the expected need for such services is somehow reflected in lower perceived human capital in the labor market, then persons who have a higher probability of use may face a less generous set of health insurance options. These behaviors imply some simultaneity in the determinants of the coinsurance rate facing an individual and their mental health use. AIM OF THE STUDY: To explore the joint determination of the use of and coinsurance for ambulatory mental health services, using non-experimental data for a nationally representative sample of the non-institutionalized who had employer-based health insurance in the United States. METHODS: I estimate an instrument for the ambulatory mental health coinsurance rate. I then estimate two models of the demand for ambulatory mental health care as a function of the coinsurance rate for this type of care and other factors, one using the actual coinsurance rate and the other using the estimated instrument for the coinsurance rate. RESULTS: In the instrumental equation, an index of the mental distress of the key worker most likely to be the policy-holder has no statistically significant effect on the worker's coinsurance rate. However, a similar measure for other members of the worker's family has a positive and statistically significant effect on the worker's coinsurance rate. In the demand equations, neither the actual coinsurance rate nor its instrument has a statistically significant coefficient. DISCUSSION: Having another family member who may need mental health care results in some effort to seek a health plan with a higher coinsurance rate for such services. While the mental health index for the key worker would motivate the same type of seeking behavior, a higher level for this index for the key worker might also be correlated with a lower level of perceived human capital in a prospective employer's eyes, and this might result in a more restricted set of plan options for mental health care in the labor market. The absence of statistical significant for the coefficients of the actual coinsurance rate and its instrument also provides some limited but suggestive evidence of employer-side selection effects. LIMITATIONS: It was not possible to model the full complexity of health plans. CONCLUSIONS: The discussions of selection bias with regard to mental health insurance and service use should be expanded to include demand-side effects in the labor market, in addition to the supply-side effects on the part of workers that are often considered. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: It may be difficult to determine the effects on ambulatory mental health care of changes in health insurance provisions. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Caution needs to be used in making estimates of the effects of changes in insurance coverage for ambulatory mental health care. Persons who find their benefits improved may not respond at the rate expected, because initial coinsurance rates are already in part intertwined with expected use. IMPLICATIONS FOR FURTHER RESEARCH: More analyses of the range of selection effects in labor markets and their impacts on health insurance are warranted.

Journal Article↗

PubMed2002

Health insurance status of the adult, nonelderly foreign-born population.

The last two decades have been marked by substantial immigration to the United States. As a result of this movement, the foreign-born population is growing rapidly. Previous studies have shown that the foreign-born population is much more likely than the native-born one to be without health insurance. The present analysis focuses on factors that distinguish the insured from the uninsured, utilizing nativity status (foreign born versus native born) as one of the independent variables in a set of logistic regression models. Results show that even after controlling for income, employment status, and other variables known to be associated with health insurance status, the foreign born are twice as likely to be without health insurance than are their native-born counterparts. Among the foreign born, recency of arrival emerges as an important factor in distinguishing the insured from the uninsured. Public policies intended to address the problem of health insurance in the foreign-born population must go beyond being based only on economic considerations and take into account factors such as cultural background and health-related attitudes to be effective.

Journal Article↗

PubMed2003

Scaling up community health insurance: Japan's experience with the 19th century Jyorei scheme.

Interest in community health insurance has grown rapidly in many developing countries, usually as a result of the weak capacity of governments to raise sufficient tax revenues and then to secure an adequate share for health care. There are many pitfalls, however, and only under specific conditions do community health insurance schemes appear to succeed in effectively improving access to care and enhancing financial protection against health care costs. In this paper, we focus on the initial experience with community health insurance in 19th century Japan, called 'Jyorei'. Whereas Jyorei began in 1835 in one village in Fukuoka Prefecture, it gradually expanded and the basic ideas came under government stewardship. It was scaled up as the core model of the National Citizen's Health Insurance Fund, one of the pillars of the Japanese social health insurance system. Several Jyorei success points are relevant today for developing countries wishing to support community health insurance. One of the key characteristics was social cohesion and the acceptance of equity goals with transfers between the rich and the poor.

Delivery of Health Care↗

PubMed2002

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression.

BACKGROUND AND OBJECTIVES: To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline. RESEARCH DESIGN: Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions. SUBJECTS: In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months. MEASURES: Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview. RESULTS: Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care. CONCLUSIONS: The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

Adult↗

PubMed1997

Social insurance for health service.

Implementation of social insurance for financing health services has yielded different patterns depending on a country's economic level and its government's political ideology. By the late 19th century, thousands of small sickness funds operated in Europe, and in 1883 Germany's Chancellor Bismarck led the enactment of a law mandating enrollment by low-income workers. Other countries followed, with France completing Western European coverage in 1928. The Russian Revolution in 1917 led to a National Health Service covering everyone from general revenues by 1937. New Zealand legislated universal population coverage in 1939. After World War II, Scandinavian countries extended coverage to everyone and Britain introduced its National Health Service covering everyone with comprehensive care and financed by general revenues in 1948. Outside of Europe Japan adopted health insurance in 1922, covering everyone in 1946. Chile was the first developing country to enact statutory health insurance in 1924 for industrial workers, with extension to all low-income people with its "Servicio Nacional de Salud" in 1952. India covered 3.5 percent of its large population with the Employees' State Insurance Corporation in 1948, and China after its 1949 revolution developed four types of health insurance for designated groups of workers and dependents. Sub-Saharan African countries took limited health insurance actions in the late 1960s and 1970s. By 1980, some 85 countries had enacted social security programs to finance or deliver health services or both.

Global Health↗

PubMed1999

Improving access for Medicaid-insured children: focus on front-office personnel.

BACKGROUND: Access to dental services for low-income children is limited. Front-office personnel play a role regarding dentists' participation in the Medicaid program. METHODS: Subjects (N = 24) represented general dental offices in Spokane County, Wash., and included participants and nonparticipants in the Access to Baby and Child Dentistry, or ABCD, program, a dental society/community program aimed at expanding dental services provided to Medicaid-insured children. The authors stratified the participants according to the number of claims their practices submitted to Medicaid for ABCD children: non-ABCD, low-ABCD and high-ABCD. Five two-hour focus group sessions were conducted to determine participants' beliefs about, attitudes toward and experiences in serving this population. RESULTS: The authors' data analysis consisted of a comprehensive content review of participants' responses from transcripted audiotapes. They synthesized frequently mentioned concepts and ideas into relevant themes. The major factors affecting practices' participation in Medicaid were office policy on seeing Medicaid-insured patients; staff members' personal connection to Medicaid-insured patients; staff members' attitudes about Medicaid-insured patients; and staff members' perceptions of Medicaid-insured patients' barriers to care. CONCLUSIONS: The data suggest that factors affecting dentists' participation in the Medicaid program are more complex than the often-stated dissatisfactions with low reimbursement fees and hassles with paperwork. CLINICAL IMPLICATIONS: Efforts to increase dentist participation in serving Medicaid-insured patients will continue to be relatively ineffective until many of the concerns raised by this study's subjects are better understood and addressed.

Administrative Personnel↗

PubMed2000

The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California.

CONTEXT: Managed care plans aggressively seek to contain costs, but few data are available regarding their impact on access to high quality care for their members. OBJECTIVE: To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in California. DESIGN: Retrospective cohort study using state-mandated hospital discharge datasets. SETTING: Pediatric cardiovascular surgical centers in California. PATIENTS: Five thousand seventy-one children admitted for open cardiac surgical procedures during 1992-1994. RESULTS: Hospitals were divided into lower- and higher-mortality groups according to adjusted surgical mortality. Using multivariate logistic regression analysis to control for medical, socioeconomic, demographic, and distance factors, children with managed care insurance were less likely to be admitted to a lower-mortality hospital for surgery relative to children with indemnity insurance (odds ratio:.53; 95% confidence interval:.45,.63). Similar findings resulted when the analysis was stratified by race/ethnicity. In addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher-mortality centers (adjusted difference:.54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,. 41). CONCLUSIONS: During this study, children with managed care insurance had significantly reduced use of lower-mortality hospitals for pediatric heart surgery in California compared with children with indemnity insurance. Further study is necessary to determine the mechanisms of this apparent insurance-specific inequity.

California↗

PubMed2000

A preliminary study on the knowledge and attitudes of physicians at two university hospitals towards the medical insurance system of Japan.

In this preliminary study, we surveyed the physicians at two academic hospitals on their knowledge of and attitudes toward the medical insurance system in Japan. Most of the physicians had not read the "Ministerial Ordinance on Insurance Medical Institutions' and Insurance Medical Doctors' Medical Treatment under Health Insurance." Of the 433 physicians who filled out the questionnaire completely, 34% had either not read or rarely read the "Medical Fee Point List." Most (89.1%) of the physicians knew that there is a stepwise reduction in the hospitalization fee as the length of a patient's hospital stay increases. However, approximately 30% did not know the stipulation of obtaining an informed consent from the patient prior to blood transfusion. As for the right of patients to see their medical care remuneration statements, which was decided by the government in 1997, 26.8% of the physicians did not know this rule. Physicians who had read the "Ministerial Ordinance on Medical Treatment," were more likely to read the "Medical Fee Point List" frequently; were more likely to know the stipulation about diminishing hospitalization fee; were more likely to know that an informed consent must be obtained prior to blood transfusion; and were more likely to know that patients had a right to see their medical care remuneration statements. The longer the clinical experience of the physician, the more likely that the physician had read the "Ministerial Ordinance on Medical Treatment" and know the other stipulations well. In these two academic hospitals, it is important to establish educational seminars for physicians on the guidelines of the medical insurance system so that physicians will become familiar with the medical insurance system quickly.

Attitude of Health Personnel↗

PubMed2005

The State Children's Health Insurance Program: a multicenter trial of outreach through the emergency department.

OBJECTIVES: We evaluated emergency department (ED)-based outreach for the State Children's Health Insurance Program (SCHIP). METHODS: We conducted a multicenter trial among uninsured children (< or = 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days. RESULTS: We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P<.05; odds ratio [OR]=3.8; 95% confidence interval [CI]=1.7, 8.6). Although the intervention effect was prominent among 118 African Americans (50% insured after intervention vs 31% of controls, P<.05), lack of family enrollment in other public assistance programs was the primary predictor of intervention success (OR=3.7; 95% CI=1.6, 8.4). CONCLUSIONS: Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.

Case-Control Studies↗

PubMed1992

Network analysis of Korean health insurance policy-making process.

This study examines how the decision-making process evolved in Korea during the initial phases of introduction and implementation of National Health Insurance. This study analyses the official documents and interviews views made with government officials and related personnel. We used the method of network analysis and multidimensional scaling in order to demonstrate how the major participants in the decision-making process developed and changed under the contemporary political situations. In the pre-implementation stage around 1976, major concerns were concentrated around the issues of financial support for social insurance, the fee schedule and who ought to be covered first. The total number of participants of the health or health-related organization was 61, which included the President, the Minister of Health and Social Affairs, representatives of special interest groups, etc. In the actual implementation period of 1982, different issues were brought up by the major participants. The number of participants in this period declined to 44 with the deletion of 19 and with the addition of two newly formed health insurance organizations. By 1988, as the implementation reached its final decision period, disagreements were centered on progressive premium rating and the administration of National Health Insurance. The number of participants increased to 60 after the addition of 16 participants. The analysis of this paper may provide some insight for other countries which wish to establish National Health Insurance; as reference to the policy-making process, it may provide some suggestions for when to initiate and how to formulate National Health Insurance policies.

Humans↗

PubMed2001

Low-wage workers and health insurance coverage: can policymakers target them through their employers?

Many policy initiatives to increase health insurance coverage would subsidize employers to offer coverage or subsidize employees to participate in their employers' health plans. Using data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey, we contrast "low-wage employers" with all other employers. Employees in low-wage businesses have significantly worse access to employment-based insurance than other employees do; they are less likely to work for an employer that offers insurance, less likely to be eligible if working in a business that offers insurance, and less likely to be enrolled if eligible. Low-wage employers contribute lower shares of premiums and offer less generous benefits than other employers do. Policies that would target subsidies to selected employers to increase insurance offers to low-wage workers are difficult to design, however, because several commonly mentioned employer characteristics (including firm size) are found to be poor indicators of low-wage worker concentration. Programs that would set minimum standards for employer plans to be eligible for "buy-ins" need to base these standards on the less generous terms offered by low-wage employers in order to effectively reach low-wage workers and their dependents.

Eligibility Determination↗

PubMed1984

Insured maximum mortgage amount for hospitals--Office of the Assistant Secretary for Housing. HUD. Proposed rule.

The Department proposes to modify its regulations governing the maximum mortgage principal amount that it will insure for a new or rehabilitated hospital. Under its existing regulations, the Department can insure a mortgage in any amount that does not exceed 90 percent of HUD's estimate of the replacement cost of the hospital (including major movable equipment). Under the proposal, however, the loan to replacement cost ratio would vary for insured mortgages on projects where the replacement cost exceeds 100 million dollars. In essence, the mortgagor's equity requirements would be required to increase as the principal obligation sought to be insured increased. This proposal is intended to (a) mitigate the possibility of large-scale defaults in future years; (b) ensure the long-term adequacy of the Department's insurance fund, and (c) avoid undue concentration of insurance commitments in a relatively small number of projects.

Financial Management↗