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PubMed2006

Competition in health insurance markets: limitations of current measures for policy analysis.

Health care reform proposals often rely on increased competition in health insurance markets to drive improved performance in health care costs, access, and quality. We examine a range of data issues related to the measures of health insurance competition used in empirical studies published from 1994-2004. The literature relies exclusively on market structure and penetration variables to measure competition. While these measures are correlated, the degree of correlation is modest, suggesting that choice of measure could influence empirical results. Moreover, certain measurement issues such as the lack of data on PPO enrollment, the treatment of small firms, and omitted market characteristics also could affect the conclusions in empirical studies. Importantly, other types of measures related to competition (e.g., the availability of information on price and outcomes, degree of entry barriers, etc.) are important from both a theoretical and policy perspective, but their impact on market outcomes has not been widely studied.

Economic Competition↗
PubMed1984

Tax policy and the demand for health insurance.

Estimates of the price and income elasticities of demand for health insurance are derived from econometric estimates of the parameters of a discrete choice model of health insurance demand using data from a survey of plan choices among a sample of federal government employees. The estimated income elasticity (+0.01) is similar to most previous estimates. The estimated price elasticity (-0.16) is in absolute value much less than the earlier previous estimates and somewhat less than the more recent previous estimates. Possible causes of these differences in price elasticity estimates are discussed.

Community Participation↗
PubMed2005

The effect of health savings accounts on health insurance coverage.

The authors investigate the potential of Health Savings Accounts (HSAs) to expand health insurance coverage. They examine how many currently uninsured people might be encouraged to buy coverage through HSAs, and what the impacts of such actions might be on the group and nongroup health insurance markets. Their main conclusions: HSAs are not likely to be an important contributor to expanding coverage among uninsured people because most of them do not face high-enough marginal tax rates to benefit substantially from the tax deductibility of HSA contributions. Meanwhile, HSAs could potentially destabilize the small-group market. To the extent that they encourage well-compensated healthy workers to abandon job-based coverage--a result that is more likely if current HSA provisions are combined with proposed premium deductibility--HSAs could undermine the entire structure of job-based coverage among small firms.

Cost Savings↗
PubMed2004

Small group health insurance: ranking the states on the depth of reform, 1999.

States are ranked based on the potential of their small group health insurance reforms to enhance health insurance uptake. Reforms were quantified based on their market impact potential. Five dimensions of reforms were identified, Access Improvement, Premium Reduction, Premium Differential Reduction, Continuity of Coverage, and Enhancing Valued Plan Features. The reform indices representing these dimensions were developed based on document review of state statutes, combined with actuarial judgment to identify and assign scores to market-relevant regulations in line with their impact potential. The distribution of the states' reform scores and rankings show wide variation in the depth and focus of their reforms. Only seven of the top ten states on the Total Reform index had consistently higher scores on two or more reform dimensions. The conceptual linkages between specific regulations and the documented small group market problems lead to normative expectations of an association between the depth of state reforms and the prevalence of uninsurance.

Health Care Reform↗
PubMed2006

Risk selection and complementary health insurance: the Swiss approach.

To avoid risk selection, the market for complementary health insurance is usually completely separate from the market for basic health insurance. In Switzerland, however, the basic benefit package and complementary insurance are offered by the same insurer. Risk-based premiums are allowed with respect to complementary insurance. This paper compares the Swiss integration approach to the separation approach. It is shown that under the integration approach insurers cream-skim by selling complementary insurance to low risks at a discount. Nevertheless, the integration approach can be Pareto-superior if the cost savings due to the integration of basic and complementary insurance are sufficiently large.

Cost-Benefit Analysis↗
PubMedDate not supplied

[Prescription of diphosphonates in ambulatory oncology. A study of the health insurance medical services].

OBJECTIVES: As requested by the Health Ministry, the Agricultural (Mutualité Sociale Agricole) and Independant Professions (Assurance Maladie des Professions Indépendantes) Health Insurances carried out a survey to analyse the use of second generation oral biphosphonates. METHODS: The data, from 3,414 prescriptions, gathered over the twelve months from May '93, showed that clodronate is prescribed mainly for breast cancer (35%), prostate cancer (23%), multiple myeloma (19%) and carcinoma of the lung (7%). The other prescriptions (16%) were either related to various malignant diseases (18 types encountered) or non-malignant diseases (mainly osteoporosis, but also Paget's disease of bone and hyperparathyroidism). The initial prescriber was most often a cancerologist (49%) but also quite frequently (17%) a general practitioner. The treatment was prescribed for an average of 41 days. 1600 mg daily was the most frequent dose (79%). However, in non-authorised indications, especially osteoporosis, the dose was lower, generally 800 mg a day. Altogether 14% non-authorised indications were linked either to non-metastatic malignant diseases (for the prevention of metastases) or with osteo-condensing type metastases (prostate cancer: 43%) or non-malignant diseases (osteoporosis, Paget's disease of bone, hyperparathyroidism, chronic renal insufficiency, sympathetic algodystrophy, bedbound decalcification, etc.). The prescription for these cases was motivated by the expected beneficial effect on bone mineralisation. Such treatment authorised was more often initiated by a general practitioner (23%) than a specialist (12%). CONCLUSION: These data raise the problem of limiting the possibility of prescribing second generation biphosphonates as initial treatment to a specialist. They also reaffirm the need to have precise guidelines in the field of medical prescription controls.

Aged↗
PubMed2004

[Evidence-based medicine and public health law: statutory health insurance].

Beyond all differences in terminology and legal principles between the laws governing private health insurance, the governmental financial support for civil, servants and statutory health insurance the fundamental issues to be solved by the courts in case of litigation are quite similar. But only a part of these refer to the quality of medical services, which is the main concern of Evidence-based Medicine (EbM); EbM, though, is not able to contribute towards answering the equally important question of how to distinguish between "treatment" and "(health-relevant) lifestyle". The respective definitions that have been developed in the particular fields of law are only seemingly divergent from each other and basically unsuitable to aid the physician in his clinical decision-making because the common blanket clauses of public health law are regularly interpreted as rules for the exclusion of certain claims and not as a confirmatory paraphrase of what is clinically necessary. If on the other hand medical quality is what lies at the core of litigation, reference to EbM may become necessary. In fact, it is already common practice in the statutory health insurance system that decision-making processes in the Federal Committee being responsible for quality assurance (Bundesausschuss) are based on EbM principles and that in exceptional cases only the courts have to medically review the Federal Committee's decisions.

Evidence-Based Medicine↗
PubMed2005

Private and public cross-subsidization: financing Beijing's health-insurance reform.

In 1998, the Chinese government proposed a universal health-insurance program for urban employees. However, this reform has been advancing slowly, primarily due to an unpractical financing policy. We surveyed over 2000 families and evaluated the financial impacts of Beijing's reform on public and private enterprises. We found that most state-owned enterprises provided effective health insurance, whereas most private firms did not; overall, 33% of employees had little or no coverage. On average, employees of private firms were healthier and earned more compared to public firms. Because the premium was proportional to income, private firms would pay more for insurance than the predicted health-care expense of their employees. International firms subsidize the most, contributing more than 60% of their insurance premiums to the employees of the public sector. Such an aggressive cross-subsidization policy is difficult to be accepted by private firms.

Adult↗
PubMed2001

[Health insurance in Tunisia, current context and future perspectives].

The Tunisian health system, notably in its health insurance component, has allowed to record a satisfactory evolution of health indicators. Nevertheless, socio-economic, demographic and epidemiological transitions impose a global reform of the system, notably of its financing. The present article, leaving from the presentation of the current system of coverage of the social security insured, analyses observed insufficiencies that have brought public authorities to commit the health insurance reform. The main observed insufficiencies refer to the multiplicity of regimes and their heterogeneity, generating iniquities between insured and a strong growth of care expenses financed directly by households. In addition, relationships of social security bodies with public and private providers of health care are little transparent, marked by a preferential processing of public structures, despite an important development of the private sector. In a second part, the author analyzes successively objectives of the health insurance reform of the social security regimes, its founder principles, characteristics of the proposed regime (a mandatory basic regime and an optional complementary regime) and sketches of providers payment methods.

Financing, Government↗
PubMed1999

[Health economic analysis of the effects of including complementary medicine in the benefit package of health insurance].

A randomized experiment was set up in which 7,500 policyholders of Switzerland's largest health insurance fund, Helvetia, were offered free supplementary insurance for complementary medicine for 3 years. This was meant to simulate a situation in which the experimental group had access to the full range of complementary medical treatments under their health insurance policies. The remaining policyholders in the scheme (670,000 people) formed the control group. A third group of policyholders who had taken out additional insurance for complementary medical services at their own expense is mentioned only in passing. The health insurer's cost and benefit data were analyzed to evaluate the effect of the offered free supplementary insurance for complementary medicine. In addition, a survey was carried out among random samples of subjects from the experimental group and from the control group using the 36-Item Short-Form Health Survey (SF-36) to examine the effects of including complementary medicine on people's subjective state of health. The analysis of the cost data showed that subjects in the experimental group used complementary medicine in addition to mainstream medical services. It became also clear that alternative medical treatments were given in combination with orthodox medicine; less than 1% of the experimental group used exclusively alternative medical services. However, as only a very small percentage of the experimental subjects (6.6%) took advantage of complementary medicine, no significant impact on overall health cost could be inferred. On the other hand, multiple regressions showed that the use of complementary medicine had a greater effect on the treatment costs than sex, age or language region. Neither at the beginning nor the end of the experiment were any significant differences noted in the scales of the SF-36 between the experimental and the control group; nor did multiple regressions reveal any effects on subjects' state of health due to the inclusion of complementary medicine in the basic insurance cover. This study was presented in the media and at a public hearing of the Swiss National Science Foundation. It triggered numerous valuable discussions. The study design and the conclusions were not left uncontested.

Adult↗
PubMed1991

Universal health insurance through incentives reform.

Roughly 35 million Americans have no health care coverage. Health care expenditures are out of control. The problems of access and cost are inextricably related. Important correctable causes include cost-unconscious demand, a system not organized for quality and economy, market failure, and public funds not distributed equitably or effectively to motivate widespread coverage. We propose Public Sponsor agencies to offer subsidized coverage to those otherwise uninsured, mandated employer-provided health insurance, premium contributions from all employers and employees, a limit on tax-free employer contributions to employee health insurance, and "managed competition". Our proposed new government revenues equal proposed new outlays. We believe our proposal will work because efficient managed care does exist and can provide satisfactory care for a cost far below that of the traditional fee-for-service third-party payment system. Presented with an opportunity to make an economically responsible choice, people choose value for money; the dynamic created by these individual choices will give providers strong incentives to render high-quality, economical care. We believe that providers will respond to these incentives.

Aged↗
PubMedDate not supplied

Alternatives for expanding health insurance coverage.

In March 1990, nearly 14 percent of the U.S. population was without health insurance. This article examines five approaches to increase coverage: tax credits for the purchase of private insurance; changes in the regulation of the private insurance market; additional requirements on employers to provide employment-based insurance; expansion of Medicaid to selected groups; and a universal public health insurance program. Coverage would be most improved under a universal public insurance plan, and least improved by regulatory changes in the private insurance market. Significant but incomplete increases in coverage could be achieved through either new employer mandates or expansion of Medicaid. A tax credit could increase coverage appreciably only if it was substantial relative to the cost of insurance, and even then most of the credits would go to those who would have purchased insurance anyway.

Data Collection↗
PubMedDate not supplied

Using tax credits and state high-risk pools to expand health insurance coverage.

There are practical proposals now on the public policy table to reduce the number of Americans without health coverage. While they won't make health care free or eliminate the forty million uninsured persons, they would help millions of Americans acquire or improve their health insurance. Practical strategies can also be taken to address access issues for unhealthy persons in the nongroup market through federal assistance to states to establish and improve state high-risk health insurance pools, as well as to make health insurance more affordable for low-income Americans.

Health Policy↗
PubMed2004

Effects of increased private health insurance on hospital utilisation in Victoria.

The proportion of Victorians and Australians generally with private health insurance (PHI) increased from 31% in 1998 to 45% in 2001. We analysed a dataset containing all hospital separations throughout Victoria to determine whether changes in the level of private health insurance have had any impact on patterns of public and private hospital utilisation in Victoria. Total utilisation of private hospitals grew by 31% from 1998-99 to 2002-03, whereas utilisation of public hospitals increased by 18%. Total bed-days have increased in both private hospitals and public hospitals by 12%. The proportion of all separations at private hospitals has remained relatively stable between these 2 years, with 33% of all separations being private patients in private hospitals in 1998-99, increasing slightly to 35% by 2002-03. Analysis of a number of specific DRGs shows that patients with more severe disease are more likely to be seen at public hospitals; notably this trend has strengthened between 1998-99 and 2002-03. The number of patients treated in Victorian public hospitals has continued to grow, despite a rapid increase in the utilisation of private hospitals. Given the limited extent of the shift in caseload share between the two sectors, the effectiveness of the Commonwealth's subsidy of private health insurance as a mechanism to reduce pressure on the public sector needs to be carefully examined.

Adolescent↗
PubMedDate not supplied

The children's hour: the State Children's Health Insurance Program.

The State Children's Health Insurance Program (CHIP) is the product of a series of policy and political compromises and generates numerous structural and policy issues for states. CHIP entitles states to federal financial aid to provide health assistance to targeted children, through Medicaid expansions, new program implementation, or a product of the two. States that elect to operate CHIP programs apart from Medicaid have enormous discretion under the law to determine how they will structure their programs, the services they will cover, the form that benefits will take, and the conditions of participation and consumer protections that will apply. Determining what approach to take, as well as how to respond to the choices posed by the statute, represents a major test of how states address the needs of children and families.

Aid to Families with Dependent Children↗
PubMed2005

Consumer preferences in social health insurance.

Allowing consumers greater choice of health plans is believed to be the key to high quality and low costs in social health insurance. This study investigates consumer preferences (361 persons, response rate 43%) for hypothetical health plans which differed in 12 characteristics (premium, deductibles, no-claim discount, extension of insurance and financial services, red tape involved, medical help-desk, choice of family physicians and hospitals, dental benefits, physical therapy benefits, benefits for prescription drugs and homeopathy). In 90% the health plan with the most attractive characteristics was preferred, indicating a predominantly rational kind of choice. The most decisive characteristics for preference were: complete dental benefits, followed by zero deductibles, and free choice of hospitals.

Adult↗
PubMed2003

The first 2 years of a state child health insurance plan: whom are we reaching?

OBJECTIVE: The Colorado Child Health Plan Plus is a non-Medicaid state Child Health Insurance Plan. The objective of this study was to compare early enrolling (EE) children with uninsured children in low-income families (ULI) with respect to 1) sociodemographic factors and previous insurance, 2) health status, and 3) previous health care access and utilization. METHODS: Cross-sectional telephone surveys were conducted during 1999 of 1) randomly selected EE children (n = 711) and 2) ULI children identified by random-dial survey (n = 105). RESULTS: Enrolling children were less likely to be Hispanic (32.7% vs 55.2%); 5.5% of EE versus 27.6% of ULI children had never been insured. Prevalence of chronic conditions was similar (16.2% of EE vs 13.5% of ULI children), but learning/behavioral difficulties (9.7% of EE vs 18.6% of ULI) and fair/poor health (5.4% of EE vs 17.2% of ULI) were higher for uninsured children. In the previous year, 88.2% of EE versus 66.1% of ULI children had a usual source of care. The mean number of preventive visits was similar (1.4 vs 1.2), but the EE group reported a higher mean number of sick visits (2.0 vs 1.1), emergency visits (0.48 vs 0.15), and hospitalizations (0.09 vs 0.02). CONCLUSIONS: In the first 2 years of the program, Child Health Plan Plus is not yet reaching the "hard-to-reach" but, rather, disproportionately high numbers of non-Hispanic children who already have a usual source of care and recent insurance. EE children did not have higher rates of chronic conditions but did demonstrate higher utilization before enrollment, possibly reflecting patterns of enrollment into the program.

Adolescent↗