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PubMed2003

Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children?

Respiratory illness and diarrhoea continue to be the leading causes of paediatric morbidity and mortality in the Dominican Republic. An important first step in alleviating this disease burden is to understand patterns and predictors of health services utilization for these conditions. This study examines the predictors of (a) health services utilization, and (b) public versus private sector use, for respiratory illness in the under-five population in the Dominican Republic. The DHS-2 dataset (1991) was utilized for analysis. Logistic regression models for predicting use and non-use, and for predicting private versus public sector use, were constructed using the Andersen Behavioural Model as the conceptual framework. Our findings indicate that sex, location and possession index quartile are factors that influence the decision to seek care or not for respiratory illness in under-fives. In contrast, the choice between the public and private sector is determined by location and insurance status. From the policy perspective, if the Dominican Republic were to undertake steps to increase private insurance coverage, our results indicate that this would lead to increased utilization of private sector providers for respiratory illness by children having private insurance, but would not have an impact on overall utilization (i.e. use vs. non-use). On the other hand, one of the ways to deliver cost-effective interventions by the publicly financed system would be to improve facilities in the rural areas.

Child Health Services↗
PubMed2005

Income stable, poverty up, numbers of Americans with and without health insurance rise.

In August 2004, the U.S. Census Bureau released a report on income, poverty, and health insurance coverage in the United States. It showed that, between 2002 and 2003, real median household income remained unchanged at $43,318; the official poverty rate rose from 12.1 to 12.5 percent; the number of people with health insurance increased by 1.0 million to 243.3 million; the number without such coverage rose by 1.4 million to 45.0 million; and the percentage of the nation's population without coverage grew from 15.2 to 15.6 percent.

Adolescent↗
PubMedDate not supplied

Increments toward what?

Incremental proposals to expand health insurance coverage, such as expansions of the State Children's Health Insurance Program (SCHIP) or creation of new tax credits, should be examined for the values that underlie them and for how they structure future options for additional incremental coverage expansions. This paper examines five design issues in incremental reform: who determines coverage options for the newly insured; what risk pool do they enter; what is the government's contribution toward their coverage; what barriers are created by efforts to encourage efficiency; and how are issues of federalism handled? Tax credits are a departure from past approaches, while an SCHIP expansion is a continuation of current policy directions.

Child↗
PubMedDate not supplied

Universal coverage: building on Medicare and employer financing.

Universal coverage requires a strategy to sever the link between insurance coverage and employment in order to build a more stable insurance base. Universality also will require subsidies to make coverage affordable. Given these realities, the authors evaluate different financing proposals--employer and individual premium mandates and taxes--in terms of equity, affordability, and administrative and political criteria. An expansion of Medicare offers an insurance alternative that takes advantage of existing administrative structures of national scope.

Community Participation↗
PubMed2005

Estimating the price elasticity of expenditure for prescription drugs in the presence of non-linear price schedules: an illustration from Quebec, Canada.

The price elasticity of demand for prescription drugs is a crucial parameter of interest in designing pharmaceutical benefit plans. Estimating the elasticity using micro-data, however, is challenging because insurance coverage that includes deductibles, co-insurance provisions and maximum expenditure limits create a non-linear price schedule, making price endogenous (a function of drug consumption). In this paper we exploit an exogenous change in cost-sharing within the Quebec (Canada) public Pharmacare program to estimate the price elasticity of expenditure for drugs using IV methods. This approach corrects for the endogeneity of price and incorporates the concept of a 'rational' consumer who factors into consumption decisions the price they expect to face at the margin given their expected needs. The IV method is adapted from an approach developed in the public finance literature used to estimate income responses to changes in tax schedules. The instrument is based on the price an individual would face under the new cost-sharing policy if their consumption remained at the pre-policy level. Our preferred specification leads to expenditure elasticities that are in the low range of previous estimates (between -0.12 and -0.16). Naïve OLS estimates are between 1 and 4 times these magnitudes.

Aged↗
PubMed2001

Sources of clinical referrals to an urban coloproctology unit in Italy.

Prompt and appropriate referrals to colorectal surgeons result in better clinical and more cost-effective outcome: the question that then arises is how patients with large bowel diseases get in contact with the specialist. The aim of the present research was to investigate the sources of clinical referrals of 1000 patients attending a dedicated coloproctology unit. One thousand consecutive new patients attending the private Coloproctology Unit of Rome were prospectively evaluated from May 1995 through December 1999. For each patient, the following data were collected: age, gender, source of referral, and disease classified as benign anal diseases, neoplasms, functional disorders or inflammatory bowel disease (IBD). There were 569 patients with benign anal disease, 334 with functional disorders, 57 with neoplasms, and 40 with IBD. Sources of referral were: surgeons (32.6%), previous patients (23.6%), other specialists (22.8%), general practitioners (11.8) and others (9.2%). Overall, referrals from non-medical sources were 32.8%, whereas 67.2% of the cases were referred by other colleagues. Most of the referring specialists were surgeons or gastroenterologists, who sent 304 patients, whereas 9.4% of the cases were referred by other colorectal surgeons. Previous patients who were satisfactorily cured sent 23.6% of the cases. Only 1.1% of patients were referred by health insurance companies and 0.2% found the Unit through Internet. Colleagues who referred patients to the coloproctologist sent mainly cases with benign anal diseases and functional disorders. Few patients were referred for colorectal cancer and IBD as these diseases are routinely treated by general surgeons and their management is expensive in a private hospital for patients without insurance coverage. In conclusion, GPs, media, health insurance and Internet may be the most valuable targets of an information campaign, as their role as sources of referral was lower than expected.

Adolescent↗
PubMed2006

Annual prevalence of diagnosed schizophrenia in the USA: a claims data analysis approach.

BACKGROUND: Schizophrenia is a debilitating chronic mental illness. However, the annual prevalence of schizophrenia is not well understood because of under-representation of schizophrenia patients in epidemiological surveys. This study used multiple administrative claims databases to estimate the annual prevalence of diagnosed schizophrenia in the USA. METHOD: The annual prevalence of diagnosed schizophrenia in the USA was estimated for different health insurance coverage groups. The prevalence for privately insured individuals was calculated from an administrative claims database of approximately 3 million privately insured beneficiaries covering the period 1999-2003. The prevalence for Medicaid enrollees was calculated from California Medicaid claims covering the period 2000-2002. The prevalence for Medicare and Medicaid/Medicare dual eligibles was estimated using a combination of both databases. Published statistics were used to estimate the prevalence of schizophrenia in the uninsured and veteran populations and to weight the prevalence rates obtained to the population of the USA. RESULTS: The 12-month prevalence of diagnosed schizophrenia in the USA in 2002 was estimated at 5.1 per 1000 lives. The Medicaid population was identified with the highest prevalence rate among the populations studied. Sensitivity analyses taking into consideration the Veterans Affairs population only changed the estimate slightly to 5.3 per 1000 lives. CONCLUSION: Analyses of administrative claims data contribute to the understanding of the prevalence of diagnosed schizophrenia.

Adolescent↗
PubMed1985

Private health insurance of the Medicare population and the Baucus legislation.

The appropriateness of the benefits associated with the private insurance coverage of the Medicare population has been the subject of considerable concern. Section 507 of the Social Security Amendments of 1980, also known as the Baucus legislation, reflects public concerns about the level of benefits in relation to premiums, duplicative coverage, the complexity and difficulty of insurance terminology, and marketing abuses. Data from the National Medical Care Expenditure Survey can provide useful baseline data on the distribution of Baucus-like plans. In 1977, private insurance held by the Medicare population was more likely to cover inpatient than outpatient services and to emphasize "first dollar" benefits for long-term care. Multivariate analyses show that the distribution of Baucus-like insurance policies is highly associated with health status, source of insurance, region, and place of residence. The importance of state regulations, suggested in other research, may account for these patterns.

Aged↗
PubMed1999

Health insurance, the quantity and quality of prenatal care, and infant health.

This paper presents a comprehensive analysis of the relationship between Medicaid, infant health, and the quantity and quality of prenatal care using data from the 1988 National Maternal and Infant Health Survey (NMIHS). This integrated approach provides a more complete picture of the effect of Medicaid and its avenues of influence, and is less likely to lead to spurious findings. The results indicate that there was no statistically significant relationship between insurance status and birth weight holding constant other observed characteristics, although there was some evidence that uninsured women and Medicaid recipients received less prenatal care than did privately insured women. Differences in prenatal care utilization, however, were small. In addition, there was no evidence that uninsured women or Medicaid recipients received lower-quality prenatal care than privately insured women did even in a period prior to implementation of state programs aimed at ensuring high-quality care. The results of this paper raise questions about the efficacy of the current public health response to poor infant health that relies on expanding insurance coverage and enriched prenatal care programs.

Birth Weight↗
PubMed2000

Tax treatment of cafeteria plans. Internal Revenue Service (IRS), Treasury. Final regulations.

This document contains final regulations relating to section 125 cafeteria plans. The final regulations clarify the circumstances under which a section 125 cafeteria plan election may be changed. The final regulations permit an employer to allow a section 125 cafeteria plan participant to revoke an existing election and make a new election during a period of coverage for accident or health coverage or group-term life insurance coverage.

Health Benefit Plans, Employee↗
PubMed1992

[Competence sharing between health insurance and medical service].

The borderlines between the areas of competence of the German compulsory health insurance authorities and their Medical Service can be drawn as follows: 1. The German compulsory health insurance body is legally obliged to clarify the facts concerning a patient and his illness. It is therefore imperative for the health insurance body to prepare the ground in each individual case in such a manner that the case in question can be entrusted to a doctor called upon to write an expertise, but the final decision in respect of the insurance coverage rests exclusively with the health insurance body. 2. The Medical Service system is component for helping to find the fact that must be known before the administrative procedure to arrive at a decision is initiated. The expertise given by the Medical Service is a decision help invaluably important on the grounds of specialist knowledge, knowledge of facts and experience gathered from medical practice. Wherever the borderlines of such competencies are overstepped, there is a risk of errors occurring in the expertise and in the administrative decisions based thereon. Such sources of error can be eliminated only if both parties know and accept their limitations and also do not expect the other side to cross these boundaries.

Disability Evaluation↗
PubMed2004

The impact and enforcement of prudent layperson laws.

STUDY OBJECTIVE: Almost every state has enacted a "prudent layperson" standard for determining insurance coverage for emergency department (ED) services. This study evaluates whether these laws are achieving their goals or causing unintended side effects. METHODS: Six states were selected for in-depth case studies to represent a range of market, demographic, and legal conditions. In each state, 11 to 15 interviews were conducted with insurers, regulators, providers, employers, patient advocates, and industry observers, for a total of 87 interviews. In addition, regulators in all 50 states completed a written survey about likely enforcement responses for hypothetical violations of these laws. RESULTS: Basic compliance with prudent layperson laws appears to be widespread. Regulators actively enforce these laws, and most subjects reported no systematic violations. Insurers explained that it is difficult to operationalize a coverage standard that relies on patients' experience of symptoms rather than on providers' assignment of diagnostic and procedure codes. No strong evidence was found that these laws have significantly increased insurance costs, which is due in part to various strategies insurers have adopted to reduce payments to providers for ED services and to greatly increase patients' copayments. Accordingly, few subjects believe these laws have increased inappropriate ED use. CONCLUSION: Prudent layperson laws have helped to catalyze industry-wide changes in how health insurers review ED claims and how they manage ED costs. Whether these changes, on balance, are beneficial to patients and to society requires further study focused on outcomes and system-wide costs.

Emergency Service, Hospital↗
PubMedDate not supplied

Current trends in the integration and reimbursement of complementary and alternative medicine by managed care organizations (MCOs) and insurance providers: 1998 update and cohort analysis.

OBJECTIVES: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services into conventional medicine. METHODS: A literature review and information search was conducted to determine which insurers had special policies for CAM. Telephone interviews were conducted with a definitive sample of 9 out of 10 new MCOs or insurers identified in 1998 and a cohort of eight MCOs and insurers who responded both to the original survey in 1997 and again in 1998 to determine trends. RESULTS: This study constitutes the results of the second year of a 3-year ongoing survey. For 1998, 10 MCOs and insurance carriers initiated CAM coverage. Survey results are analyzed for these 10 new providers as well as the results of a cohort of eight insurers surveyed in both 1997 and 1998 to determine current trends. A majority of the insurers interviewed offer some coverage for the following: nutrition counseling, biofeedback, psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. All new MCOs and insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness, consumer interest, demonstrable clinical efficacy, and state mandates. Among the most common obstacles listed to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition and division, and lack of standards of practice. CONCLUSIONS: Consumer demand for CAM is motivating more MCOs and insurance companies to assess the benefits of incorporating CAM. Outcomes studies for both conventional and CAM therapies are needed to help create a health care system based upon treatments that work, whether they are conventional, complementary, or alternative.

Cohort Studies↗
PubMed2003

Enrollee appeals of preservice coverage denials at 2 Health Maintenance Organizations.

CONTEXT: Congress and state legislatures are considering patient bills of rights that seek to strengthen opportunities for patients to have denials of coverage reconsidered by their health plans. Little is publicly known about such appeals systems. OBJECTIVE: To improve understanding of the sources, types, and outcomes of conflicts between patients and managed care organizations over coverage of services. DESIGN AND SETTING: Descriptive study of information abstracted from 1774 preservice appeals out of a larger stratified random sample of 3519 appeals lodged between January 1998 and June 2000 at 2 large US health maintenance organizations. MAIN OUTCOME MEASURES: Classification of preservice appeals according to whether they contested access to out-of-network care, the contractual limits of coverage, or the medical necessity of services; analysis of contractual coverage and medical necessity appeals by the services in dispute and out-of-network appeals by enrollees' reasons for seeking care; and comparison of the proportions of appeals won by enrollees across types of appeals and services. RESULTS: Approximately one third (36.9%) of preservice appeals involved medical necessity determinations, another third (36.6%) centered on the scope of contractually covered benefits, and most of the remainder (19.7%) involved out-of-network care. Enrollee wins were significantly more frequent among medical necessity appeals than out-of-network or contractual coverage appeals (52.2% vs 35.4% and 33.2%, respectively; P<.001). Appeals were concentrated among relatively few services and among therapies that are generally regarded as nonessential. CONCLUSIONS: A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care.

California↗
PubMed2000

Small employers and health benefits: findings from the 2000 Small Employer Health Benefits Survey.

Many small employers (between two and 50 workers) are making decisions about whether to offer health benefits to their workers without being fully aware of the tax advantages that can make this benefit more affordable. Fifty-seven percent of small employers did not know that they can deduct 100 percent of their health insurance premiums. Nearly one-half of small employers are not aware that workers who purchase health insurance on their own generally cannot deduct 100 percent of their health insurance premiums. Small employers are largely unaware of the laws that have been enacted by nearly all states and the federal government with the intent of making health insurance more accessible and more affordable for many small employers. More than 60 percent did not know that insurers may not deny health insurance coverage to small employers even when the health status of their workers is poor. Most employers offer sound business reasons for offering health benefits to workers. Many have found that it helps with employee recruitment and retention, increases productivity, and reduces absenteeism. Nearly 50 percent of the employers offering dependent (family) coverage report that the workers do not take coverage for their dependents because the dependents have coverage from somewhere else. Twenty-seven percent report their employees decline dependent coverage because they cannot afford the premiums. Many small employers that do not offer health benefits are potential purchasers. Twelve percent are either extremely or very likely to start offering health benefits in the next two years, and 17 percent are somewhat likely to start offering health benefits. A number of factors would increase the likelihood that a small business would seriously consider offering a health benefits plan. Two-thirds of small-business owners said they would seriously consider offering health benefits if the government provided assistance with premiums. Almost one-half would consider doing so if insurance costs fell 10 percent. In addition, one-half would be more likely to seriously consider offering a health benefits plan if employees demand it. Many small employers with health benefits have recently switched health plans, and 34 percent report that they did so within the past year. Affordability for the employer and the worker is clearly a critical factor affecting the likelihood of switching health plans. Nearly all employers who have switched health plans within the past five years cite cost as the main reason. One-third of companies offering health benefits think they will change coverage, and 5 percent think they would drop coverage if the cost of health insurance were to increase by 5 percent.

Commerce↗
PubMed1997

Growth hormone coverage policy and implementation: a four-year experience.

Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings.

Child↗