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At least 1,207 records · Page 67Linked to original sources
PubMed1991

The effect of owning private long-term care insurance policies on out-of-pocket costs.

This article examines the effect of owning long-term care insurance policies on the amount of out-of-pocket costs incurred by the elderly during their nursing home stays, and the importance of different policy features and restrictions. Data were drawn from the 1985 National Nursing Home Survey, and from copies of long-term care insurance policies collected from 11 leading companies during the spring and summer of 1988. The study results show a great deal of uncertainty concerning amounts the policies are likely to pay toward nursing home stays. This implies that the policies collected did not adequately fulfill one of the primary purposes of insurance: a reduction in risk and uncertainty. To examine whether rapid policy changes in recent years have made a difference, we assessed each of seven policy features and found that the two most important restrictions in long-term care insurance policies are prior hospitalization and level-of-care requirements. Recently, the National Association of Insurance Commissioners (NAIC) recommended that states prohibit the sale of policies containing these restrictions. Our findings confirm the wisdom of this recommendation. We did find, however, that two other policy restrictions--policy maximums and lack of inflation adjustment--are problematic. We recommend that the NAIC expand its model regulations to require that policy maximums be a minimum of four years, and that some form of inflation protection be incorporated into policy benefit structures.

Aged↗
PubMed1989

The prevalence of health insurance in a Jamaican suburb and its correlations with service utilisation.

The prevalence of health insurance in a low-income Jamaican community was determined from a systematic sample of 103 households. A household prevalence for health insurance of 32 per cent was found. Differentials in health service utilisation were more striking for private practitioner services where the highest correlation with coverage was found (r = 0.346, p less than 0.001). A negative correlation (r = -036, N.S. with local health centre utilisation was obtained. For every 100 people attending a private facility, 33 had health insurance coverage. The level of health insurance coverage in the community and its impact on service utilisation would suggest the possibility of harsh economies in the health sector, forcing consumers in low-income groups to seek a buffer for the expenses incurred from needs unmet by the public services. Part of this favourable prevalence of health insurance may also be due to job-related coverage.

Community Health Services↗
PubMed1993

Insurance coverage and usage of preventive health services.

The 1991 Florida Behavioral Risk Factor Survey which included 2,246 respondents to a random-digit-dial telephone survey, showed that 19.2% of Florida residents aged 18 and older reported they had no health insurance, and 24.7% reported they had no insurance covering outpatient services. Lack of insurance coverage was reported more frequently by younger adults (70% under age 40 vs 93% over age 60), by those with less than a high-school education (69% vs 85% for those with some college), by members of racial-ethnic minority groups (Hispanics 67.5%, Blacks 71.5%, whites 85%), and by residents of southeastern Florida. Persons without insurance coverage were less likely to report having had a check-up by a physician in the last year, more likely to report they needed to see a physician but could not because of cost (37% vs 9%), and less likely to have received a mammogram (33% vs 56%) or Pap smear (51.6% vs 67.8%) in the last year. These findings support the need for health-care reform to include assurance that health insurance covers preventive services.

Adolescent↗
PubMed1993

Private medical insurance among Philadelphia residents diagnosed with AIDS.

We used medical insurance information gathered on each Philadelphia resident with AIDS to examine time trends in private medical insurance at the time of diagnosis. The proportion of AIDS patients with private medical insurance decreased from 51.9% in July-December 1988 to 28.6% in July-December 1991. During the same time period, an increasing proportion of people diagnosed with AIDS were female, poor, members of minority groups, or abusers of injection drugs. A discrete multivariate model showed that the (point) prevalence of private medical insurance at AIDS diagnosis decreased significantly with time, even after adjustment for changes with time in the age, gender, race, estimated income, history of injection drug use, and history of homosexual contact of those who were affected with AIDS. Thus the decreasing prevalence of private medical insurance among people newly diagnosed with AIDS does not simply reflect changes in the demographic and behavioral characteristics of the people affected.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Opiate dependency among the subscribers of a New York area private insurance plan.

OBJECTIVE: To estimate the prevalence of opiate use among the subscribers of a large private insurance plan, Empire Blue Cross and Blue Shield (EBCBS). DESIGN: Six and a half million hospital inpatient claims for the period January 1, 1982, through June 30, 1992, were reviewed. Thirty-one thousand eight hundred ten different individuals who had a total of 55,143 hospital admissions with a primary diagnosis of opiate dependency (International Classification of Diseases, Ninth Revision, Clinical Modification 304.0 and 304.7) were identified. In the same period, 17,493 EBCBS subscribers (15,191 male and 2302 female) were identified from hospital admissions data as having acquired immunodeficiency syndrome. These data were cross-matched with the opiate dependency data to estimate the "capture" of opiate users in the EBCBS subscribers with acquired immunodeficiency syndrome and to model the size of the opiate using population in EBCBS. RESULTS: It is estimated that between 1982 and 1992 EBCBS insured approximately 141,000 opiate users, 85,000 of whom are currently insured by EBCBS. CONCLUSION: There is a large population of insured opiate users who may be excluded from the estimates of the overall number of opiate users as insured opiate users are less likely to be counted via contact with government agencies. This suggests that current estimates of the number of opiate users and their social characteristics should be reconsidered.

Acquired Immunodeficiency Syndrome↗
PubMed1993

The health care status of the diabetic population as reflected by physician claims to a major insurer.

BACKGROUND: Conventional epidemiologic data suggest that diabetic patients use more health care resources than nondiabetic patients, yet overall health care use by diabetic individuals has never been fully quantitated. We took a new approach to this issue based on the actual economics of the provision of health care to diabetic insured individuals. METHODS: The claims records in the Mutual of Omaha Current Trends database, which contains information on more than 400,000 individuals, were surveyed to identify patients with diabetes and create the contrast population of nondiabetic patients by exclusion. International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Physicians' Current Procedural Terminology, Fourth Edition, codes were used to determine all diagnoses recorded and all physician services rendered to the contrast populations. Age- and sex-adjusted comparisons were performed using Mantel-Haenszel procedures to determine an adjusted odds ratio (AOR). RESULTS: A total of 13,304 diabetic individuals and 388,053 nondiabetic individuals who received health care services from January 1, 1988, to January 1, 1989, were identified. Diabetic insured individuals constituted 3.1% of the overall insured population yet accounted for 8.3% of the charges (P < .01). Inpatient charges accounted for 81% of total diabetic charges but only 61.5% of total nondiabetic charges (P < .001). Diabetic insured individuals had twice as many physician office visits (AOR = 1.87; 95% confidence interval [CI], 1.79 to 1.96), with 2.5 times more physician hospital visits [AOR = 2.50; 95% CI, 2.27 to 2.75). However, the increases in physician care were not uniformly distributed across the diagnostic spectrum. The frequencies of well-established complications of diabetes, such as ischemic heart disease (AOR = 3.32; 95% CI, 3.12 to 3.53), peripheral vascular disease (AOR = 3.14; 95% CI, 2.79 to 3.53), and eye disease (AOR = 3.10; 95% CI, 2.94 to 3.27), were threefold higher in the diabetic group, with parallel increases in related medical services, such as cardiac catheterization (AOR = 3.02; 95% CI, 2.27 to 4.0), vascular surgery (AOR = 2.94; 95% CI, 2.64 to 3.27), and ophthalmologic procedures (AOR = 2.94; 95% CI, 2.72 to 3.18). In contrast, most diagnostic categories showed little or no increase. For example, the frequency of neoplasms (AOR = 1.11; 95% CI, 1.03 to 1.19) was minimally increased, and the associated procedural concomitants of therapeutic radiology (AOR = 0.81; 95% CI, 0.47 to 1.39) and chemotherapy (AOR = 0.98; 95% CI, 0.60 to 1.60) were not increased in the diabetic group. CONCLUSIONS: Our most important new finding is that diabetic patients have neither an elevated risk for a wide spectrum of diseases nor an increase in the receipt of physician services for diagnostic categories without increased risk, despite more frequent physician encounters. We provide real-world risk estimates that help in calculating the effect of offering specific insurance to diabetic individuals or including them in group health plans. The techniques we have developed to analyze computerized claims databases in this way may serve to better quantify the true impact of chronic diseases on the health care system.

Adult↗
PubMed1995

The use of case management services in long-term care insurance policies.

This article presents findings from a recently completed Health Insurance Association of America-sponsored survey that sought to measure the extent to which long-term care insurers utilize case/care management services in their policies. The survey sought to measure the extent to which long-term care insurers paid for newer, long-term care alternatives. Contrary to previous findings in the literature, the survey results show that case management services are typically delivered through a combination of internal and external networks, and are utilized primarily by insurers in employer markets. In light of national health care reform, these survey results indicates a need to reexamine the role of case management in delivering long-term care services, particularly within private financing mechanisms such as long-term care insurance.

Case Management↗
PubMed1997

Differences in private health insurance coverage for working male Hispanics.

In 1993, 33.8% of all nonelderly adult Hispanics living in the United States lacked health insurance coverage (either private or public), compared to 8.1% of the entire nonelderly population. Because Hispanics are more likely to be uninsured than any other ethnic group and because they are the fastest growing minority group in the United States, the increase in the Hispanic population is likely to increase the proportion of the population without health insurance. Particularly striking are differences in private health insurance coverage among the three major Hispanic groups--Cuban-Americans, Mexican-Americans, and Puerto Ricans. In this paper, regression-based decomposition analysis is used to explain the sources of differences in private health insurance coverage among working males in these three group. The results indicate that among the study population, Cuban-Americans have higher rates of private health insurance coverage than Mexican-Americans and Puerto Ricans, and that wage rates, levels of education, age, occupation, and marital status explain most of the difference.

Adult↗
PubMed1978

[Insurance and preventive medicine].

Not only do insurance companies have to pay in case of death, injuries or disease, they are also concerned with their prevention. This is particularly true for the "Swiss National Accident Insurance Fund" (Caisse nationale suisse d'assurance en cas d'accidents--(CNA): for them the prevention of work related accidents and occupational diseases is required by law. Preventive activities in this area are very promising. The progress in the sickness insurance programmes for preventive medicine in the general population has, however, not been as successful. To date, the legislation denies payment for preventive medical care. Why is there this difference? In the case of accidents and occupational diseases, the cause of the pathologies are for the most part exogenous and develop in well known and controlled environments. In the case of disease or invalidity in the general population, the factors are in a large part endogenous and therefore very difficult to supervise, as they develop in much more complex and uncontrolled environments. Nevertheless progress has been done in this field as well. At present, some selected scientifically proven preventive examinations could be included in insurance programmes as part of a general plan and with strict quality control of laboratory findings.

Accidents, Occupational↗
PubMed2002

Alternative health insurance schemes: a welfare comparison.

In this paper, we present a simple model of health insurance with asymmetric information, where we compare two alternative ways of organizing the insurance market. Either as a competitive insurance market, where some risks remain uninsured, or as a compulsory scheme, where however, the level of reimbursement of loss is to be determined by majority decision. In a simple welfare comparison, the compulsory scheme may in certain environments yield a solution which is inferior to that obtained in the market. We further consider the situation where the compulsory scheme may be supplemented by voluntary competitive insurance; this situation turns out to be at least as good as either of the alternatives.

Actuarial Analysis↗
PubMed2002

Community rating in health insurance and different benefit packages.

This paper presents a model of a competitive health insurance market with two risk types and two health benefits. In the benchmark case, community rating insurers (CRIs) are only allowed to offer the basic benefit. The additional benefit is sold by risk rating insurers (RRIs). It is shown that low risk types can only be better off at the expense of high risk types if CRIs are allowed to offer the additional benefit and no additional measures are taken. However, high risk types can be made better off if CRIs must offer the additional benefit or if community rating health insurers offering the additional benefit are subsidized while those selling only the basic benefit are taxed.

Actuarial Analysis↗
PubMed2003

A comparison of single- and multi-payer health insurance systems and options for reform.

A major choice confronting many countries is between single-payer and multi-payer health insurance systems. This paper compares single-payer models in the areas of revenue collection, risk pooling, purchasing, and social solidarity. Single-payer and multi-payer systems each have advantages which may meet countries' priorities for their health insurance system. Single-payer systems are usually financed more progressively, and rely on existing taxation systems; they effectively distribute risks throughout one large risk pool; and they offer governments a high degree of control over the total expenditure on health. Multi-payer systems sacrifice this control for a greater ability to meet the diverse preferences of beneficiaries. Several major reforms of single-payer insurance systems--expansion of the role of private insurance and transformation to a multi-payer system--are then described and illustrated using specific country examples. These reforms have been implemented with some success in several countries but face several important challenges.

Consumer Behavior↗
PubMed2002

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries. Such an analysis, however, is largely lacking, especially with regard to LMICs. This paper attempts to fill this gap. For each of the following lessons, it considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce a principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other regions and social groups may be feasible to achieve universality. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third. in a pluralistic SHI system equity, as well as risk pooling and spreading, can be enhanced if funds merge. The optimal number of funds, however, will depend on the stage of development of the SHI system as well as on other objectives of the system, including choice and competition. A risk equalisation scheme may prevent the adverse effects of risk selection, if competition between insurance funds is introduced into the system. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralising and democratising a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behaviour is constrained by either political pressure or technical means.

Developing Countries↗
PubMed2002

Inside the sausage factory: improving estimates of the effects of health insurance expansion proposals.

The fate of a proposal to expand health insurance is influenced by predictions of the proposal's effects on the number of newly insured and the cost of new coverage. Estimates vary widely, for reasons that are often hard to discern and evaluate. This article describes and compares the frameworks and parameters used for insurance modeling. It examines conventions and controversies surrounding a series of modeling parameters: how individuals respond to a change in the price of coverage, the extent of participation in a new plan by those already privately insured, firms' behavior, and the value of public versus private coverage. The article also suggests ways of making models more transparent and proposes "reference case" guidelines for modelers so that consumers can compare modeling results.

Fees and Charges↗
PubMed1983

Psychiatric benefits and insurance regulation in Massachusetts: a national model?

The Massachusetts Mandatory Mental Health Insurance Act requires all health insurance plans in the state to cover mental illness. Because of their concerns that this law might be taken as a national model, the authors describe the problems encountered in implementing it and the conflicts between the insurance carriers and psychiatry. The authors attribute the problems to some insurance carriers' failure to deal directly with organized psychiatry in obtaining screening guidelines, the absence of psychiatrists on the carriers' central committees, and psychiatrists' generally indifferent and hostile attitudes toward the carriers. The authors describe recent improvements and recommendations based on 10 years of experience.

Attitude of Health Personnel↗
PubMed1991

Premiums without benefits: waste and inefficiency in the commercial health insurance industry.

The U.S. system of health insurance is wasteful and inefficient. For every dollar the commercial health insurance industry paid in claims in 1988, the industry spent 33.5 cents for administration, marketing, and other overhead expenses. Thus, not including profits, the commercial insurance industry spent 14 times as much on administration, overhead, and marketing per dollar of claims paid as did the Medicare system, and 11 times as much per dollar of claims paid as the Canadian national health system. Had an efficient public program such as Medicare or the Canadian system provided the same amount of benefits, consumers and businesses served by commercial insurers would have saved $13 billion. The sources of waste include excessive marketing costs and administrative costs bloated by discriminatory underwriting practices that segregate the profitable groups and individuals--people who are healthy, young, and in "safe" professions--from everyone else.

Canada↗
PubMed2004

Adverse selection and the challenges to stand-alone prescription drug insurance.

This paper investigates a possible predictor of adverse selection problems in unsubsidized stand-alone prescription drug insurance: the persistence of an individual's high spending over multiple years. Using Medstat claims data and data from the Medicare Survey of Current Beneficiaries, we find that persistence is much higher for outpatient drug expenses than for other categories of medical expenses. We then use these estimates to develop a simple and intuitive model of adverse selection in competitive insurance markets and show that this high relative persistence makes it unlikely that unsubsidized drug insurance can be offered for sale, even with premiums partially risk adjusted, without a probable adverse selection death spiral. We show that this outcome can be avoided if drug coverage is bundled with other coverage, and we briefly discuss the need either for comprehensive coverage or generous subsidies if adverse selection is to be avoided in private and Medicare insurance markets.

Drug Prescriptions↗
PubMed2001

Health Insurance family style: public approaches to reaching the uninsured.

This issue brief explores existing and potential opportunities to further expand the availability of health coverage for the uninsured and the under insured, given the current economy and the resulting state budget shortfalls. It also considers the implications of the Health Insurance Flexibility and Accountability initiative recently announced by the Centers for Medicare and Medicaid Services and the legislative options for health care reform being debated in Washington, including tax-credit incentives and additional federal funding for public coverage expansions through Medicaid and the State Children's Health Insurance Program. The Forum session will explore state, federal, and academic perspectives on public coverage expansions and the variety of paths available to support such expansions. The meeting will also address the cost implications of the differing perspectives in the context of the shifting economy. This is expected to lead to a discussion among presenters and participants of the future of and priorities for public financing of health insurance coverage.

Child↗