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At least 1,207 records · Page 67Linked to original sources
PubMed1986

The health insurance plight of patients with sickle cell disease.

Despite chronic illness that requires routine medical follow-up as well as occasional acute care and hospitalizations, many persons with sickle cell disease (SCD) are not getting the care that they need. The primary reason for lack of proper care is due to the patients' lack of health insurance coverage. This paper will examine the problem of health insurance coverage among persons with chronic illnesses using SCD as a model. It is speculated by the author that persons who suffer from other chronic illnesses may also experience similar problems in obtaining health coverage. Supporting data for this report are derived from a survey on the health insurance status of a randomly selected group of SCD patients treated at the Howard University Center for Sickle Cell Disease. This survey revealed that 20 percent of 70 adult and pediatric patient respondents had no form of health insurance coverage.

Adolescent↗
PubMed1997

Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis.

Life expectancy for individuals with cystic fibrosis (CF) has increased dramatically in the last 30 yr, but it is unclear whether the improved survival has applied equally to individuals with different health insurance status. We developed a retrospective inception cohort of all 189 patients with CF born 1/1/55 to 12/31/70 who had at least one hospitalization at a university referral center. The median survival for patients with CF who were without health insurance was 6.1 yr compared with 20.5 yr for those with Medicaid and 20.5 yr for those with private insurance. Using multivariate Cox regression, health insurance and increased socioeconomic status were independently associated with longer survival. The adjusted relative risk of death was greater for the absence of health insurance than for factors previously shown to predict mortality in individuals with CF (female sex and presentation with meconium ileus). In summary, the absence of health insurance was associated with increased mortality rate in children with CF and was a stronger predictor of mortality than variables previously shown to be associated with mortality for CF. If increasing numbers of children with CF lose health insurance coverage, our results suggest that their life expectancy will decrease dramatically.

Adult↗
PubMed2000

The health plan choices of retirees under managed competition.

OBJECTIVE: To investigate the effect of price on the health insurance decisions of Medicare-eligible retirees in a managed competition setting. DATA SOURCE: The study is based on four years of administrative data from the University of California (UC) Retiree Health Benefits Program, which closely resembles the managed competition model upon which several leading Medicare reform proposals are based. STUDY DESIGN: A change in UC's premium contribution policy between 1993 and 1994 created a unique natural experiment for investigating the effect of price on retirees' health insurance decisions. This study consists of two related analyses. First, I estimate the effect of changes in out-of-pocket premiums between 1993 and 1994 on the decision to switch plans during open enrollment. Second, using data from 1993 to 1996, I examine the extent to which rising premiums for fee-for-service Medigap coverage increased HMO enrollment among Medicare-eligible UC retirees. PRINCIPLE FINDINGS: Price is a significant factor affecting the health plan decisions of Medicare-eligible UC retirees. However, these retirees are substantially less price sensitive than active UC employees and the non-elderly in other similar programs. This result is likely attributable to higher nonpecuniary switching costs facing older individuals. CONCLUSIONS: Although it is not clear exactly how price sensitive enrollees must be in order to generate price competition among health plans, the behavioral differences between retirees and active employees suggest that caution should be taken in extrapolating from research on the non-elderly to the Medicare program.

Aged↗
PubMed1998

Oral health systems in Europe. Part I: Finance and entitlement to care.

OBJECTIVE: To describe and compare the oral health systems in 18 European countries. BASIC RESEARCH DESIGN: Semi-structured, in-depth validation interviews were carried out with key informants from the main national dental associations of EU and associated countries. The interviews were structured around the responses to a previously completed questionnaire, the topics and terminology of which had been agreed in advance with the collaborating associations. The resulting descriptions of dental practice and the dental workforce in each country were returned for further validation and correction by the collaborating associations. Ultimate editorial control over the review of each country's oral health system rested with the authors. RESULTS AND CONCLUSIONS: Oral health care is mainly financed by government-regulated or compulsory social insurance in seven of the 18 countries examined here: Austria, Belgium, France, Germany, Luxembourg, The Netherlands and Switzerland. Providing universal or near-universal coverage by membership of insurance institutions, these systems provide oral health care for about 180 million people across Europe, and almost half of all EU citizens. In the Nordic countries and the UK entitlement to care is typically based upon residence or citizenship, and apart from in Norway and Iceland is provided within a tax-funded and government-organised health service. In southern Europe, Norway, Ireland and Iceland oral health care is largely financed directly by the patient, with occasional support through private insurance. Some publicly-funded and organised services do exist in these countries but generally only for specific population groups (e.g. children, unemployed), or in particular regions.

Child↗
PubMedDate not supplied

[Physician confidentiality and information owed to the insurance companies].

The ethical problems and deontological consequences, following the insurance companies request about medical care to their insured, was analysed. We have had in mind the patient's right to privacy and the doctor's commitment to confidentiality, on the one hand, and the insurance company's right to the necessary information, on the other. We analysed the health questionnaires of the insurance companies. And we administered a questionnaire to specialists of an University Hospital, and to employees in General Services: business administration, promotion, admissions, and archive of clinical records. The client's signature on the health questionnaire authorizes the doctors and centres to provide the insuring body with complete information regarding the client's state of health in most of the companies. All the insurance companies, 8 of the 11 mutual benefit societies, and all the public health services had asked the doctor directly for information about their clients. The confidentiality of patients' medical records with regard to the insuring bodies is not generally conceptualised in terms of legality or illegality, but conflicts of professional ethics do arise. It is the doctors and the representatives of the health care centres who have to safeguard the patients' rights.

Confidentiality↗
PubMed1986

[Health manpower in Argentina].

The health manpower situation in Argentina is characterized by a lack of proportion among categories of personnel, an unbalanced geographic distribution, the incorporation of health activities in certain categories of personnel, and a lack of coordination among personnel-training institutions. The different categories of personnel have evolved without any coherent or sustained policy (the number of nonmedical professional personnel increased by more than 100% between 1969 and 1980). The most recent data reveal a persistent trend toward clustering in capital cities and major commercial centers, although the large number of physicians in these places has compelled professionals to practice in small rural localities as well. While this maldistribution is widespread in the country, Buenos Aires province is a classic example of an imbalance between the proportions of physicians and nurses (in 1983 there were reportedly 27,307 physicians and 11,722 nurses). Moreover, there is no coordination whatever between the demand for physicians and the numbers of physicians graduating, not is there any planning for the posts of other health professionals. The authors note that, while women account for 60% of the personnel, they are clustered mainly in the categories of auxiliaries and aides (in 1980, 80% of the professional and directorial positions were held by men). Rectification of this system-wide manpower imbalance is part of the National Health Insurance plan proposed in 1985 and based on five principles: universal coverage, the national will, pluralism, community participation, and federalism.

Argentina↗
PubMed1999

The dilemmas of incrementalism: logical and political constraints in the design of health insurance reforms.

Health care reform became a premier issue on the U.S. policy agenda in the 1990s. While the comprehensive proposal put forth by President Clinton failed, states and the federal government successfully pursued a variety of lesser initiatives. This article focuses on a set of reforms intended to make private health insurance more accessible and affordable to individuals and workers in small firms. It outlines the key arguments made by experts to justify stronger regulation of health insurance and the options and difficult tradeoffs that must be considered in policy design. It then examines the scope and strength of legislation adopted by 45 states and the federal government from 1990 to 1996. The substantial variation in state policies demonstrates that even though insurance market reform was the one issue that commanded nearly universal support in the health care debate, few design features were universally accepted by those who crafted the reforms. The article concludes by assessing the pattern of state and federal action. The reforms represent some progress on nominal access to insurance but little progress on the affordability of insurance for individuals and small groups. Few of the reforms present a serious challenge to existing practices and interests of the insurance industry. This pattern of policy design reflects the logical and political constraints of incrementalism. In a system where insurance coverage is voluntary, changes to increase access for one group tend to increase costs and thereby decrease access for another segment of the population. In addition, because incremental reforms will not attract sustained attention and support from the general public, it is politically difficult to impose substantial new regulation on a powerful industry.

Group Purchasing↗
PubMed1980

Selection of health insurance by an employee group in Northern California.

Enrollment trends for a large employee group were analyzed to determine the extent to which consumers chose Blue Cross or Health Maintenance Organization (HMO) health insurance under various premium differentials. Data were collected from employment records of six University of California campuses for the period 1967 to 1978. Enrollment in the Kaiser Foundation Health Plan (an HMO) more than doubled during this period while enrollment in Blue Cross remained relatively stable. This increased preference for Kaiser coverage was associated with a concurrent relative rise in costs to employees of Blue Cross coverage. These data suggest that consumers are sensitive to insurance costs, and that given the opportunity HMOs can compete effectively with traditional health insurance.

Blue Cross Blue Shield Insurance Plans↗
PubMed2006

Creating technology-enhanced practice: A university-home care-corporate alliance.

Insuring full benefit of consumer health informatics innovations requires integrating the technology into nursing practice, yet many valuable innovations are developed in research projects and never reach full integration. To avoid this outcome, a team of researchers partnered with a home care agency's staff and patients and their corporate parent's Information Systems and Research group to create a Technology-Enhanced Practice (TEP) designed to enhance care of home bound patients and their family care givers. The technology core of TEP, the HeartCare2 web site, was built in a collaborative process and deployed within the existing patient portal of the clinical partner. This paper describes the innovation and the experience of bringing it into full operation.

Cooperative Behavior↗
PubMed2002

Atrial fibrillation after coronary surgery: comparison between different health care systems.

AIMS: No studies have evaluated the influence of management strategies in different health insurance environments on atrial fibrillation (AF). This observational study compared the incidence of and treatment strategies for postoperative AF after primary coronary bypass surgery. METHODS AND RESULTS: One insurance and one public funded location was compared: University of Michigan Health Center (USA, n=272) and Tampere University Hospital (Finland, n=314). USA patients had more co-morbidities and were treated more aggressively after acute myocardial infarction. More Finns were on beta-blockers both preoperatively (93 vs. 68%, P<0.001) and postoperatively (97 vs. 66%, P<0.001). However, AF was more frequent among Finns (38 vs. 29%, P=0.037) and present on 4.6% of cases when transferred postoperatively. No USA patients had AF at time of discharge. Mean length of stay was 8.6 days at USA, and not affected by AF. The incidence of in-hospital death, strokes and multiorgan failures was similar. Multivariable analysis, adjusted for site and selection biases (propensity analysis) revealed increasing age [OR=1.063 (1.042, 1.084), P<0.0001] and use of radial arteries [OR=2.175 (1.071, 4.417), P=0.032) to be independent predictors to the incidence of postoperative AF. CONCLUSIONS: We found several major differences in patient selection and treatment strategies among primary coronary bypass patients managed in the two institutions. Despite the marked practice variation, the incidence of postoperative AF was rather similar. Despite routine use of beta-blockers, AF occurred in 29-38% of patients. However, the length of stay was not particularly affected by postoperative AF.

Adrenergic beta-Antagonists↗
PubMed1995

Hospitalization charges, costs, and income for firearm-related injuries at a university trauma center.

OBJECTIVE: To quantify the actual cost of inpatient medical care for firearm-related injuries at a university trauma center. DESIGN: Retrospective case series of all hospital admissions for firearm-related injuries for the 3 years 1990 through 1992. Total inpatient financial data were examined by means of a recently instituted cost-accounting methodology. SETTING: Level I trauma center at a university hospital that provides trauma care and tertiary care to 3.7 million residents of 23 counties. PATIENTS: A total of 787 consecutive patients were admitted to the hospital with firearm-related injuries. Information from the trauma registry and hospital finance records were linked for 750 (95%) of these patients. MAIN OUTCOME MEASURES: Total inpatient hospital charges, costs, revenues, and net income according to payer source. RESULTS: Men aged 15 to 44 years accounted for 77% of patients with firearm-related injuries. The overall mean and median hospital charges per admission were $52,271 and $28,033, respectively, whereas the overall mean and median hospital costs per admission were $13,794 and $7964, respectively. The net income per patient ranged from an average loss of $6980 for each patient having no insurance to an average profit of $28,557 for each patient with a health maintenance organization contract. The losses sustained on nonsponsored and Medicaid patients were more than offset by net income from patients having private health insurance, Medicare, or other insurance coverage such that there was an average profit of $5809 per admission for a firearm-related injury. CONCLUSIONS: Treatment of firearm-related injuries produces net income for this university trauma center by virtue of the cost shifting built into its pricing structure. If data from this institution are extrapolated to the nation, then the actual cost of providing medical care for firearm-related injuries in the United States in 1995 is projected to be $4.0 billion. The majority of this cost will be paid indirectly by private health insurance.

Adolescent↗
PubMedDate not supplied

Caring for the underserved: using patient and physician focus groups to inform curriculum development.

BACKGROUND: Training pediatric residents to care for the underserved is a recognized curricular need. A literature review revealed that curricula specific to caring for the underserved tend to focus on specific medical diagnoses rather than physician or patient behaviors. OBJECTIVE: To collect and evaluate information essential for developing a curriculum to teach care for the underserved. METHODS: Focus groups were conducted to identify themes responsive to the question, "What does a physician need to know to care for the underserved?" Each of 3 focus groups met twice. The physician group included 5 pediatricians and 3 family practitioners. There were 2 patient groups: one Spanish-speaking (N = 13) and one English-speaking (N = 8). Content analysis was used to identify themes from each of the focus groups. RESULTS: Prevailing themes from the 3 groups were communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems. Patients expressed an almost universal wish for physicians to listen to them and to attempt to "understand my life." Physicians expressed concerns with lacking the time to establish quality patient relationships and the need to serve multiple roles. The groups did not discuss issues related to specific medical conditions. CONCLUSIONS: Physicians and underserved patients identified communication/respect, cultural issues, and frustration with systems, such as health insurance, transportation, and health delivery systems, as important factors in caring for the underserved. Curricula to teach care of the underserved should include these themes.

Adult↗
PubMed2005

Restructuring primary health care markets in New Zealand: from welfare benefits to insurance markets.

BACKGROUND: New Zealand's Primary Health Care Strategy (NZPHCS) was introduced in 2002. Its features are substantial increases in government funding delivered as capitation payments, and newly-created service-purchasing agencies. The objectives are to reduce health disparities and to improve health outcomes. ANALYSIS: The NZPHCS changes New Zealand's publicly-funded primary health care payments from targeted welfare benefits to universal, risk-rated insurance premium subsidies. Patient contributions change from fee-for-service top-ups to insurance premium top-ups, and are collected by service providers who, depending upon their contracts with purchasers, may also be either insurance agents or risk-bearing insurance companies. The change invokes the tensions associated with allocating risk-bearing amongst providers, patients and insurance companies that accompany all insurance-based funding instruments. These include increases in existing incentives for over-consumption and new incentives for insurers to limit their exposure to variations in patient health states by engaging in active patient pool selection. The New Zealand scheme is complex, but closely resembles United States insurance-based, risk-rated managed care schemes. The key difference is that unlike classic managed care models, where provider remuneration is determined by the insurer, the historic right for general practitioners to autonomously set patient charges alters the fiscal incentives normally available to managed care organisations. Consequently, the insurance role is being devolved to individual service providers with very small patient pools, who must recoup the premium top-ups from insured individuals. Premium top-ups are being collected only from those individuals consuming care, in proportion to the number of times care is sought. Co-payments thus constitute perfectly risk-rated premium levies set by inefficiently small insurers, raising questions about the efficiency and equity of a 'universal' insurance system pooling total population demands and costs. The efficacy of using financial incentives to constrain costs and encourage innovation when providers retain the right to arbitrarily recoup costs directly from patients, is also questioned. RESULTS: Initial evidence suggests that total costs are higher than initially expected, and prices to some patients have risen substantially under the NZPHCS. Limited competition and NZPHCS governance requirements mean current institutional arrangements are unlikely to facilitate efficiency improvements. System design changes therefore appear indicated.

Journal Article↗
PubMed1998

Frequent ED users: patterns of use over time.

The objective of this study was to examine the pattern of emergency department (ED) use by frequent ED users over time. This study was a retrospective study of adults with more than 10 visits to a university hospital ED from 8/90 through 7/91. ED visits of this cohort to all hospitals in the metropolitan area were followed for 3 years. Records were reviewed for the etiology of each patient's ED visits. This cohort was comprised of 76 patients making 1,119 (1.9%) of the total 59,051 ED visits. Thirty-five of the 76 (46%) were frequent ED users in only the initial year. Thirteen of the 76 (17%) made more than 10 visits in all 4 years. The remainder had sporadic episodes of ED use. Thirty-five (46%) were evaluated at three or more EDs in years in which they were frequent users. Forty-two (55%) had a medical problem for the cause of the majority of their ED visits. Fifty-eight percent of patients making more than 10 visits in more than 1 year had psychiatric or substance abuse problems. The pattern of ED use in this cohort changed over time and was influenced by substance abuse and psychiatric problems. These data suggest that most patients do not remain frequent ED users over time.

Adult↗
PubMed2002

Bargaining health benefits in the workplace: an inside view.

Before contract negotiations in 1999, the author served on an "issue-based" health benefits committee of faculty union representatives and university administrators. Although the committee solicited estimates from health insurers regarding the impact of higher copayments on monthly premiums, in subsequent negotiations, the projected cost savings did not lead to changes in coverage or copayments. The explanations offered are (1) national or regional employers may be reluctant to raise employees' health benefit copayments when labor markets are tight; (2) collective bargaining, particularly when other, nonmonetary issues are being bargained, may lead to results different from those from a strictly competitive model; and (3) employers with market power in the product market may shift these highest costs to consumers through higher prices.

Administrative Personnel↗