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PubMed2005

[Self-responsibility as a component of quality-oriented care-reflections on further development of nursing care insurance].

Further development of nursing care insurance must consider both ethical aspects and scarcity of resources. An economy that serves human life has two principal targets: safeguarding the basis of existence and extension of the fulfillment of life. From an ethical perspective welfare and personal responsibility have to be equilibrated by promoting individuality and self-responsibility and maintaining relatives' willingness to become a caregiver. Discussing the role of prevention and rehabilitation in nursing care it is argued that the legally committed primacy of prevention and rehabilitation over care has still not been put into practise due to unresolved problems at the interface of health insurance and nursing care insurance as well as at the interface of inpatient and outpatient providers. Moreover, it seems necessary to strengthen prevention and rehabilitation in the context of care. A comprehensive understanding of individual demands for help, support, and care requires a revision of the common definition of need for care in terms of activities of daily living which neglects particularly psycho-social needs. Case management is a suitable approach to provide adequate and coordinated support as a prerequisite for quality of life in people in need for care. Overcoming compartmentalization of inpatient and outpatient sectors and crosslinking of services are described as essential challenges for future provision of nursing care insurance. Intensification of counseling and advice for patients and relatives, extension and diversification of local providers, upgrading of ambulant services, daily care and short-term care, diversification of nursing homes and other housing arrangements, further development of hospices and palliative care, and acceptance of institutions for the elderly as indispensable components of the future care system are discussed as specific tasks in the further development of nursing care insurance.

Aged↗
PubMed2004

Estimating rural households' willingness to pay for health insurance.

In many developing countries limited health budgets are a serious problem. Innovative ways to raise funds for the provision of health services, for example, through health care insurance, have a high priority. Health care insurance for rural households shields such patients from unexpected high costs of care. However, there are questions about whether, and how much, rural households are willing to pay to purchase such insurance, as well as the factors determining willingness to pay. In recent years the Iranian government has tried to improve health and medical services to rural areas through a health insurance program. This study was conducted to estimate rural households' demand and willingness to pay for health insurance. A contingent valuation method (CVM) was applied using an iterative bidding game technique. Data has been collected from a sample of 2,139 households across the country.

Adolescent↗
PubMed1991

Preoperative insurance status influences postoperative complication rates for gastric bypass.

One hundred morbidly obese patients who had gastric bypass surgery were studied to determine how various demographic and medical variables affected complication rates, weight loss, and reduction in comorbidities associated with obesity. During the follow-up period (range: 12 to 59 months), 42 patients developed at least 1 complication. Twenty-three patients developed postoperative medical complications, 9 developed psychiatric complications, and 24 developed complications related to food ingestion. No significant relationships were observed between outcome and age, sex, age of obesity onset, or associated medical disorders. Striking differences in outcome were noted, however, when patients were contrasted according to their preoperative insurance status. Patients dependent on medical assistance, social security disability, or workman's compensation (publicly funded group) (n = 40) developed significantly more medical and psychiatric complications than did those (n = 60) who had private medical insurance (p less than 0.02). Despite the higher complication rate, both groups had the same average weight loss (44.9 +/- 15.3 kg for the publicly funded group versus 43.1 +/- 12.9 kg for those with private insurance) and similar reductions in percent excess weight (66.0 +/- 18.4% versus 75.7 +/- 23.0%) during the first postoperative year. All patients also had similar reductions in medication requirements for hypertension, diabetes, and degenerative joint disease. Additionally, 45% of the publicly funded insurance group who either received public welfare (n = 26) or disability benefits (n = 14) preoperatively were able to attain either full-time or part-time employment postoperatively which allowed them to decrease their level of support (58% and 21%, respectively). Forty-six percent of women in the private insurance group who were not working outside the home also began part-time or full-time employment postoperatively. All patients who were working preoperatively continued to work. These data suggest that although the risks associated with gastric bypass surgery are greater in patients dependent on public funding, these patients benefit significantly from the surgery.

Adolescent↗
PubMedDate not supplied

Effects of changes in professional liability insurance on certified nurse-midwives.

A stratified random sample of 500 ACNM members was surveyed by mail in June, 1987, using a questionnaire designed to describe the effects of the liability insurance crisis on the practice of nurse-midwifery. A majority of the 286 respondents indicated that the increased cost and decreased coverage of liability insurance is having a direct and negative impact on midwifery practice in terms of financial burden, increased defensive interventions, increased cost of care, decreased availability of care, restricted practice privileges, and stressed employer/employee relationships. A dramatic increase in insurance premiums has occurred without a comparable increase in income. The increased use of defensive medicine reported by CNMs has produced higher costs to the public. Job opportunities have diminished due to loss of insurance coverage, physician back-up, and hospital privileges. The active political involvement of nurse-midwives is needed in order to reverse the negative effects of the liability insurance crisis.

Certification↗
PubMed1995

Health services financing in Greece: a role for private health insurance.

Private health insurance can play a significant role in the financing and delivery of health services in relatively undeveloped health systems which suffer from limited public expenditures, resource shortages, and quality of care problems. Research results, however, indicate that private health insurance in Greece has not yet assumed that role. The rapid increase of private health insurance was the result of underfinancing by the public sector and restrictive policies for the private sector. The private sector, however, largely financed by private health insurance, found alternative investment and profit opportunities, which, unfortunately, did not improve health system microeconomic efficiency. In this paper we propose that a way of cooperation could exist between the public sector and private health insurance, which would improve public health services provision and the overall technical, allocative and dynamic efficiency of the health system.

Delivery of Health Care↗
PubMed1996

Health care triage alternatives and the influence of health insurance, education and race.

The relationship between one of Andersen's enabling factors, health insurance status and the choice of a pharmacist as the initial contact in the health care system was examined via telephone surveys. Eighty-seven percent of the sample reported having some form of health insurance. Of all intended health care provider contacts, pharmacists were selected as the initial contact 21% of the time. Logistic regression identified insurance status, education and race as significant (alpha < 0.05) covariates in the model. The odds ratios generated from the logit model indicated that non-whites, persons with less education and no health insurance were more likely to select a pharmacist for triage. The study concluded that uninsured persons were nearly twice as likely to seek pharmacist triage than insured individuals. Pharmacists may be filling an important triage gap for individuals who have limited financial access to traditional sources of physician care.

Adolescent↗
PubMed2004

Private medical insurance and saving: evidence from the British Household Panel Survey.

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.

Cost Savings↗
PubMed2004

A median voter model of health insurance with ex post moral hazard.

One of the main features of health insurance is moral hazard, as defined by Pauly [Pauly, M.V., 1968. The economics of moral hazard: comment. American Economic Review 58, 531-537), people face incentives for excess utilization of medical care since they do not pay the full marginal cost for provision. To mitigate the moral hazard problem, a coinsurance can be included in the insurance contract. But health insurance is often publicly provided. Having a uniform coinsurance rate determined in a political process is quite different from having different rates varying in accordance with one's preferences, as is possible with private insurance. We construct a political economy model in order to characterize the political equilibrium and answer questions like: "Under what conditions is there a conflict in society on what coinsurance rate should be set?" and "Which groups of individuals will vote for a higher and lower than equilibrium coinsurance rate, respectively?". We also extend our basic model and allow people to supplement the coverage provided by the government with private insurance. Then, we answer two questions: "Who will buy the additional coverage?" and "How do the coinsurance rates people are now faced with compare with the rates chosen with pure private provision?".

Insurance, Health↗
PubMed2004

Colorectal cancer screening, 1997-1999: role of income, insurance and policy.

BACKGROUND: Receipt of age-appropriate cancer screens can lead to reduced incidence and mortality. Yet, low-income and uninsured experience barriers to screening. This paper examines colorectal cancer rates by income, racial and insured groups 1997 and 1999. These years focus on changes pre/post a 1998 policy change for Medicare beneficiaries that reduced their out-of-pocket costs for colorectal screening. METHODS: The 1997 and 1999 Behavioral Risk Factor Surveillance System (BRFSS) survey is used to examine changes in age-appropriate fecal-occult blood testing (FOBT), flexible sigmoidoscopy screens. Differences in the odds that Medicare beneficiaries, relative to private insured, receive screens pre/post 1998 are examined using multivariate logit models. RESULTS: Average rates of sigmoidoscopy increased significantly during 1997-1999 but remain below desired levels. While Medicare beneficiaries are more likely than privately insured to be screened, gaps between low- versus high-income groups in both Medicare and non-Medicare populations remain. The 1998 Medicare policy change was associated with a significant increase in the odds of screening among low-income (<$25,000) Medicare beneficiaries. CONCLUSIONS: Policy makers should consider reasons for continued low colorectal screening rates among all insured groups. Barriers such as patient perceptions and physician advice should be considered along with the vulnerability that low income and lack of insurance imposes.

Colorectal Neoplasms↗
PubMed2004

The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States.

BACKGROUND: Nearly half of recent immigrants to the United States lack health insurance. Access to cancer screening services for this group is problematic. We examine the role of health insurance and having a usual source of care (USC) on Pap smear and mammography utilization by immigrant women using a nationally representative sample. METHODS: We used a telephone survey that oversampled racial and ethnic minorities. We analyzed data on 3,622 women age 18-70. We classified the 822 foreign-born women as recent immigrants if they had resided in the United States for under 10 years; LT immigrants were those with a longer tenure. RESULTS: Among recent immigrants, 73% and 78% (SE 4%) reported a Pap smear or mammogram, respectively, in the previous 2 years versus 89% and 89% of U.S.-born women (P < 0.05 for both comparisons). Among those with insurance or a USC, differences in screening between recent immigrants and U.S.-born women were four percentage points or less and not statistically significant. However, uninsured recent immigrants were less likely than uninsured U.S.-born women to have Pap smears [60% (SE 7%) versus 71%, P < 0.05]. Adjusting for differences in sociodemographics, health attitudes or beliefs, patient or provider communication, and the medical care environment, insurance remained the strongest predictor of screening. CONCLUSION: Disparities in screening were greatly attenuated among the insured population. Increasing awareness of available safety net sources of care may also improve cancer screening among uninsured recent immigrants.

Adolescent↗
PubMed1998

Hospital admissions through the emergency department: does insurance status matter?

PURPOSE: To assess the effect of insurance status on the probability of admission and subsequent health status of patients presenting to emergency departments. SUBJECTS AND METHODS: We performed a prospective cohort study of patients with common medical problems at five urban, academic hospital emergency departments in Boston and Cambridge, Massachusetts. The outcome measure for the study was admission to the hospital from the emergency department and functional health status at baseline and follow-up. RESULTS: During a 1-month period, 2,562 patients younger than 65 years of age presented with either abdominal pain (52%), chest pain (19%) or shortness of breath (29%). Of the 1,368 patients eligible for questionnaire, 1,162 (85%) completed baseline questionnaires, and of these, 964 (83%) completed telephone follow-up interviews 10 days later. Fifteen percent of patients were uninsured and 34% were admitted to the hospital from the emergency department. Uninsured patients were significantly less likely than insured patients to be admitted, both when adjusting for urgency, chief complaint, age, gender and hospital (odds ratio = 0.5, 95% confidence interval 0.3 to 0.7), and when additionally adjusting for comorbid conditions, lack of a regular physician, income, employment status, education and race (odds ratio = 0.4, 95% confidence interval 0.2 to 0.8). However, there were no differences in adjusted functional health status between admitted and nonadmitted patients by insurance status, either at baseline or at 10-day follow-up. CONCLUSIONS: Uninsured patients with one of three common chief complaints appear to be less frequently admitted to the hospital than are insured patients, although health status does not appear to be affected. Whether these results reflect underutilization among uninsured patients or overutilization among insured patients remains to be determined.

Abdominal Pain↗
PubMed1990

Development of an effective utilization management program at Celtic Life Insurance Company.

Celtic Life Insurance Company's (Celtic) utilization management program demonstrates that insurance companies, like hospitals, can develop a high level of quality assurance in utilization management by maintaining a professional clinical staff, developing special programs to target specific medical concerns, and conducting ongoing audits. Celtic's High Risk Maternity Program, developed in 1988 as an adjunct to the utilization management program, provides education about pregnancy and childbirth, screens pregnant insureds, and offers case management for high-risk pregnancies. Pregnant insureds who volunteer to case management are referred to the Rose Bud Program, a premature labor prevention program that was developed by Northwestern National Life Insurance Company with Abbott Northwestern Hospital.

Cost-Benefit Analysis↗
PubMed1995

Reimbursement and insurance coverage in cases of suspected sexual abuse in the emergency department.

OBJECTIVE: To characterize third party payor types and rates of reimbursement for hospital costs in emergency department (ED) evaluations of preadolescents presenting as suspected victims of sexual abuse (SSA). DESIGN AND METHODS: Retrospective chart review, comparing a set of 186 SSA patients with 623 evaluated for upper limb fracture and cumulative reimbursement and insurance data for all patients presenting to the ED during a 12-month period. RESULTS: A greater percentage of SSA patients was uninsured (N = 96, 52%) as compared to patients with fractures (N = 9, 1%); 23% of all ED billing came from the uninsured. Of the 96 self-pay SSA patients' bills only 4% reimbursement was received. Of the insured, a greater percentage of the SSA patients was covered by publicly-funded plans (n = 59, 66%) as compared to fracture patients (N = 327, 52%). A lower percentage of insured SSA bill reimbursement was received from publicly-funded insurance than from commercial insurance (28% vs. 58%). CONCLUSIONS: Hospital costs of SSA patients are more often and to a greater degree underwritten by the hospital itself as a result of lower reimbursement and a higher percentage of uninsured and publicly-funded plans in that group, raising critical questions about how care for children with serious socially-based diagnoses is delivered and funded.

Arm Injuries↗
PubMed2000

Health insurance and retirement behavior: evidence from the health and retirement survey.

This paper studies the role of health insurance in the retirement decisions of older workers. As policymakers consider mechanisms for how to increase access to affordable health insurance for the near elderly, considerations of the potential labor force implications of such policies will be important to consider--potentially inducing retirements just at a time when the labor force is shrinking. Using data from the 1992 and 1996 waves of the Health and Retirement Survey, this study demonstrates that access to post-retirement health insurance has a large effect on retirement. Among older male workers, those with retiree health benefit offers are 68% more likely to retire (and those with non-employment based insurance are 44% more likely to retire) than their counterparts who would lose employment-based health insurance upon retirement. In addition, the study demonstrated that in retirement models, when retiree health benefits are controlled for, the effects of pension coverage are reduced, suggesting that these effects may have been overestimated in the prior literature.

Aged↗
PubMed2002

Managed competition and consumer price sensitivity in social health insurance.

This paper examines whether the introduction of managed competition in Dutch social health insurance has resulted in effective price competition among insurance funds. We find evidence of limited price competition, which may be caused by low consumer price sensitivity. Using aggregate panel data from all insurance funds over the period 1996-1998, estimated premium elasticities of market share are -0.3 for compulsory coverage and -0.8 for supplementary coverage. These elasticities are much smaller than in managed competition settings in US group insurance. This may be explained by differences in switching experience and higher search costs associated with individual insurance.

Actuarial Analysis↗
PubMed1997

Medical insurance and the use of health care services by the elderly.

The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance.

Activities of Daily Living↗
PubMed1999

The value of health insurance: the access motive.

Why do people purchase health insurance? Many economists would answer that it permits purchasers to avoid risk of financial loss. This note suggests that health insurance is also demanded because it represents a mechanism for gaining access to health care that would otherwise be unaffordable. For example, although a US$300,000 procedure is unaffordable to a person with US$50,000 in net worth, access is possible through insurance because the annual premium is only a fraction of the procedure's cost. The value of insurance for coverage of unaffordable care is derived from the value of the medical care that insurance makes accessible.

Community Participation↗
PubMed1999

Towards a reinforced agency role of health insurers in Belgium and The Netherlands.

This article describes some recent developments in health insurance in Belgium and the Netherlands. Both countries are moving towards greater financial responsibility of health insurers by means of risk-adjusted capitation payment systems. Although for the unwary observer it would appear as if both countries were following similar paths towards a common model, the authors make clear that rather different underlying rationales are driving these trends. In the Netherlands, the grand design 'Dekker proposal' for regulated competition has been replaced by a more gradual implementation of reforms with more limited scope. The ultimate goal remains a system of managed competition, albeit only for part of the health care services. In Belgium, prospective risk-adjusted capitation payment has always been at the heart of the original system in principle since its inception, but non-enforcement led to retrospective and inequitable financing in practice. Although the rhetoric of managed competition has never been used explicitly in any Belgian official government policy document, it seems unlikely that putting the insurers at financial risk without simultaneously also reinforcing their agency role by providing instruments for care management-like, for example, selective contracting--is viable in the longer run without jeopardizing the solvency of the insurers. The authors conclude that although the logic of the managed competition model is appealing, the lack of conclusive empirical evidence of success elsewhere makes governments reluctant to surrender their traditional cost containment tools. But making insurers financially accountable without simultaneously providing them with tools to take on the accountability seems useless and illogical.

Belgium↗