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PubMed1989

Adjusting employer group capitation premiums by Community Rating by class factors.

Community rating of employer group health maintenance organization (HMO) capitation premiums results in low premiums for some groups and high premiums for other groups, as compared with the marginal costs of providing services. In effect, low health risk groups are cross subsidizing high health-risk groups in an HMO. This has caused several inefficiencies in the health plan marketplace, which have directly benefited higher-risk groups. For this reason, certain low-risk groups are searching for new strategies to improve market efficiency. One strategy is Community Rating by Class (CRC), a system which adjusts community rated capitation premiums by broad-based risk factors. This article examines CRC as a strategy to help reduce the inefficiencies caused by current federal regulations. In regressions predicting future year total family health expenditures, the CRC Model achieved an R2 value of 0.211. This value was over half the R2 value of an experience rated approach, based on prior year utilization and expenditure variables. Family size accounted for 80% of the variance explained by the CRC Model. The results indicate that the CRC rating approach may be a good mechanism to correct for cross subsidization of employer group capitation premiums.

Adolescent↗
PubMed1992

The inequality of medical expenditures for several years in a healthy, nonelderly population.

Previous studies have shown that the distribution of annual medical expenditures for a population is very unequal and remains so for periods of more than 1 year. The authors use a better measure of inequality, the Gini coefficient, to test its persistence for longer periods. This measure is applied to data collected from the Rand Health Insurance Experiment. The experiment enrolled a nonelderly population typical of those covered by employer health plans for periods up to 5 years. The distributions of annual expenditures for this population are highly unequal, in line with previous studies. Inequality declines substantially when longer periods are considered.

Adolescent↗
PubMedDate not supplied

Patients' fear of genetic discrimination by health insurers: the impact of legal protections.

PURPOSE: The impact of laws restricting health insurers' use of genetic information has been assessed from two main vantage points: (1) whether they reduce the extent of genetic discrimination and (2) whether they reduce the fear of discrimination and the resulting deterrence to undergo genetic testing. A previous report from this study concluded that there are almost no well-documented cases of health insurers either asking for or using presymptomatic genetic test results in their underwriting decisions, either before or after these laws, or in states with or without these laws. This report evaluates the perceptions and the resulting behavior by patients and clinicians. METHODS: A comparative case study analysis was performed in seven states with different laws respecting health insurers' use of genetic information (no law, new prohibition, mature prohibition). Semistructured interviews were conducted in person with five patient advocates and with 30 experienced genetic counselors or medical geneticists, most of whom deal with adult-onset disorders. Also, multiple informed consent forms and patient information brochures were collected and analyzed using qualitative methods. RESULTS: Patients' and clinicians' fear of genetic discrimination greatly exceeds reality, at least for health insurance. It is uncertain how much this fear actually deters genetic testing. The greatest deterrence is to those who do not want to submit the costs of testing for reimbursement and who cannot afford to pay for testing. There appears to be little deterrence for tests that are more easily affordable or when the need for the information is much greater. Fear of discrimination plays virtually no role in testing decisions in pediatric or prenatal situations, but is significant for adult-onset genetic conditions. CONCLUSION: Existing laws have not greatly reduced the fear of discrimination. This may be due, in part, to clinicians' lack of confidence that these laws can prevent discrimination until there are test cases of actual enforcement. Ironically, there may be so little actual discrimination that it may not be possible to initiate good test cases.

Ethics, Medical↗
PubMedDate not supplied

Australian empirical study into genetic discrimination.

This paper outlines a major empirical study that is being undertaken by an interdisciplinary team into genetic discrimination in Australia. The 3-year study will examine the nature and extent of this newly emerging phenomenon across the perspectives of consumers, third parties, and the legal system and will analyze its social and legal dimensions. Although the project is confined to Australia, it is expected that the outcomes will have significance for the wider research community as this is the most substantial study of its kind to be undertaken to date into genetic discrimination.

Australia↗
PubMed2006

Explaining racial and ethnic disparities in health care.

OBJECTIVES: The substantial racial and ethnic disparities in access to and use of health services are well documented. A number of studies highlight factors such as health insurance coverage and socioeconomic differences that explain some of the differences between groups, but much remains unexplained. We build on this previous research by incorporating additional factors such as attitudes about health care and neighborhood characteristics, as well as separately analyzing different Hispanic subgroups. METHODS: We use the Oaxaca-Blinder regression-based method to decompose differences among racial and ethnic groups in 3 measures related to access, quantifying the portion explained by each of a number of underlying characteristics and the differences that remain unexplained. We use data from the 2000 and 2001 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the noninstitutionalized U.S. population. We link these data to detailed neighborhood characteristics from the Census Bureau and local provider supply data from the Health Services Resource Administration (HRSA). RESULTS: Consistent with earlier studies, we find insurance status and socioeconomic differences explain a significant part of the disparities. Additionally, neighborhood racial and ethnic composition account for a large portion of disparities in access, and language differences help explain observed disparities in the use-based access measure. However, much of the differences between racial and ethnic groups remain unexplained. We also found substantial variation in the level of disparities among different groups of Hispanics. CONCLUSIONS: Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved.

Adult↗
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↗
PubMed1995

Privatization and just healthcare.

When advocates of insurance-privatization consider whether private insurance-dominated systems achieve justice at all, they tend to rely on an incomplete set of criteria for a just healthcare system. They also mistakenly assume that it is enough to show that justice is in principle achievable within a private insurance-dominated system. This essay offers a more complete set of criteria for a just healthcare system. It then argues that the motivational assumptions needed to make insurance-privatization at all plausible (on grounds of choice, efficiency, and quality of care) are inconsistent with the motivational assumptions needed to show that in practice a private insurance-dominated system will achieve justice. A private insurance-dominated system can be expected to satisfy the criteria for just healthcare only if (a) there is extensive and effective regulation to constrain the normal competitive behavior of private insurers or if (b) generous public funds are provided to fill the gaps in access left by the private insurance market. Yet the assumptions about the motivations and abilities of the public, regulators, and public officials needed to satisfy conditions (a) or (b) contradict the privatization advocate's explanations of how privatization will maximize efficiency, choice, and quality of care.

Altruism↗
PubMed2004

The magnitude and nature of risk selection in employer-sponsored health plans.

OBJECTIVE: To determine whether health maintenance organizations (HMOs) attract enrollees who use relatively few medical resources and whether a simple risk-adjustment system could mitigate or eliminate the inefficiency associated with risk selection. DATA SOURCES: The first and second rounds of the Community Tracking Study Household Survey (CTSHS), a national panel data set of households in 60 different markets in the United States. STUDY DESIGN: We use regression analysis to examine medical expenditures in the first round of the survey between enrollees who switched plan types (i.e., from a non-HMO plan to an HMO plan, or vice versa) between the first and second rounds of the survey versus enrollees who remained in their original plan. The dependent variable is an enrollee's medical resource use, measured in dollars, and the independent variables include gender, age, self-reported health status, and other demographic variables. DATA COLLECTION METHODS: We restrict our analysis to the 6,235 non-elderly persons who were surveyed in both rounds of the CTSHS, received health insurance from their employer or the employer of a household member in both years of the survey, and were offered a choice of an HMO and a non-HMO plan in both years. PRINCIPAL FINDINGS: We find that people who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in a non-HMO plan, and that this relatively low use persisted once they enrolled in an HMO. Furthermore, people who switched from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than those who remained in an HMO plan. CONCLUSIONS: HMOs are experiencing favorable risk selection and would most likely continue to do so even if employers adjusted health plan payments based on enrollees' gender and age because the selection is based on enrollee characteristics that are difficult to observe, such as preferences for medical care and health status.

Adolescent↗
PubMed2006

Restrictions on provider access in health plans and socioeconomic status.

OBJECTIVE: To model the socioeconomic determinants of restrictions on provider access and choices in health plans. DATA SOURCES: Data from the 1996-97 Community Tracking Study are used. Publicly available enrollee data including enrollee reports of health care plan characteristics are linked with restricted use data with insurer reports of health plan characteristics. STUDY DESIGN: This is an observational study. A mixed multinomial logit model is used to model the enrollees' choice between health plans, each plan being treated as a bundle of attributes formed from restrictions on provider access. PRINCIPAL FINDINGS: There are important differences between the enrollee responses and the insurer reports, which may be due to poor information dissemination on the part of health plans and/or lack of attention on the part of enrollees. There is no evidence of selection into plans with restrictive attributes on the basis of observed health status but there is evidence of selection on the basis of race, ethnicity, gender and other socioeconomic characteristics. Determinants of plan supply, i.e., employment characteristics, are the most important determinants of plan attribute choices. CONCLUSION: The finding suggests that plan designs optimized using "objective" knowledge and with the best intentions may not receive favorable reviews from enrollees because enrollees have different perceptions of these plans.

Adolescent↗
PubMed2006

How much risk pooling is there in the individual insurance market?

OBJECTIVE: To examine how much pooling of risks occurs among potential purchasers in the individual market, how much pooling occurs among those who purchase coverage, and whether there is greater pooling among longer-term enrollees. DATA SOURCES: The data are administrative records for enrollees in individual insurance plans in California in 2001, and from a survey of Californians enrolled in the individual insurance market and the uninsured. STUDY DESIGN: Logit models were estimated for 5 health outcome measures to compare the insured and uninsured after adjusting for other factors that affect insurance status and health. Multivariate models were also estimated to explore the relationship between health and three measures of pooling in the market: plan type, pricing tier, and the actuarially adjusted premium paid by the enrollee. PRINCIPAL FINDINGS: Those who purchase individual health insurance are in better health than those who remain uninsured. On the other hand, a large share of people with health problems does obtain individual insurance. The distribution of subscribers across plan type and pricing tier varies with their health status. Those in poor health are less likely to purchase low benefit plans. There is less separation of risks for those who become sick after enrollment based on the measure of pricing tier. The distribution of subscribers across plan type for those who have health problems at enrollment and those who become sick differs, but so does the distribution of those who become sick and those who remain healthy. CONCLUSIONS: Despite small differences among the healthy and sick, our results support the conclusion that there is considerable risk pooling in the individual market. To some extent, this pooling occurs because underwriting happens at the time people enroll and there is greater pooling among those who become sick than those who enroll sick. Our results however suggest that health savings accounts may further fragment the market.

California↗
PubMed1993

Genetic screening technology: ethical issues in access to tests by employers and health insurance committees.

Whereas the introduction of new technologies previously has raised the ethical question of who ought to have access to a new procedure or device, genetic testing technology raises the new ethical question of to whom access to a new technology ought to be limited. In this article we discuss the implications of employers and private health insurance companies having access to genetic testing technology. Although there may be legitimate business interests in allowing employers and insurers to conduct genetic screening, there are other valid societal interests in regulating or limiting the use of this technology by third parties. Public policy developed in the area of new genetic technology must reflect such interests.

Employment↗
PubMed2003

Rural-urban differences in health care benefits of a community-based sample of at-risk drinkers.

CONTEXT: Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas. PURPOSE: This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas. METHODS: A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. FINDINGS: Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees. CONCLUSIONS: Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.

Actuarial Analysis↗
PubMed1993

Genetic testing and the social responsibility of private health insurance companies.

In this paper, I have pressed the general question, "Are private health insurers responsible for preventing the problems of equity and access that genetic discrimination would pose?" I have argued that socially responsible insurance companies will avoid genetic discrimination, even if they conceive of their social responsibility in narrow terms. The significance of this point extends beyond the specific question of genetic testing, and bears relevance to broader debates about reforming the nation's health care system. Ultimately, society's attraction to retaining a private health insurance market depends upon private health insurers affirming and meeting responsibilities to the wider society. How society and the insurance industry respond in the face of new genetic testing capabilities will be a moral guidepost indicating how we as a society should devise and implement health care reform.

Delivery of Health Care↗