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PubMed2003

[Disease management programs from a health insurer's point of view].

Disease Management Programmes represent a great challenge to the German statutory health insurance system. According to politicians, disease management programmes are an appropriate tool for increasing the level of care for chronically ill patients significantly, while at the same time they can slow down the cost explosion in health care. The statutory health insurers' point of view yields a more refined picture of the chances and risks involved. The chances are that a medical guideline-based, evidence-based, co-operative care of the chronically ill could be established. But also, there are the risks of misuse of disease management programmes and of misallocation of funds due to the ill-advised linkage with the so-called risk compensation scheme (RSA) balancing the sickness funds' structural deficits through redistribution. The nation-wide introduction of disease management programmes appears to be a gigantic experiment whose aim is to change the care of chronically ill patients and whose outcome is unpredictable.

Disease Management↗
PubMed1976

Visits to a small coastal communities of Northern Norway by a doctor and a health insurance officer.

What can we learn by visiting small remote communities, giving information about health insurance and social allowances, assisting clients in completing application forms, etc.? In the present study we met attitudes that made some people bear numet needs instead of craving their legal rights. Our visits improved the communication between the people concerned and the Local Health Insurance Office. The officer realized what impairment might mean for working capacity in such communities, and got in a better position to handle various applications.

Adult↗
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↗
PubMed2007

Usage of the claim database of national health insurance programme for analysis of cisapride-erythromycin co-medication in Taiwan.

PURPOSE: This study aimed to use the National Health Insurance Research Database, Taiwan for risk analysis of concomitant use of cisapride and erythromycin. METHODS: The sample consisted of subjects identified in the Outpatient Sampling Database (OSD) and Longitudinal Health Insurance Database 2000 (LHID 2000), derived from the original claim data of the National Health Insurance Research Database, Taiwan. RESULTS: According to the LHID 2000, a total of 464 individuals experienced 685 episodes of cisapride-erythromycin co-medication prescribed by 295 physicians, revealing a prevalence of 4.5% concomitant use, with higher prevalence in clinics (9.2%) than in other medical institutes (3.7-5.4%). Among the co-medication episodes, 81.9% and 61.2% were prescribed from the same health institutes and by the same physicians, respectively. No medical record of cardiac arrhythmias was found among these patients in 2001 and 2002, probably due to the fact that 78.9% of the 464 individuals were under age 16, 84.0% had short exposure duration (1-4 days) and 98.0% of the episodes were prescribed with a cisapride dose of less than 0.8 mg/kg/day. CONCLUSIONS: Findings from this study suggest that there exists an urgent need for accreditation in terms of pharmacovigilance of clinical sites and their practicing physicians for the prevention of irrational concomitant prescription in Taiwan. Our findings also indicate that it is necessary to investigate other possible conditions of potentially dangerous co-medication in Taiwan and other developing countries.

Adolescent↗
PubMedDate not supplied

Have small-group health insurance purchasing alliances increased coverage?

We use data from 1993 and 1997 employer surveys to assess whether the three largest statewide small-group health insurance purchasing alliances--in California, Connecticut, and Florida--increased coverage in small business. They did not. Specifically, they did not reduce small-group market health insurance premiums, and they did not raise small-business health insurance offer rates. We explore and discuss some reasons why. Alliances do permit employers to offer much greater choice in the number and types of plans; employees are found to take advantage of this wider choice.

California↗
PubMed1999

Changes in access to care, 1977-1996: the role of health insurance.

OBJECTIVE: To describe changes in Americans' access to care over the last 20 years focusing on the uninsured, Hispanic American, and young adult populations, and to analyze the factors underlying these changes with a particular focus on the role of health insurance. DATA SOURCES/STUDY SETTING: Data from the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 Medical Expenditure Panel Survey. STUDY DESIGN: Focusing on whether each individual has a usual source of health care, we present descriptive statistics and algebraic decompositions. DATA COLLECTION/EXTRACTION METHODS: We combine data from the household surveys with questions from access to care supplements that were administered each time. PRINCIPAL FINDINGS: Hispanic Americans and young adults age 18-24 are more likely to lack a usual source of care than other Americans; these inequalities increased over the period studied and cannot be explained solely by changes in health insurance coverage. CONCLUSIONS: Although increasing health insurance coverage will likely improve access to care among Hispanics and young adults, our findings suggest that the expansion of insurance coverage will not be sufficient to eliminate current disparities in access to care.

Adolescent↗
PubMed1999

NGOs in community health insurance schemes: examples from Guatemala and the Philippines.

In poor rural communities, access to basic health care is often severely limited by inadequate supply as well as financial barriers to seeking care. National policies may introduce social health insurance, but these are likely to begin with the salaried public and private sector workers while the informal sector population may be the last to be covered. Community initiatives to generate health care financing require a complex development process. This paper covers attempts to develop such schemes in rural populations in Guatemala and the Philippines through non-government organizations and notes the major factors which have contributed to unequal progress in the two schemes. The scheme of the Association por Salud de Barillas (ASSABA) in Guatemala was not sufficiently established as an administrative body at the conceptual stage and there was no clear national policy on health care financing. By the time the necessary action was taken, local conflicts hindered progress. In the Philippines, the ORT Health Plus Scheme (OHPS) was implemented during the period of legislation of a national health insurance act. The appraisal after three years of operation shows that OPHS has made health care affordable and accessible to the target population, composed mainly of low and often unstable income families in rural areas. The major success factors are probably the administrative structure provided by a cooperative and controls in the delivery system and in expenditures, through the salaried primary health care team, referral process and the capitation agreement for hospital-based services. The proliferation of such schemes could benefit from national guidelines, a formal accreditation process and an umbrella organization to provide assistance in design, training and information services, involving government, non-government and academic institutions as an integral part of the development process.

Accreditation↗
PubMed2005

Determining the "Health Benefit Basket" of the Statutory Health Insurance scheme in Germany: methodologies and criteria.

The issue of defining health benefit catalogues has recently gained new importance in Germany as a result of the creation of the new Institute for Quality and Efficiency. The Institute was designed to support the Federal Joint Committee conducting effectiveness studies for benefit coverage decisions. The Committee and the contractual partners (sickness funds and providers) define the benefit catalogues for the Statutory Health Insurance in the framework of Social Code Book V, Germany's most relevant health care scheme. Unlike other countries, the German federal government limits its regulatory role to defining procedures that determine the scope of Statutory Health Insurance services. The explicitness of the benefit catalogues varies greatly between different sectors. While benefits in outpatient care are rather explicitly defined, benefit definitions for inpatient care are vague. It is argued that the establishment of the new Institute and the development of the DRG system are initial steps towards a more effective and explicit benefit catalogue.

Germany↗
PubMed1977

Prepaid group practice under universal health insurance in Canada.

This paper describes the experience of the two prepaid group practice plans in Ontario before and after universal health insurance. Both plans were capitalized, before national health insurance, by member contributions and both have had persistent problems with enrollment constraints and professional opposition. The Sault Ste. Marie Plan began in 1963, six years before Canadian medicare. The plan was paid a capitation fee for medical services but did not share in savings from its reduced hospital use. After universal insurance sharing in decreased hospital use was offset by regulations which allowed plan members to use non-plan physicians at Plan expense. Payments to non-plan physicians now take up 20 per cent of Plan income. Active enrollment of members has been replaced by a Ministry of Health registration system which is based on overall utilization. The St. Catharine's Plan began at the same time as universal insurance in 1969. Its out-of-plan use averaged about 40 per cent of total income. Most recently this program has shifted from capitation to cost-reimbursement payment. In Canada present trends include cost containment, financing by general tax revenues rather than premiums and increased categorical benefits. Under Canadian universal health insurance prepaid group practice has an uncertain future.

Canada↗
PubMed2006

Meeting the need for state-level estimates of health insurance coverage: use of State and Federal survey data.

OBJECTIVE: Critically review estimates of health insurance coverage available from different sources, including the federal government, state survey initiatives, and foundation-sponsored surveys for use in state policy research. STUDY SETTING AND DESIGN: We review the surveys in an attempt to flesh out the current weaknesses of survey data for state policy uses. The main data sources assessed in this analysis are federal government surveys (such as the Current Population Survey's Annual Social and Economic Supplement, and the National Health Interview Survey), foundation-supported surveys (National Survey of America's Families, and the Community Tracking Survey), and state-sponsored surveys. PRINCIPAL FINDINGS: Despite information on estimates of health insurance coverage from six federal surveys, states find the data lacking for state policy purposes. We document the need for state representative data on the uninsured and the recent history of state data collection efforts spurred in part by the Health Resources Services Administration State Planning Grant program. We assess the state estimates of uninsurance from the Current Population Survey and make recommendations for a new consolidated federal survey with better state representative data. CONCLUSIONS: We think there are several options to consider for coordinating a federal and state data collection strategy to inform state and national policy on coverage and access.

Data Collection↗
PubMed2006

Providing health insurance in rural china: from research to policy.

The focus of this case study is utilizing research to influence policy in a large developing country. Our experiences involve the lack of health insurance for China's rural populations and how our research helped shape China's recent policy attention and efforts on this issue. More than 80 percent of China's 700 million rural residents have no health insurance. This has been the case for the past thirty years, since the collapse of the once-successful Rural Cooperative Medical System after the economic reforms of the early 1980s. In 2002, the Chinese government announced a new rural health financing policy to provide health insurance for its rural populations, financed by a matching fund with contributions from central and local governments, as well as from individual households. This article documents the authors' experiences in addressing several critical questions for converting research results into policy actions, including the following: How are researchers to address policy relevant questions? How are they to acquire the attention of top policy makers to a specific problem? When is the issue at hand serious but not yet critical? And lastly, how are researchers to develop policy recommendations that stand a good chance of being accepted and enacted? Major lessons learned include the need to better understand the mandates and institutional constraints of the policy makers, the appropriateness of timing of both research result and policy efforts, how to use a country's cultural context to garner support of the government, how to enhance the policy's impact by combining formal and informal channels of communication for research dissemination, and the importance of following the policy process through the implementation phase to ensure the original objectives are achieved.

China↗
PubMed1995

Health insurance and utilization in Pneumocystis carinii pneumonia.

To examine the relationship between health insurance status and health services utilization among HIV-infected patients with active Pneumocystis carinii pneumonia (PCP), the discharge and outpatient databases of a large California medical facility were reviewed. Four hundred fifty records met the inclusion criteria. Logistic regression indicated that those who had publicly funded insurance were about half as likely (95% CI 0.28, 0.99) as were those who had private insurance to undergo bronchoscopy with bronchoalveolar lavage at the time of their first PCP episodes. Further research is required to identify the reasons for this difference.

AIDS-Related Opportunistic Infections↗
PubMed2004

The State Children's Health Insurance Program: has it reduced the percentage of uninsured children?

Recent data indicate that the percentage of children in the United States who are uninsured is declining. Although many factors have contributed to that decline, this study assesses the role of public health insurance, specifically the State Children's Health Insurance Program (SCHIP), in reducing the percentage of uninsured children without health insurance from 1998-2000 and whether Medicaid and SCHIP crowd out exists. While this research confirms a significant decline in the percentage of uninsured children since SCHIP began enrolling children in 1998, other factors, including the poverty rate, the percentage of children on Medicaid, geographic region and race had a greater impact in explaining that result than SCHIP. Lastly, the data findings are consistent with research suggesting crowd out does exist.

Child↗
PubMed2004

Reinvention of health insurance in the consumer era.

The private health insurance industry in the United States has fundamentally changed its strategic focus, product design, and pricing policy as a result of the backlash against managed care. Rather than seek to influence the behavior of physicians through capitation and utilization review, the major health plans now seek to influence the behavior of patients through benefit designs that cover a broad range of services but with high co-payments, tiered network designs that cover a broad range of physicians but with variable coinsurance, and medical management programs that provide incentives for patients to better manage their own health care. Premium prices are carefully adjusted to cover the expected costs of care for each type of product and each class of patient, with a commensurate willingness to abandon enrollment where insurance premiums cannot outrun medical costs. The contemporary product and pricing policies reflect a retreat by the insurance industry from previous efforts to transform the health care system and embody a delegation to individual consumers of responsibility for setting priorities and making financial tradeoffs.

California↗
PubMed2000

A comparison of the socioeconomic and health status characteristics of uninsured, state Children's health insurance program-eligible children in the united states with those of other groups of insured children: implications for policy.

OBJECTIVES: To describe the sociodemographic and health status characteristics of the national uninsured, State Children's Health Insurance Program (SCHIP)-eligible population, and to compare this population with Medicaid-enrolled children, privately insured children, and privately insured children who have family income in the SCHIP eligibility range. PROCEDURES: Data were analyzed for 50 950 children 0 to 18 years of age included in the 1993 and 1994 National Health Interview Surveys. The survey obtained information on insurance coverage and sociodemographic and health status measures. Bivariate analyses were conducted to identify the relationships between SCHIP eligibility and sociodemographic and health status characteristics. Multivariate analyses were conducted to assess the independent association of the sociodemographic and health status variables with the likelihood of being uninsured, SCHIP-eligible. PRIMARY FINDINGS: Results indicate that SCHIP children exhibit markedly different socioeconomic and health status characteristics than do both Medicaid- enrolled and privately insured children, although these differences are less significant in privately insured children. SCHIP children more often live with college- educated (39.4%) and employed adults (91.2%) than do Medicaid-enrolled children (23.0% and 53.9%, respectively). However, SCHIP children live with college-educated and employed adults less than do all privately insured children (66.7% and 96.9%, respectively) and privately insured/same-income children (57.8% and 97.0%, respectively). Parents of SCHIP-eligible children are also disproportionately self-employed or employed in industries (e.g., retail trade) and occupations in which health insurance coverage is less available or affordable. SCHIP-eligible children are also 2 times more likely to be adolescents and 11/2 times more likely to be in excellent health than Medicaid-eligible children. Compared with privately insured children, SCHIP-eligible children are nearly 3 times more likely to be Hispanic and nearly 2 times more likely to be rated in fair or poor health. CONCLUSIONS: The results demonstrate that uninsured, SCHIP-eligible children are substantially different from children in these groups, particularly compared with Medicaid-enrolled children. These differences need to be taken into account when setting policies and implementing programs intended to increase health insurance coverage and access to health care.

Adolescent↗