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PubMed1998

Managed care's impact on the financial well-being of social workers in private practice.

The authors used the rosters from the Register of Clinical Social Workers, the American Psychological and American Psychiatric Associations to contrast a random sample of 167 private practicing social workers, 158 psychologists and 187 psychiatrists from across the nation with respect to changes in these practitioners' financial well-being since joining managed care organization panels. Although no statistically significant differences were found between the three groups with respect to many indicators of financial well-being, each of the groups reported that their financial well-being had been adversely affected by managed care organization guidelines. Because the social workers in this study were found to spend a greater percentage of their time in private practice than psychologists and psychiatrists, managed care organizations' policies with respect to financial reimbursement are likely to impact them more adversely than professionals in other disciplines. Other changes in overhead costs, including office staffing, record keeping and malpractice insurance, as required by managed care organizations, were considered by many of the respondents to be among the most prominent issues affecting their financial well-being.

Educational Status↗
PubMed1996

Developing private health care in Macedonia.

The Republic of Macedonia is the sole former Yugoslavian republic that has had a peaceful transition to independence. The current socialist health care system is bankrupt with an over-emphasis on specialty care and too many doctors. While clinical standards equal those in Western Europe, customer service is at a low level. Private initiatives are being encouraged by most members of the health care community. However, the current state system should be retained with a sound financial base. Private initiatives have a high potential for success.

Economic Competition↗
PubMed1991

High quality private long-term care insurance: can we get there from here?

The private long-term care insurance market has undergone rapid change in the last several years. Although the quality of policies has generally improved, problems remain. Consumer protection issues include the lack of adequate inflation protection features, how activities of daily living are measured, potentially high lapse rates and lack of nonforfeiture values, how home care benefits are defined, and the appropriate loss ratio standards. The concerns of consumer and elderly advocates about the quality of private long-term care insurance have prompted congress to consider the need for federal intervention. While there are numerous approaches that the federal government could take, mandatory standards substantially higher than the current model standards of the National Association of Insurance Commissioners may prove the most effective in improving the quality of policies on a nationwide basis.

Aged↗
PubMed1992

Financing long-term care with limited resources: combining the resources of the public and private sectors.

Under Connecticut's recently implemented public/private partnership to finance long-term care, individuals will no longer need to impoverish themselves in order to receive Medicaid assistance. To encourage those people who can afford to buy a private long-term care insurance policy to do so, the state promises to shield one dollar in assets from Medicaid "spend-down" rules for every dollar a private policy pays out for Medicaid-covered services. This article describes the Partnership, shows how dwindling resources and budget constraints affected the development of this model, and then contrasts Connecticut's experience with that of other states and describes what can be learned from this demonstration.

Aged↗
PubMed1996

Financing reform for long-term care: strategies for public and private long-term care insurance.

The way the nation provides for the financing and delivery of long-term care is badly in need of reform. The principal options for change are private insurance, altering Medicaid, and public long-term care insurance. This article uses the Brookings-ICF Long-Term Care Financing Model to evaluate each of these options in terms of affordability, distribution of benefits, and ability to reduce catastrophic out-of-pocket costs. So long as private insurance is aimed at the elderly, its market penetration and ability to finance long-term care will remain severely limited. Affordability is a major problem. Selling to younger persons could solve the affordability problem, but marketing is extremely difficult. Liberalizing Medicaid could help solve the problems of long-term care, but there is little public support for means-tested programs. Finally, universalistic public insurance programs do well in meeting the goals of long-term care reform, but all social insurance programs are expensive and seem politically infeasible in the current political environment.

Aged↗
PubMedDate not supplied

Outcomes and effectiveness research in the private sector.

Private-sector health care organizations increasingly tout the use of outcomes and effectiveness research in activities ranging from pharmaceutical research to insurance coverage determinations. The rapid development of this research raises important questions about the role of the Agency for Health Care Policy and Research (AHCPR) as the producer, funder, and champion of outcomes and effectiveness research. To address this issue, we reviewed the activities of pharmaceutical companies, insurers, managed care organizations, health information technology companies, and other private-sector actors in outcomes and effectiveness research. We found that it is being used in a focused way to promote business goals and other organizational objectives, particularly in the pharmaceutical, insurance, and managed care industries. We also found significant gaps in its application to important public health issues and virtually no overlap with prior federal activities in this area.

Health Services Research↗
PubMedDate not supplied

Promoting private health insurance in Australia.

Health insurance policy in Australia has been distinguished by considerable instability over the past five years. This paper reviews the rationale and emerging evidence on three major policy initiatives--a move to allow selective contracting, the introduction of a 30 percent government subsidy for private health insurance, and the abolition of pure community rating. Policy making on private health insurance has been characterized by insufficient attention to research that might provide a stronger evidence basis for policy reforms.

Adolescent↗
PubMedDate not supplied

Insuring low-income adults: does public coverage crowd out private?

During the mid-1990s Minnesota, Washington State, Oregon, and Tennessee implemented programs to provide subsidized health insurance for low-income persons who were not previously eligible for Medicaid. We estimate the effects of these programs on the health insurance status of low-income adults in these states. We find that among persons with family incomes below 100 percent of the federal poverty level, subsidized public coverage reduced the number of uninsured persons with very little effect on private coverage rates. Among persons with income between 100 percent and 200 percent of FPL, public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.

Adult↗
PubMedDate not supplied

Can hospitals and physicians shift the effects of cuts in Medicare reimbursement to private payers?

Leaders of health insurance companies, hospital systems, and physician organizations believe that when Medicare and Medicaid reduce payment rates to hospitals or physicians, these providers respond by raising prices to private insurers to offset a portion of the loss in revenue. This would mean that payment reductions in public programs contribute to increasing premiums for private insurance. But on both theoretical and empirical grounds, economists have been skeptical about the existence of this "cost shifting." I show that more realistic models of the behavior of hospitals and physicians than exist in basic economics texts provide a conceptual basis for cost shifting.

Cost Allocation↗
PubMedDate not supplied

The rising prevalence of treated disease: effects on private health insurance spending.

In this paper we present a new framework for understanding the factors driving the growth in private health insurance spending. Our analysis estimates how much of the rise in spending is attributable to a rise in treated disease prevalence and spending per treated case. Our results reveal that the rise in treated disease prevalence, rather than the rise in spending per treated case, was the most important determinant of the growth in private insurance spending between 1987 and 2002. A rise in population risk factors and the introduction of new technologies underlie these trends.

Adolescent↗
PubMed2004

US hospital care for patients with HIV infection and pneumonia: the role of public, private, and Veterans Affairs hospitals in the early highly active antiretroviral therapy era.

STUDY OBJECTIVES: We evaluated differences in processes and outcomes of HIV-related pneumonia care among patients in Veterans Affairs (VA), public, and for-profit and not-for-profit private hospitals in the United States. We compared the results of our current study (1995 to 1997) with those of our previous study that included a sample of patients receiving care during the years 1987 to 1990 to determine how HIV-related pneumonia care had evolved over the last decade. SETTING/PATIENTS: The sample consisted of 1,231 patients with HIV infection who received care for Pneumocystis carinii pneumonia (PCP) and 750 patients with HIV infection who received care for community-acquired pneumonia (CAP) during the years 1995 to 1997. MEASUREMENT: We conducted a retrospective medical record review and evaluated patient and hospital characteristics, HIV-related processes of care (timely use of anti-PCP medications, adjunctive corticosteroids), non-HIV-related processes of care (timely use of CAP treatment medications, diagnostic testing, ICU utilization, rates of endotracheal ventilation, placement on respiratory isolation), length of inpatient hospital stay, and inpatient mortality. RESULTS: Rates of timely use of antibiotics and adjunctive corticosteroids for treating PCP were high and improved dramatically from the prior decade. However, compliance with consensus guidelines that recommend < 8 h as the optimal time window for initiation of antibiotics to treat CAP was lower. For both PCP and CAP, variations in processes of care and lengths of in-hospital stays, but not mortality rates, were noted at VA, public, private not-for-profit hospitals, and for-profit hospitals. CONCLUSIONS: This study provides the first overview of HIV-related pneumonia care in the early highly active antiretroviral therapy era, and contrasts current findings with those of a similarly conducted study from a decade earlier. Quality of care for patients with PCP improved, but further efforts are needed to facilitate the appropriate management of CAP. In the third decade of the epidemic, it will be important to monitor whether variations in processes of care for various HIV-related clinical diagnoses among different types of hospitals persist.

AIDS-Related Opportunistic Infections↗
PubMed1985

Cost-effectiveness of sealants in private practice and standards for use in prepaid dental care. Council on Dental Research.

Whether sealants are more cost-effective than restorative dentistry in reaching dental health goals for patients of private practitioners will depend on the relative excellence of materials and techniques, and on the values of prevention per se held by practitioner and patient. Given this heavy dose of subjectivity in the equation, it is doubtful if experimental cost-effectiveness studies of sealants in private practice will be fruitful. A more likely approach to answering questions on cost-effectiveness would be empirical testing of sealant reimbursement in prepayment programs under the standards suggested.

Cost-Benefit Analysis↗
PubMed2005

Private practice and the economic rate of return for residency training as a prosthodontist.

BACKGROUND: The authors used survey data to estimate the economic rate of return from undertaking an investment in residency training to become a practicing prosthodontist. METHODS: The authors estimated earnings of practicing prosthodontists using results from a survey of 2500 U.S. prosthodontists. Survey data were used to assess the total costs of prosthodontic residency and earnings of practicing general practitioners. The authors applied statistical methods to estimate the internal rate of return (IRR) for prosthodontic residency training. RESULTS: The estimated IRR ranged from 8.23 percent for private practitioners with no financial assistance during residency training to 12.18 percent for full-time private practitioners with stipends and loans. Total costs of residency ranged from 271,835 dollars to 441,321 dollars, depending on the amount of forgone earnings, time in practice and how soon practice began after the residency. CONCLUSIONS: All of the estimates of IRR in this study were positive, indicating that prosthodontic residency is a financially attractive investment. PRACTICE IMPLICATIONS: The positive IRR for prosthodontic residency indicates that the demand for advanced education in prosthodontics will continue, and that the amount of time spent in practice increases the rate of return.

Cost-Benefit Analysis↗
PubMed2005

Readmission among chemical dependency patients in private, outpatient treatment: patterns, correlates and role in long-term outcome.

OBJECTIVE: Similar to other chronic conditions, chemical dependency is a chronic, relapsing condition. Yet predominant treatment models do not provide ongoing, long-term treatment services; readmission is the available long-term care for alcohol and drug patients. We examine readmission patterns and the role of readmission in 5-year outcome in chemical dependency patients in a private, integrated health plan. METHOD: We used health plan utilization databases and self-report at 5-year follow-up to measure readmission and routine primary care services in 647 chemical dependency outpatients from a private health plan. Logistic regression was used to examine whether readmission and primary medical care predicted abstinence at 5 years. RESULTS: Controlling for demographic characteristics and dependence type, higher odds for past-year alcohol and drug abstinence at 5 years following treatment was predicted by having been readmitted in the first 4 years after index episode (odds ratio =1.59, p = .006). Receiving routine medical care predicted past 30-day (but not past-year) abstinence at 5-year follow-up. CONCLUSIONS: The relationship of readmissions to better outcome at 5 years suggests that long-term continuing care may benefit patients' long-term outcomes. More research is needed on the relationship of primary medical care to long-term outcome in chemical dependency patients.

Adolescent↗
PubMed2002

[Bambuí Project: an evaluation of private, public and unionized dental services].

OBJECTIVE: Since one of the goals of dental services is to reduce the effects of social inequality on dental health, it was assessed whether there are inequalities among those seeking dental care from private, public and unionized services. METHODS: The study population consisted of adults aged 18 years or more living in the city of Bambuí, Brazil. Participants were interviewed using a structured questionnaire. Data analysis was carried out using Pearson's chi-square test, odds ratio and 95% confidence intervals (Woolf's method). RESULTS: There were included 656 subjects who met the study's inclusion criteria. Adjusted results using multiple logistic regression showed that those using private services were more likely to be satisfied with their teeth's looks (OR=3.03; 95%CI =1.70-5.39) and chewing ability (OR=2.27; 95%CI=1.17-4.40) compared to those using public services. Also, they were less likely to perceive their need for dental treatment (OR=0.39; 95%CI=0.18-0.86) and were more likely to have had restorative (OR=9.57; 95%CI=4.72 - 19.43) and/or preventive (OR=5.57; 95%CI=2.31 - 13.40) treatment in their last visit to the dentist's. Those using unionized services were more likely to have had restorative (OR=8.51; 95%CI=2.80 - 25.92) and/or preventive treatment (OR=11.42; 95%CI=3.49 - 37.43) in their last visit to the dentist's when compared to those using public services. However, there were no differences regarding satisfaction with their teeth's looks, chewing ability, and perceived treatment needs. CONCLUSION: Public dental care services have not been able to reduce social inequalities related to oral health care.

Adolescent↗
PubMedDate not supplied

Human papillomavirus status and cervical abnormalities in women from public and private health care in Rio de Janeiro State, Brazil.

This article reports the HPV status and cervical cytological abnormalities in patients attended at public and private gynecological services from Rio de Janeiro State. It also comments the performance of each HPV DNA tests used. A set of 454 women from private health clinics was tested by routine Capture Hybrid II HPV DNA assay. Among these, 58.4% presented HPV and nearly 90% of them were infected by high risk HPV types. However, this group presented few premalignant cervical lesions and no invasive cervical cancer was registered. We also studied 220 women from low income class attended at public health system. They were HPV tested by polymerase chain reaction using My09/11 primers followed by HPV typing with E6 specific primers. The overall HPV prevalence was 77.3%. They also showed a high percentage of high squamous intraepithelial lesion-HSIL (26.3%), and invasive cervical carcinoma (16.3%). HPV infection was found in 93.1% and 94.4% of them, respectively. The mean ages in both groups were 31.5 and 38 years, respectively. In series 1, HPV prevalence declined with age, data consistent with viral transient infection. In series 2, HPV prevalence did not decline, independent of age interval, supporting not only the idea of viral persistence into this group, but also regional epidemiological variations in the same geographic area. Significant cytological differences were seen between both groups. Normal and benign cases were the most prevalent cytological findings in series 1 while pre-malignant lesions were the most common diagnosis in the series 2. HPV prevalence in normal cases were statistically higher than those from series 1 (p<0.001), indicating a higher exposure to HPV infection. Women from both samples were referred for previous abnormal cytology. However, socio-demographic evidence shows that women from series 1 have access to treatment more easily and faster than women from series 2 before the development of pre-malignant lesions. These data provides baseline support for the role of social inequalities linked to high risk HPV infection leading to cervical cancer. Broadly screening programs and the development of safe and effective vaccines against HPV would diminish the toll of this disease that affect mainly poor women.

Adolescent↗
PubMed2005

Characteristics and control of severe hypertension in a specialist, private practice in Jamaica.

OBJECTIVE: To determine the characteristics of patients with severe uncontrolled hypertension, in a Jamaican specialist practice; the level of blood pressure control achieved in routine clinical practice, and the number/type of antihypertensive medications required for blood pressure control. DESIGN: This was a retrospective analysis of the medical records of 500 consecutive patients presenting to a consultant physician private group-practice between January and December 2000. Data were extracted from the records of the 48 patients with severe (Grade III) hypertension (WHO/ISH). RESULTS: Fifty per cent (252) werefound to be hypertensive, 19% (48) had Grade III hypertension. The patients with severe uncontrolled hypertension were of mixed ethnicity, predominantly African. Most were less than 65 years old, never smoked cigarettes and were overweight/obese. Nearly one-half had LDL cholesterol >3.4 mg/dL. Diabetes (31%) and congestive heart failure (21%) were the most common comorbid conditions. Fifteen per cent had no illnesses other than severe hypertension. Cardiovascular symptoms were predominant, followed by dizziness. Only 19% of patients were asymptomatic. More than half of the patients achieved blood pressure > 140/90 mm Hg during the study period. Most patients received four drugs and the number of drugs prescribed increased with duration of follow-up. The antihypertensive medications most prescribed at one year were--angiotensin converting enzyme inhibitors (87%), diuretics (78%), calcium channel blockers (63%) and beta-blockers (69%). CONCLUSION: Severe hypertension was a common problem in the specialist private practice in Jamaica. Most patients had cardiovascular symptoms, were dyslipidaemic and required four or more antihypertensive drugs for adequate long-term control.

Adult↗
PubMed2005

[Annual cost of ischemic heart disease in Brazil. Public and private perspective].

OBJECTIVE: To estimate the annual cost of coronary artery disease (CAD) management in Public Health Care System (SUS) and HMOs values in Brazil. METHODS: Cohort study, including ambulatory patients with proven CAD. Clinic visits, exams, procedures, hospitalizations and medications were considered to estimate direct costs. Values of appointments and exams were obtained from the SUS and the Medical Procedure List (LPM 1999) reimbursement tables. Costs of cardiovascular events were obtained from admissions in public and private hospitals with similar diagnoses-related group classifications in 2002. The price of medications used was the lowest found in the market. RESULTS: The 147 patients (65 +/- 12 years old, 63% men, 69% hypertensive, 35% diabetic and 59% with previous AMI) had an average follow-up of 24 +/- 8 months. The average estimated annual cost per patient was R$ 2,733.00, for the public sector, and R$ 6,788.00, for private and fee-for-service plans. Expenses with medications (R$ 1,154.00) represented 80% and 55% of outpatient costs, and 41% and 17% of total expenses, in public and non-public sectors, respectively. The occurrence of cardiovascular event had a great impact (R$ 4,626.00 vs. R$ 1,312.00, in SUS, and R$ 13,453.00 vs. R$ 1,789.00, for HMOs, p<0.01) on the results. CONCLUSION: The average annual cost of CAD management was high, being the pharmacological treatment the main determinant of public costs. Such estimates may subsidize economical analyses in this area, and foster related healthcare policies.

Brazil↗