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PubMed2005

Disparities in access to infertility services in a state with mandated insurance coverage.

The objective of our study was to examine the demographic and socioeconomic characteristics of patients accessing infertility services in a state (Massachusetts) with mandated and comprehensive insurance coverage for such services. Even in a state with such insurance coverage, disparities in access to infertility services exist, with the majority of individuals accessing those services being Caucasian, highly educated, and wealthy.

Chi-Square Distribution↗

PubMed2007

Does providing cost-effectiveness information change coverage priorities for citizens acting as social decision makers?

Escalating costs have generated increasing calls for Medicare to use cost-effectiveness as one criterion in determining coverage decisions. Decision-makers in U.S. health care have largely assumed that the public will reject any explicit consideration of cost in coverage policy, but there has been little formal testing of that hypothesis. We tested this assumption in a pilot study in which groups of citizens learned about and discussed health care costs, CEA methods, and common ethical issues embedded in CEA. Participants received information about 14 conditions and treatments and were asked to prioritize them for funding by Medicare under assumptions of constrained resources. Contrary to prevailing assumptions, this diverse sample understood CEA, were largely open to its use, and changed their own funding priorities when given cost-effectiveness ratio information.

Adolescent↗

PubMedDate not supplied

Health insurance for type 1 diabetes mellitus: US competition and French coverage.

Chronic diseases present a major challenge to individuals, health professionals, and policy makers. Disease burdens and fears of a lifelong condition are complicated by the volatility of health insurance. Individuals with type 1 diabetes mellitus face these challenges daily. Treatment needs persist despite changes in individual health insurance or health plan coverage, yet this costly and devastating disease does not discriminate economically. The demands for care are the same for the under- and uninsured as they are for the fully insured. As life expectancy lengthens for individuals with type 1 diabetes mellitus, a greater potential exists for significant variability in coverage. This article presents a review and analysis of health insurance issues among adults 18-64 years old and extrapolates the consequences for those in the United States (US) with type 1 diabetes mellitus. Comparisons are made with the French health care system, ranked 1st by the World Health Organization in 2000.

Diabetes Mellitus, Type 1↗

PubMed2000

Recent trends in employer-sponsored health insurance coverage: are bad jobs getting worse?

We examine whether the decline in the availability of employer-provided health insurance is a phenomenon common to all jobs or is concentrated only on certain jobs. We find that declines in own-employer insurance coverage over the 1988-1997 period are driven primarily by declines in take-up for long-term full-time workers and declines in eligibility for new and part-time workers. We also look at trends by workers' education level, and see how much of the decline in is offset by an increase in coverage through a spouse's policy.

Eligibility Determination↗

PubMed2000

Access to coverage for high-risks in a competitive individual health insurance market: via premium rate restrictions or risk-adjusted premium subsidies?

A competitive market for individual health insurance tends to risk-adjusted premiums. Premium rate restrictions are often considered a tool to increase access to coverage for high-risk individuals in such a market. However, such regulation induces selection which may have several adverse effects. As an alternative approach we consider risk-adjusted premium subsidies. Empirical results of simulated premium models and subsidy formulae are presented. It is shown that sufficiently adjusted subsidies eliminate the need for premium rate restrictions and consequently avoid their adverse effects. Therefore, the subsidy approach is the preferred strategy to increase access to coverage for high-risk individuals.

Economic Competition↗

PubMed2004

Disputes over coverage of emergency department services: a study of two health maintenance organizations.

STUDY OBJECTIVE: We describe the characteristics and outcomes of enrollee-health plan disputes over insurance coverage for emergency department (ED) services at 2 large health maintenance organizations (HMOs) that apply the prudent layperson standard. METHODS: We abstracted information from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs (hereafter referred to as Plan 1 and Plan 2). We describe appeals involving ED services in terms of the timing of visits, patient age, costs of services, primary reason the patient sought care, and appeal outcome. RESULTS: Disputes over ED services accounted for approximately one half (52%) of postservice appeals at Plan 1 and one third (34%) at Plan 2. Nearly one half (46%) of ED appeals involved weekend, nighttime, or holiday visits to the ED; 22% were children's visits. The average cost of services in dispute was US$1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64%), injuries (22%), and services related to disease (8%). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6%); earaches or ear infections (3.4%); and lacerations/cuts (2.9%). Enrollees won more than 90% of appeals. CONCLUSION: The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard.

Adult↗

PubMedDate not supplied

Medicare and drug coverage: a women's health issue.

The lack of prescription drug coverage under the Medicare program translates into high out-of-pocket drug costs for seniors. This nationwide study of older Americans with hypertension ("high blood pressure") demonstrates that women bear the disproportionate burden of this gap in Medicare coverage. Women form the majority of older people with hypertension, and are less likely to have supplemental policies to cover the cost of the prescription drugs that are needed to treat the disease. Moreover, women have substantially lower incomes. Despite their economic vulnerability, older women with hypertension spend substantially more on prescription drugs than men.

Aged↗

PubMed2004

Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening.

BACKGROUND AND AIMS: Recent legislation passed in July 2001 provides coverage for all Medicare beneficiaries for average-risk screening colonoscopy. METHODS: We analyzed the Clinical Outcomes Research Initiative national endoscopic database to characterize colonoscopy practice patterns before and after the introduction of this coverage. RESULTS: Between January 1998 and May 2002, 205,638 patients underwent colonoscopy, of whom 8.3% underwent average-risk colon cancer screening. The proportion of procedures performed for average-risk screening has increased dramatically from 4.6% (before July 2001) to 14.2% (after July 2001). With the increased volume of average-risk screening examinations, colonic lesion detection (masses and polyps greater than 9 mm) has declined (4.9% before July 2001 to 3.8% after July 2001). CONCLUSIONS: There has been a dramatic increase in the rates of screening colonoscopy during the past 4 years. If rates continue to increase, optimal resource utilization will assume increasing importance.

Colonic Neoplasms↗

PubMed1998

The health insurance puzzle: a new approach to assessing patient coverage preferences.

Previous studies of preferences for health insurance benefits have required individuals to make a series of complex and repetitive decisions, and have assumed that all insured benefits are desirable. This study reports the development and testing of a simple, innovative instrument to measure preferences for health insurance benefits. The newly developed instrument (Puzzle) is designed to allow subjects to select health benefits in a way that underscores the trade-offs dictated by budgets and costs. A "puzzle-like" frame representing budget constraints and "puzzle piece" benefit cards proportionately sized to represent the premium price of a single year's coverage comprise the instrument. In a comparison procedure (Money Game), participants "purchase" individual benefits by exchanging "play" money for benefit tokens. The Puzzle's utility was assessed by examining the convergence of results from both instruments and the subject's ratings of and preference for the instruments. One hundred five elderly Medicare enrollees seen in the general Internal Medicine outpatient clinic of a major southeastern teaching hospital were interviewed. Subjects answered interviewer-administered questionnaires and completed both the Puzzle and the Money Game. Both McNemar's test and Kendall's tau-b indicated a high degree of concordance between benefit choices made using the two instruments. Descriptive statistics demonstrated that the Puzzle was clear, easy to use, understandable, and preferred to the Money Game. The results suggest that the Puzzle is a promising tool for assessing health insurance coverage preferences under circumstances of limited expenditures, which can be modified for use with various populations who face limited insurance benefits.

Aged↗

PubMed2002

Employer offers, private coverage, and the tax subsidy for health insurance: 1987 and 1996.

Economists have long been interested in the effect of tax-based subsidies on private health insurance coverage. We examine this relationship using pooled data from the 1987 National Medical Expenditure Survey and the 1996 Medical Expenditure Panel Survey. Our main tax price elasticity estimates for employer offers and for private coverage are near the mid-point of the existing literature. However, these estimates may mask substantial differences in tax-price responsiveness across subsets of workers. Our more disaggregated analysis reveals tax price responsiveness to be significantly above average for low-income workers, workers with low health risks, and workers in small firms--precisely those groups whose continued participation in employment-related risk pooling is of greatest policy concern. In addition, we present family-level elasticities that allow for joint decision-making in two-worker families.

Adult↗

PubMed1999

Information needs for medication coverage decisions in a state Medicaid program.

BACKGROUND: Health plans commonly face the conflicting demands of trying to provide access to novel technologies, including new classes of medications, while trying to contain costs. These demands are particularly acute for California's Medicaid program, known as Medi-Cal, which is responsible for delivery of medical care to an unusually large population of mentally ill individuals in the context of a culturally diverse environment. To meet the challenge, Medi-Cal has instituted a formal process for technology assessment of new and existing pharmaceutical products known as the Therapeutic Class Review (TCR). OBJECTIVE: The purpose of this paper is to describe the information produced for Medi-Cal in the TCR process for antidepressant medications and the individual petition review of antipsychotic medications, and to synthesize our experience in a series of policy recommendations designed to improve the quality of coverage decisions. OUTCOME: A collaborative process between Medi-Cal and Lilly resulted in a substantive body of new evidence regarding the needs of Medi-Cal recipients, the quality of current treatment, and prospects regarding the cost-effectiveness of introducing newer treatments. CONCLUSION: Medi-Cal has a formal process for evaluating new medicines. This process allows researchers to understand the needs of those who make coverage decisions. We recommend increasing routine epidemiologic surveillance, including service use, and clinical trials that include aspects of usual medical care early in the drug development process.

Antidepressive Agents, Tricyclic↗

PubMed2001

A dog's breakfast: prescription drug coverage varies widely across Canada.

BACKGROUND: Each province in Canada independently assesses drugs for their reimbursement eligibility. Publicly funded access to specific drugs is therefore dependent on province of residence. OBJECTIVE: Evaluate the variability of access and its determinants for publicly available prescription drugs across Canada, and discuss the feasibility of implementing a national plan. METHODS: For a sample of 58 drugs receiving Health Protection Branch approval in Canada between 01/01/1996 and 12/31/1997, all provinces were surveyed about their formulary inclusion/exclusion decision. Kappa values were estimated to measure concordance between provincial coverage decisions. Logistic analysis using Generalized Estimating Equations was used to assess the impact of key features of provincial plans on the decision. RESULTS: Among the 58 drugs, 5 (9%) were included in all 10 and 14 (24%) by at least 8 provincial formularies. None were excluded by all the provinces. Concordance rates among provinces were low (overall kappa-like statistic = 0.20 and range of pairwise kappa = -0.11 to 0.64). Logistic regression showed that therapeutic category, price ratio to comparator, the integration of public with private coverage, and the existence of ability-to-pay criteria were significant determinants of the inclusion decision. CONCLUSIONS: Findings show that public access to the same prescription medications differs widely across provinces. If Canada were to adopt a "National" plan without disrupting current individual prescriptions, all currently funded drugs in each province would have to be "grandfathered" and included in the new National formulary. Such an all-inclusive list would also make such a plan unaffordable.

Canada↗

PubMed2002

Clinical utility of ambulatory blood pressure: perspectives for national insurance coverage.

During 2001, the Center for Medicare and Medicaid Services (CMS, formally known as HCFA) independently evaluated the US national insurance coverage policy for ambulatory blood pressure monitoring. Diagnostic uses evaluated included screening for white-coat hypertension, assessment for possible antihypertensive drug resistance, evaluation of hypotensive symptoms, episodic hypertension, and autonomic dysfunction. In their analysis, the committee presented and analyzed the relevant scientific and clinical literature on the use of ABPM in certain patient populations and delineated the reason for a limited national coverage decision for patients with suspected white-coat hypertension.

Blood Pressure Monitoring, Ambulatory↗

PubMed2005

Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus.

BACKGROUND AND OBJECTIVES: Associations of insurance coverage and source of care with use of human immunodeficiency virus (HIV)-related health, mental health, and substance abuse services are examined in a large, diverse, highly active antiretroviral therapy-era cohort. METHODS: Adults who were infected with HIV (n = 3818) were interviewed in clinics and community agencies in Los Angeles, Milwaukee, New York, and San Francisco regarding drug use behaviors, health status, and health care utilization. RESULTS: Most participants were insured by Medicaid. During the previous 3 months, 90% of privately insured, 87% of publicly insured, and 78% of uninsured participants had visited any provider. Publicly and privately insured participants were similar in receipt of antiretrovirals, prophylaxis against Pneumocystis carinii pneumonia, substance abuse services, and antidepressants. Uninsured participants were less likely to receive antiretrovirals but were more likely to use substance abuse services. Participants with no usual source of care were less likely to receive PCP prophylaxis. CONCLUSIONS: A lack of insurance is associated with barriers to care, but the advantage of private over public coverage appears smaller than in previous studies. PCP prophylaxis, substance abuse treatment, and antidepressants remain markedly underutilized. Educational initiatives about these treatments targeting providers and patients are indicated.

AIDS-Related Opportunistic Infections↗

PubMed2006

Racial differences in impact of coverage on diabetes self-monitoring in a health maintenance organization.

BACKGROUND: Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care. OBJECTIVES: We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes. RESEARCH DESIGN: Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy. SUBJECTS: The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy. RESULTS: Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients. CONCLUSIONS: The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence.

Black or African American↗

PubMed2004

A political history of medicare and prescription drug coverage.

This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2004

The effects of state mental health parity legislation on perceived quality of insurance coverage, perceived access to care, and use of mental health specialty care.

OBJECTIVE: To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care. DATA SOURCES: The study sample came from two waves of a national household survey first fielded in 1997-1998 and then in 2000-2001. The analysis used a subset of the sample. STUDY DESIGN: The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law). PRINCIPAL FINDINGS: Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates. CONCLUSIONS: The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.

Attitude to Health↗

PubMed2006

Rules for medical markets: the impact of medicare contractors on coverage policies.

OBJECTIVE: Examine Medicare's local contractors' claim payment rules, focusing on how technology affects the balancing of competing demands to respond to local medical markets (rule heterogeneity) with concerns about national consistency in payment rules (rule homogeneity). DATA SOURCES: Local medical review policies (LMRPs) posted in policy sets by contractor organizations on the Centers for Medicare and Medicaid Services (CMS) website and a survey of Contractor Medical Directors. STUDY DESIGN: We classified LMRPs based on type (NT=new technology; TE=technology extensions, and UM=utilization management), and examined the effect of technology type on LMRP focus, evidence use, policy revisions, implementation speed, and reference material citation characteristics of LMRPs using multivariate analysis. PRINCIPAL FINDINGS: NT policies were more homogenous, as were policies among contractors related through multistate affiliation or through informal networks. UM policies were more heterogeneous. NT policies were more likely than UM policies to cite research journals as evidence while UM policies were more likely to cite medical reference materials. CONCLUSIONS: Coverage policies associated with new technologies diffuse rapidly and are homogenous compared to utilization management coverage policies. This suggests that new technology policies are responsive to the development of new technologies at the national level. In contrast, utilization management policies are responsive to local heterogeneity in health care practice. Congress has mandated reforms to the contracting process to achieve consistency and reduce duplication. Our data elucidate the nature and sources of variation and will help policymakers strike a balance between homogeneity and local adaptation.

Health Care Sector↗