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PubMed1997

Cesarean birth trends in Chile, 1986 to 1994.

BACKGROUND: Despite indications of high cesarean section rates in various parts of Latin America, relatively few comprehensive studies of national birth intervention trends have been conducted in that continent. Recent national statistics suggest that Chile may now have the highest reported cesarean section rate in the world. This paper examines cesarean birth trends in Chile with reference to changing patterns in health care financing. METHODS: The growth in the national cesarean birth rate is analyzed, with reference to regional patterns, differences according to insurance coverage, and recent shifts in the financing pattern of health care provision, using insurance fund data and hospital reporting systems data for both public and private sector care from the mid-1980s to mid-1990s. RESULTS: Chile had a cesarean birth rate of 37.2 percent for the 301,955 births covered by either the National Health Fund or private health insurance in 1994. This was a one-third increase from the 1986 rate of 27.7 percent. The private health insurance sector revealed consistently far higher cesarean section rates than the National Health Fund sector (59% vs 28.8% in 1994); intrasectoral rates remained fairly stable over the 8-year period. CONCLUSIONS: The overall increase in Chile's cesarean section rate correlates with the growth in the proportion of all births whose care was privately insured during these years (from 7.5% to 24.8%). This change may be partly explained by the doubling (to 32%) of the percentage of women with a personal obstetrician rather than a "duty" practitioner attending the birth of their baby.

Birth Rate↗
PubMed1993

Health care reform and people with disabilities.

As a group, people with disabilities or chronic conditions experience higher-than-average health care costs and have difficulty gaining access to affordable private health insurance coverage. While the Americans with Disabilities Act will enhance access by prohibiting differential treatment without sound actuarial justification, it will not guarantee equal access for people in impairment groups with high utilization rates. Health care reform is needed to subsidize the coverage of such individuals. Such subsidization can be achieved under either a casualty insurance model, in which premiums based on expected costs are subsidized directly, or a social insurance model, in which low-cost enrollees cross-subsidize high-cost enrollees. Cost containment provisions that focus on the provider, such as global budgeting and managed competition, will adversely affect disabled people if providers do not have adequate incentives to meet these people's needs. Provisions focusing on the consumer, such as cost sharing, case management, and benefit reductions, will adversely affect disabled people if they unduly limit needed services or impose a disproportionate financial burden on disabled people.

Adolescent↗
PubMed1991

Utilization of health services in a cohort of intravenous drug users with known HIV-1 serostatus.

BACKGROUND: Intravenous drug users (IVDUs) with human immunodeficiency virus (HIV) infection and AIDS often have no health insurance or rely on public programs to finance their health care. We examined the independent contributions of HIV serostatus, clinical symptoms, CD4 cell counts, and health insurance to utilization of health services among 1881 intravenous drug users in Baltimore, Maryland. METHODS: Participants in an ongoing natural history study of HIV were informed of HIV serostatus and seropositives were informed of CD4 cell counts; 6 months later, participants were administered a questionnaire concerning self-reported use of health services, insurance coverage, and HIV-related symptoms. RESULTS: Of 1881 participants, 67% had health insurance (including Medicaid), 48% had at least one outpatient visit, and 12% had at least one inpatient visit within the prior 6 months. The proportion of the study population that was HIV-1 seropositive was 32%. In multivariate analysis, the single most important predictor of health care utilization was the presence of two or more HIV-related clinical symptoms. HIV positive serostatus alone or known low CD4 counts were not significantly associated with use of health care services. CONCLUSIONS: These data suggest that HIV seropositive IVDUs are not receiving recommended preventive care. Additional efforts will be needed to ensure that HIV-seropositive drug users participate in currently recommended protocols for early treatment of asymptomatic HIV-1 infection.

Adult↗
PubMed1990

Use of Veterans Administration outpatient facilities by older, rural veterans.

A mail survey was conducted in rural northeastern Missouri to study the factors affecting use of Veterans Administration (VA) outpatient medical services by older veterans. During the year preceding the survey, 39.6% of the 169 responding veterans had used VA outpatient facilities. Travel time, long waiting time at the clinic, and travel expense were the most common perceived barriers to use. However, these factors were generally poor predictors of use. The reported percentage of each perceived geographic or administrative barrier to use was consistently greater for previous users than for nonusers of these facilities. Multiple regression analysis revealed private medical insurance coverage to be the only significant predictor of use. Veterans with private medical insurance were more likely to receive ambulatory medical care from local providers than from the VA. The potential impact of removing perceived barriers to use in this population remains unclear.

Aged↗
PubMed1997

Errors and correlates in parental recall of child immunizations: effects on vaccination coverage estimates.

OBJECTIVE: We evaluated the accuracy of parental recall of children's immunization histories as compared with provider records and examined how errors in parental recall correlate with sociodemographic characteristics. DESIGN: The validation study was part of a population-based household survey designed to assess immunization levels among Texas children under age 2 years. For 72% (n = 3278), interviewers used vaccination records from the parent to copy dates for the diphtheria and tetanus toxoids and pertussis vaccine (DTP), oral polio vaccine (OPV), and measles, mumps, and rubella (MMR) shots. For parents without shot records (n = 1216), interviewers asked about each vaccine, whether the child had received the shot, how many, and at what age. Of these, 85% (n = 1029) were validated with health provider records. RESULTS: Measured against provider records, only 34% of parents accurately recalled the number of DTP shots a child had. More often (42%) parents underestimated the number of DTP shots than overestimated (24%). Agreement between parental recall and provider records was high (83%) for the single dose of MMR. Accuracy of parents' recall did not differ by race/ethnicity, education level, or type of health insurance coverage, but decreased as child's age increased. Having a vaccination record at home was associated with a higher immunization status. Hispanic, lower educated, and uninsured parents were more likely to have a vaccination record than non-Hispanic, higher educated, and privately insured parents. DISCUSSION: Validity of parental recall of children's immunization histories depends on the vaccine and the age of the child, which is highly correlated with the number of shots parents must recollect. Results suggest that inclusion of parent recall information from vaccination surveys underestimates DTP:OPV:MMR coverage. This underestimation is consistent across economic and race/ethnic groups. Thus, community surveys based on cards and recall should provide reliable conclusions about which groups need intensive program efforts. For the routine monitoring of vaccination coverage, reasonable estimates can be obtained by combining parent-held record and parent recall data. Caution is required when comparing coverage estimates from different surveys since the source of information and method of derivation will produce widely varying coverage rates.

Black or African American↗
PubMedDate not supplied

Health insurance and health status: implications for financing health care reform.

Self-reported health status measures from the 1987 National Medical Expenditure Survey indicate significant differences among each of five population groups defined by current health insurance coverage. These differences in health status imply that the groups are likely to exhibit different patterns of expenditures, even if enrolled in the same health insurance after health care reform. The healthiest group along most dimensions is the population covered by employer-sponsored insurance, followed in order by the population with nongroup private insurance, the uninsured population, the population that qualifies for public coverage based on income, and the population that qualifies for public coverage based on medical need. While the general health and mental health of the uninsured are slightly worse in comparison to the privately insured, the uninsured have fewer chronic health problems. The uninsured who recently lost private insurance or who live in working families are significantly healthier than the long-term or low-income and nonworking uninsured.

Adolescent↗
PubMedDate not supplied

The costs of mental health parity: still an impediment?

Parity in mental health benefits rectifies unfairness in health insurance coverage and reduces financial risk for those with mental illness. However, increased coverage for mental illness has been seen as creating inefficiencies and increasing total spending, based largely on results from the RAND Health Insurance Experiment conducted in the 1970s. Newer evidence suggests that cost control techniques associated with managed care give health plans alternatives to discriminatory coverage for containing costs. We review both eras of research on mental health insurance and conclude that comprehensive parity implemented in the context of managed care would have little impact on total spending.

Cost Control↗
PubMed1999

An alternative approach to measuring the effects of insurance market reforms.

Reforms in the small group and individual insurance markets could make it easier for the currently insured to keep their coverage, and could expand coverage by making insurance more accessible to the currently uninsured. We use data from the 1989 through 1995 Current Population Survey to measure the impact of these reforms on state-level rates of uninsurance and private health insurance coverage. Instead of examining the effect of each of the various types of insurance marker reforms, we estimate the impact of packages of reforms on insurance coverage, reflecting how policies were implemented. We find that small group reforms have done little to affect insurance coverage. Individual market reforms, on the other hand, appear to increase uninsurance rates and reduce private coverage. Our findings suggest that small group reforms may have prevented erosion of private coverage, but have not reduced the numbers of uninsured people.

Employment↗
PubMed2006

National evaluation of adherence to beta-blocker therapy for 1 year after acute myocardial infarction in patients with commercial health insurance.

BACKGROUND: Quality measures of evidence-based medications post-myocardial infarction have focused on prescription at hospital discharge. Yet survival benefits of these medications are best realized with sustained therapy. We sought to examine long-term beta-blocker adherence over the first year after myocardial infarction in patients with commercial health insurance and prescription drug benefits. METHODS: This multicenter analysis examined health plan records from members of 11 health plans who had myocardial infarction in 2001, survived at least 1 year, and maintained insurance coverage (N = 17,035). The primary outcome measure was adherence to beta-blockers (defined as prescription claims covering > or = 75% of days) for 360 days post-discharge. We also examined associations with adherence--time from discharge, health plan product (commercial or Medicare + Choice [M + C]), age (35-64 or > or = 65), sex, and region. RESULTS: For 360 days after discharge, only 45% of patients were adherent to beta-blockers, with the biggest drop in adherence between 30 and 90 days. In a multivariable model, statistically significant predictors of lower adherence were participation in M + C product, residence in the Southeast, and age (driven by young participants in M + C and young females in commercial products). CONCLUSIONS: In a population of patients with health insurance and prescription drug coverage, adherence to beta-blocker therapy in the first year after myocardial infarction is poor, indicating that factors other than medication cost are important determinants of long-term adherence. Quality improvement initiatives focused on long-term adherence are needed to realize maximal benefit from medical therapy in post-myocardial infarction patients.

Adrenergic beta-Antagonists↗
PubMed1981

[The cost-insurance-spiral in health care].

The working hypothesis is that a cost-insurance spiral is operating in the Swiss health care system. It consists of three causal links. First, insurance coverage is one of the factors influencing the probability with which an individual sees a physician for a given condition. With improved coverage, demand for initial contacts will rise, inducing changes in ambulatory cost per case treated as well as in the propensity of hospitalization. Due to this second relationship, members of the sick funds find themselves exposed to an increased financial risk. Therefore, they tend to adjust coverage accordingly. With this third link, a feedback is established, and the cost-insurance spiral is ready to go into another round. The questions of whether such a spiral exists, the speed with which it turns, and how it could be slowed down are at the core of an investigation that will be completed in 1982. Members of a major sick fund have already been sampled in order to supplement insurance records with socioeconomic data.

Ambulatory Care↗
PubMed1989

Reintegration and maintenance of employees with breast cancer in the workplace.

For many persons with cancer, return to work serves as a measure of recovery from the treatment aspect of the illness as well as a positive step toward the future. Problems related to insurance coverage exist for cancer survivors due to the lack of legal requirement that an insurance company insure any applicant. The occupational health nurse brings knowledge of cancer, cancer therapy, and rehabilitation to the employer and the employee and serves as a liaison between the needs of the organization and the employee with respect to return to work. Information sharing, values clarification, role playing, and legal and ethical consultation may be effective in helping the employer as well as the co-workers meet identified goals.

Breast Neoplasms↗
PubMed1997

Genetic discrimination and health insurance: a call for legislative action.

Fear of genetic discrimination in health insurance is a growing reality. Individuals who might otherwise choose genetic testing may decline it based on their fear that they or their family members will not be able to obtain or maintain health insurance coverage. This commentary notes the evolving legislative efforts to address genetic discrimination in health insurance and urges physicians to help move this legislative agenda forward.

Genetic Diseases, Inborn↗
PubMed2000

The quality of care and influence of double health care coverage in Catalonia (Spain).

AIMS: To analyse inequalities by social class in children's access to and utilisation of health services in Catalonia (Spain), private health insurance coverage, and certain aspects of the quality of care received. DESIGN: Cross sectional study using data from the 1994 Catalan Health Interview Survey. SETTING: Child population of Catalonia. PARTICIPANTS: A representative sample of non-institutionalised children younger than 15 years (n = 2433). MAIN OUTCOME MEASURES: Health services utilisation, perceived health, type of health insurance (only National Health System (NHS) or both NHS and private health insurance), and social class. RESULTS: No inequalities by social class were found for the utilisation of health care services provided by the NHS among children in most need. Double health care coverage does not influence the social pattern of visits. Nevertheless, social inequalities still remain in the use of those health services provided only partially by the NHS (dentist) and when characteristics of the last consultation are taken into account. That is, subjects who paid for a private service waited an average of 14.8 minutes less than those whose visit was paid for by the NHS only. CONCLUSION: Equitable access and use of medical care services in relation to need, regardless of the type of insurance and social class of their children and families, has been achieved in this region of Spain; differences by social class remain for those services incompletely covered by national health insurance and aspects of the quality of care provided.

Adolescent↗
PubMed2004

Insurance for children with special health care needs: patterns of coverage and burden on families to provide adequate insurance.

OBJECTIVE: To update national estimates of insurance coverage for children with special health care needs (CSHCN) to reflect better the current economic and policy environment and to examine the burden on families and adequacy of coverage. METHODS: I analyzed data on children who were aged 0 to 17 and included in the sample child files of the 2000 and 2001 National Health Interview Survey (NHIS). CSHCN were identified using a noncategorical approach. Various measures of insurance coverage type, premium contributions, unmet need for care, and out-of-pocket spending were compared for CSHCN and children without special needs across all incomes and stratified by poverty status. RESULTS: Compared with other children, CSHCN had higher rates of public insurance (29.8% vs 18.5%), lower rates of private insurance (62.5% vs 69.1%), and a smaller percentage without insurance (8.1% vs 11.5%). More than 13% of low-income CSHCN were uninsured. Most (78.1%) families of CSHCN contributed to private insurance premiums. Family premium contributions for employer-sponsored insurance plans averaged 2058 dollars, or 4.4% of income; premiums for private nongroup insurance were higher (3593 dollars) and consumed a larger percentage of income (6.6%). For children with insurance, rates of unmet need for specific services were relatively low, suggesting that insurance coverage was adequate. However, almost 20% of low-income CSHCN experienced some form of unmet need and of out-of-pocket spending was significantly higher for families with CSHCN compared with those without CSHCN. CONCLUSIONS: CSHCN are more likely to have insurance coverage, but among low-income CSHCN, lack of insurance remains a problem. In addition, the burden on families of CSHCN to provide insurance is greater, yet coverage purchased is not always adequate to meet the needs of many children and places addition burdens on families to pay directly for care.

Adolescent↗
PubMed1976

The medical malpractice problem, and some possible solutions.

The solutions to the problems of medical malpractice and malpractice insurance coverage are primarily in the hands of state legislatures. Legislation enacted has been primarily palliative, to assure continued availability of professional liability insurance. Unfortunately, no limit can be placed on the costs of such coverage. Unfortunately, too, no long-term solution has been forthcoming. Any long-term solution must encompass some method or methods of reducing injuries to patients and at the same time changing the system from defense of the physician to compensation of the patient. If such changes are not forthcoming, physicians will become uninsurable and the private practice of medicine as we now know it will disappear in this country.

Anesthesiology↗
PubMed1999

Geographic variation in physician visits for uninsured children: the role of the safety net.

CONTEXT: Although an extensive literature exists comparing national access to health care for uninsured vs insured children, few data exist regarding differences in access across states. OBJECTIVE: To examine variation in access to physician services for uninsured children in 10 states, the safety net's role in explaining this variation, and the potential effects of the State Children's Health Insurance Program (CHIP) on insurance coverage and access. DESIGN AND SETTING: The population-based Robert Wood Johnson Foundation Family Health Insurance Survey, conducted between summer 1993 and spring 1994 in 10 states (Colorado, Florida, Minnesota, New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington), with a response rate of families by state ranging from 61% to 83%. PARTICIPANTS: A total of 8565 children who were uninsured (1586), covered by Medicaid (2723), or covered by employer-sponsored private insurance (4256) for 1 full year prior to the survey. MAIN OUTCOME MEASURES: Percentage of low-income children who are uninsured and predicted annual physician visits by state if insurance was provided to uninsured children in families with incomes of less than 200% of poverty level. RESULTS: In the 10 study states, low-income children ranged from 61% to 86% of all uninsured children and the uninsured rate for low-income children varied from 9% to 31%. On average, providing public coverage would increase annual physician visits from 2.3 to 4.6 (a 105% increase), but the increase would range from 41% to 189% across states. The annual physician visit rate in the 3 states with the highest access for the uninsured was 160% of that in the 3 lowest-access states. Safety net capacity in the high-access states ranged from 120% to 220% of that in the low-access states. CONCLUSIONS: Our data suggest that the potential effects of CHIP vary substantially across states. Notably, improvements in access to health care by uninsured low-income children should be greater in states with the fewest safety net resources.

Child↗
PubMed2004

Physician and enrollee knowledge of Medicaid coverage for tobacco dependence treatments.

BACKGROUND: The 2000 Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommends health insurance coverage for tobacco-dependence treatments proven effective in helping smokers to quit. Two states with comprehensive coverage for tobacco-dependence treatments in their Medicaid programs were selected to document awareness of coverage for tobacco-dependence treatments among primary care physicians who treat Medicaid enrollees and Medicaid-enrolled smokers. METHODS: In 2000, surveys were conducted among Medicaid smokers (n =400) and physicians (n =160) to document knowledge of covered tobacco-dependence treatments under state Medicaid programs in two states with comprehensive coverage. RESULTS: Only 36% of Medicaid-enrolled smokers and 60% of Medicaid physicians knew that their state Medicaid program offered any coverage for tobacco-dependence treatments. Physicians were more than twice as likely to know that pharmacotherapies were covered compared to counseling. CONCLUSIONS: Greater effort is needed to make Medicaid smokers and physicians aware that effective pharmacotherapies and counseling services are available to assist in treating tobacco dependence. Additionally, future research should explore the methods that are most effective in informing patients and providers regarding covered benefits.

Adolescent↗