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PubMed1995

Local responses to expanded Medicaid coverage for pregnant women.

Concern about high infant mortality and morbidity in the United States, combined with the erosion of private insurance coverage, sparked major expansions in the Medicaid program in the 1980s. This study examines how the Medicaid expansions for pregnant women affected access to prenatal care for low-income women through case studies conducted in four states early in 1991. Despite the significantly greater share of births covered by Medicaid in the period 1986 to 1991, the timely initiation of prenatal care improved in only one state. Although prenatal services increased in some areas, significant problems persisted in others. The growth in capacity of the prenatal care system was greatest when state and local policies designed to increase supply were also instituted. While the Medicaid expansions eliminated significant barriers to prenatal care for low-income women, other policies that have been designed to reduce the remaining barriers may be necessary in order significantly to expand access to prenatal care and to improve birth outcomes.

Eligibility Determination↗
PubMed2004

Disparities in the adequacy of depression treatment in the United States.

OBJECTIVE: There is evidence of disparities in depression treatment by factors such as age, race or ethnicity, and type of insurance. The purpose of this study was to assess whether observed disparities in treatment are due to differences in rates of treatment initiation or to differences in the quality of treatment once treatment has been initiated. METHODS: Logistic regression models using data from the 2000 Medical Expenditure Panel Survey were estimated to assess the role of age, race or ethnicity, and type of insurance on rates of initiation of depression treatment for persons with self-reported depression and on rates of adequate treatment for those receiving treatment. RESULTS: African Americans and Latinos were significantly less likely to fill an antidepressant prescription than Caucasians. However, among patients who filled at least one prescription for an antidepressant, there were no racial or ethnic disparities in the probability of receiving an adequate trial of antidepressant medication. African Americans were more likely than Latinos and Caucasians to receive an adequate course of psychotherapy. Persons who did not have insurance coverage were less likely to initiate any depression treatment compared with those who did have insurance. However, if treatment was initiated, no difference in the probability of receiving adequate treatment was observed. Elderly persons were less likely to receive an adequate course of psychotherapy or counseling compared with younger persons. CONCLUSIONS: Disparities in depression treatment appear to be due mainly to differences in rates of initiation of depression treatment, given that rates of adequate care generally did not differ once treatment was initiated.

Adolescent↗
PubMed1995

No insurance, public insurance, and private insurance: do these options contribute to differences in general health?

This paper examines the validity of two of the basic assumptions made about health care insurance and health, namely that having any insurance is associated with better health and, in particular, that having public, welfare-based insurance has better health consequences for the poor than does having no insurance. These questions were addressed using data from the National Medical Expenditure Survey, a national household-based survey in 1987 of more than 36,000 people who were asked to report in detail about their medical care use and expenditures, health insurance coverage, and health and functional status. The results of the analysis indicate that being without insurance is associated with having poorer general health compared to persons with private insurance, and that the health of persons who qualify for public insurance is the poorest of any group--poorer even than those without insurance.

Adolescent↗
PubMed1993

Healthcare reform: second opinions. If you must insure part-timers. Part 1.

One of the central goals of the Clinton healthcare reform proposal is to provide insurance coverage for all Americans. This will be possible largely by requiring all employers to pay insurance for all their employees, including part-timers. The proposed plan requires all employers to offer full medical benefit packages to any employee who works more than 30 hours a week, and to cover employees who work 10 to 30 hours a week on a prorated basis. The following are foodservice operators' opinions on how this legislation, if passed, will affect their operations.

Food Services↗
PubMed2000

[Genetic discrimination in insurance and employment].

The results of the Human Genome project will eventually have a great impact on medicine. However, the expansion of genetic testing due to these results exacerbates ethical, legal, and economic problems related to the project even today. Virtually free access to the data of testing would present an encroachment on personal freedom, since it may lead to discrimination based on genetic characteristics, i.e., genetic discrimination. Examples of this discrimination are already known; they include unsubstantiated refusals to employ carriers of certain alleles and denials of life or health insurance coverage and the ability to adopt a child. The use of genetic information in the insurance and employment fields is of primary concern due to its economic importance. Consumers consider genetic discrimination in these areas to be intolerable moral and social injustice. Genetic discrimination may eventually lead to the formation of a class of people who cannot buy an insurance policy, and, in the employment field, rejection of persons with "undesirable" genes infringes on citizens' rights to equal opportunity. However, selection for genetic characteristics in employment is justified if these characteristics determine sensitivity to occupational hazards.

Employment↗
PubMed1994

Beyond the uninsured: problems in access to care.

This paper investigates the difficulties that people encounter in their attempt to obtain needed health services, other than their third-party coverage or lack of it. These problems can be temporal, geographic, attitudinal, or financial (even with insurance). A state-wide sample survey conducted in 1989 revealed that about 17% of Michigan's population experienced one or more of these kinds of difficulties in their attempts to receive medical care. Those at greater risk included persons with public insurance coverage (mostly Medicaid), persons with low incomes, persons in poor health, women, and members of some ethnic minority groups. The findings suggest that addressing the problem of access to care through an exclusive focus on the uninsured, especially through public programs, could leave significant residual problems for several segments in American society.

Adolescent↗
PubMed1995

Private payers of health care in Brazil: characteristics, costs and coverage.

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.

Brazil↗
PubMed2006

Caring for the new uninsured: Hospital charity care for older people without coverage.

Despite near-universal coverage through Medicare, a number of elderly residents in the United States do not have health insurance coverage. To the author's knowledge, this study is the first to document trends in the use of hospital charity care by uninsured older people. Data from the New Jersey Charity Care Program, which subsidizes hospitals for services provided to low-income uninsured people, were used to analyze trends in charity care utilization by older people from 1999 to 2004. Charity care charges are standardized to uniform Medicaid reimbursement rates and inflation adjusted using the Medical Care Consumer Price Index. From 1999 to 2004, use of charity care by older people grew much faster than it did for younger patients. As a result, older people now account for a greater share of hospital charity care in New Jersey than children. Elderly users of charity care generated higher costs per patient than their younger counterparts. Cost differences were especially salient at the upper end of the distribution, where high-cost elderly patients used significantly more resources than high-cost patients in other age groups. These results highlight an emerging source of strain on the healthcare safety net and point to a growing population of uninsured residents who have costly and complex medical needs. Similar experiences are likely to be found in other states, especially those that have growing populations of elderly immigrants who are likely to lack health insurance.

Adult↗
PubMed1995

TennCare--health system reform for Tennessee.

TennCare, the health care system reform plan implemented in Tennessee on January 1, 1994, was developed with the dual objectives of controlling the rapidly rising cost of the state's Medicaid program and extending health insurance coverage to most Tennesseans without access to employer-sponsored or other government-sponsored health insurance. Beneficiaries enroll in competing, state-chartered managed care organizations that are responsible for providing broad preventive, inpatient, and outpatient services and are reimbursed by the state on a capitation basis at a rate based on a statewide global budget for health care. The program initially proposed to enroll up to 1,775,000 citizens and was projected to result in a cumulative cost savings to Tennessee and the federal government of $7.2 billion by the end of the 5-year demonstration period. However, major start-up problems encountered by the state and by managed care organizations and limitations imposed by the government have significantly constrained these expectations. At the end of its first year, more than 1.2 million citizens were enrolled, but the program incurred a $99 million deficit. Managed care organizations and hospitals have reported major financial problems, and constituency groups--especially those representing physicians--have attempted to block the program. Our objective is to describe the design and rationale of TennCare and discuss key issues the plan continues to face that may affect its long-term success.

Capitation Fee↗
PubMed1997

Children's health care use in the Healthy Kids Program.

BACKGROUND: In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. METHODS: Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. RESULTS: A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. CONCLUSIONS: The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

Child↗
PubMed2000

The history, economics, and financing of mental health care. Part 3: The present.

1. Health care system changes, particularly the managed care plans, are altering mental health practices in significant ways. The autonomy and independent judgment of clinicians are being limited. 2. Market expansion created child and adolescent hospitals in the private sector. This market was very favorable to growth because of the great ambiguity in diagnosis and treatment, and the nonexistence of commitment laws for this population. 3. While insurance coverage for psychiatric diagnoses has expanded, more affluent people, with good employment possibilities, still have better insurance than poor individuals.

Hospitalization↗
PubMed1992

Dentistry and national health insurance.

Access to dental care is not equitable in the United States. The dental health of the population varies widely by socioeconomic status. Private dental insurance coverage has peaked at about 40% of the population, and benefits are variable. Dentistry is not included in Medicare and is optional for adults under Medicaid. Inflation is greater than for all goods and services. There is considerable administrative waste, and quality is variable. In this author's opinion, only a national system with universal coverage, one set of benefits, a single payer, a cap on expenditures, and no participation by insurance companies that is increasingly based on salaried consumer-or community-owned group practices with dentist input into decision making can hope to solve the existing problems.

Dental Care↗
PubMed1982

Insurance reimbursement mechanisms for rehabilitation equipment and environmental modifications.

Third party payment mechanisms are reviewed from the viewpoint of one commercial insurer. Attention is focused upon insurance coverage for rehabilitation equipment, environmental modifications, orthotics, prosthetics, and durable medical equipment. Numerous variables influence coverage decisions. Typical examples, unique in rehabilitation literature, illustrate situations related to the major types of insurance (Group Health, Miscellaneous Lines, Workers' Compensation, and Reinsurance). The importance of the rights of disabled persons and the impact of national financial estimates are discussed. Consideration is given to several approaches which might improve the benefits available. Techniques to cope with the system include prompt communication, accurate correspondence, and employer policyholder awareness.

Health Maintenance Organizations↗
PubMed2004

Is universal coverage a solution for disparities in health care? Findings from three low-income provinces of Thailand.

The policy on universal coverage (UC) of health care has been adopted and implemented incrementally by the government of Thailand since April 2001 with the aim of providing the access to care for the uninsured population. The success of UC, however, depends on how effective its design and implementation arrangements are in reaching population and affecting households' health seeking behavior and abilities to take up benefits of UC. The results from the household survey of 1834 respondents conducted in three low-income provinces (Tak, Sakol Nakorn, Narathiwat) show that the Gold card with exemption scheme was pro-poor while other insurance schemes tended to favor the rich with 2.6% of respondents reported having more than one type of health insurance coverage and 8.9% without health insurance. The insurance status had statistically significant association with health care use, and knowledge on family planning method and sexually transmitted diseases. Additionally, consumer preferences and socioeconomics factors are a key to disparities in health care utilization.

Adolescent↗
PubMedDate not supplied

Uncovering the missing Medicaid cases and assessing their bias for estimates of the uninsured.

General population surveys of health insurance coverage are thought to undercount Medicaid enrollment, which may bias estimates of the uninsured. This article describes the results of an experiment undertaken in conjunction with a general population survey in Minnesota. Responses to health insurance questions by a known sample of public program enrollees are analyzed to determine possible reasons for the undercount and the amount of bias introduced in estimates of uninsured people. While public program enrollees often misreport the type of coverage they have, the impact on estimates of those without insurance is negligible. Restrictions to generalizing the finding beyond this study are discussed.

Bias↗
PubMed1996

Sexual assault victims' compliance with follow-up care at one sexual assault treatment center.

OBJECTIVE: To determine whether patients who receive emergency care at a sexual assault treatment center (SATC) follow suggested guidelines for prevention and/or treatment of associated sexually transmitted diseases (STDs). DESIGN: The research was a descriptive study of 26 adult victims of sexual assault who had been treated initially at a SATC. METHODS: A nine-item questionnaire was designed to query participants by telephone 6 to 8 weeks after their initial care for sexual assault. Participants were questioned about their compliance with the suggested medication regimen and follow-up medical attention. In addition, health insurance coverage information was retrieved from participants' records to ascertain possible patterns of compliance by availability of health insurance. Participant perceptions of the nursing care received in the SATC also were elicited. Data were analyzed with frequencies and percentages, as well as qualitative categorization procedures. RESULTS: Twenty-six women, aged 19 to 43 years (mean = 27), participated in the study. Seventy-three percent reported taking all of the prophylactic medication prescribed or given to them at the SATC, whereas only 50% had made and kept a recommended follow-up appointment with a physician. No association could be determined between compliance with the suggested follow-up protocol and the availability of health insurance. Reasons for not following suggested protocols varied greatly. Of particular importance for those who were noncompliant were the implied misunderstandings related to the need to take medications after a sexual assault. CONCLUSIONS: Although concern has been expressed in the literature regarding sexual assault victims' compliance with follow-up regimens for the prevention and treatment of STD, the findings from this study indicate that compliance, particularly with medication protocols, may be higher than expected. However, continuing work is needed to ensure that all victims receive all recommended information regarding follow-up care during the first encounter with the nurse and that the rationale for follow-up care is fully understood by the patient. Nurses who interact with victims of sexual assault are in the best position to enhance compliance with follow-up regimens by identifying victims who may be at risk of noncompliance.

Adult↗
PubMed1994

Early adoption of cyclosporine and recombinant human erythropoietin: clinical, economic, and policy issues with emergence of high-cost drugs.

The discovery of new drugs and their introduction into US markets will become an intense area of focus should health care reform result in Medicare insurance coverage for prescription drugs. Particular attention will be focused on high-cost drugs. Two high-cost drugs, cyclosporine and recombinant human erythropoietin (rHuEPO), introduced into the clinical management of patients with kidney disease during the past decade, provide some experience concerning the forces affecting the use of expensive drugs in a cost-conscious health care system. The decision to prescribe a drug will depend on provider's judgements of the drug's clinical benefits and costs compared with those of other possible therapies. It may also depend on payment policy. Both cyclosporine and rHuEPO were adopted rapidly and extensively by providers of end-stage renal disease care following US Food and Drug Administration approval, despite their high costs. Both drugs were remarkably effective, relatively safe, and able to be administered without great difficulty compared with the therapies they have replaced. There was no additional payment to hospitals for the initial use of cyclosporine, which was introduced in 1983 at the time when Medicare's prospective payment was established, since choice of immunosuppressive agent did not affect the fixed, per-admission payment determined by the diagnosis-related group for kidney transplantation. Medicare coverage for continuing outpatient use of cyclosporine was not initially provided, in contrast to rHuEPO, which was introduced in 1989 with Medicare outpatient coverage and payment of 80% of the allowed charge. Despite their high costs and different methods of insurance payment both drugs achieved a rather quick and high penetration rate into their respective populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclosporine↗