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PubMedDate not supplied

Direct reimbursement of nurse practitioners in health insurance plans of research universities.

The purpose of this study was to explore the nature of health insurance coverage research universities offer their employees and the extent to which these employers offer options providing for reimbursement of services of independent nurse practitioners. A request for health insurance documents mailed to 77 public research universities resulted in a response rate of 83 per cent. A total of 75 per cent sent usable descriptions of insurance coverage for analysis. Among the respondents, 69 per cent (n = 40) reported offering insurance through Blue Cross/Blue Shield companies. Nursing services reimbursed generally included traditional nursing care such as private duty nursing and home health care. Coverage of nursing services that overlap with traditional medical practice, such as prenatal care and labor and delivery services of nurse midwives, anesthesia services of nurse anesthetists, psychiatric services of nurse specialists, and primary care nursing services of nurse practitioners, was less evident. Findings generally indicated that in spite of the presence of enabling or mandatory state legislation for third-party reimbursement of nursing services, legislation is not being implemented in many states by employers in their purchase of group policies.

Data Collection↗
PubMed2003

[Medical counseling of public health-insurances in questions of occupational diseases in regard to economical benefits--project of cooperation between AOK Hesse and the Medical Advisory and Expertising Service Hesse].

Since September 1998 exists a project of cooperation and consultation between the AOK Hesse and the Medical Advisory and Expertising Service Hesse with the aim to identify occupational diseases and to survey decisions of the Employer's Liability Insurance Association. The procedure is based on a computer-added recognition-system, a profound preparation of the single cases by the employees of the health-insurance and a very intensively carried out deliberation by Medical Doctors of occupational medicine. In a period of four and a half year 8391 cases have been reviewed of which 4859 have already been determined. An approval as occupational disease by the Employer's Liability Insurance Association has been determined in 1954 cases, in 2905 cases the acknowledgement has not been determined. Regarding the determined cases a recourse of 10,078,922.27 EUR has been realized. In regard to the invested small resources of personnel the procedure has proved itself as highly effective to discover and to assert recourses. Beside the economical aspects for the public health-insurance, other results of the project were the assurance of the entitlement to benefits of people coming down with occupational diseases or their relatives. New insights about the actual development of occupational diseases in Germany als well as their prevention can be proceeded.

Accidents, Occupational↗
PubMed2002

Comparison of children's medical and dental insurance coverage by sociodemographic characteristics, United States, 1995.

BACKGROUND: Insurance coverage can reduce financial barriers that constitute a significant deterrent to obtaining medical and dental care, especially for children who reside in low-income households. We present baseline information on the codistribution of medical and dental coverage among US children according to sociodemographic characteristics before the enactment of the State Children's Health Insurance Program (SCHIP). METHODS: Data for 27,059 children 0-17 years old from the 1995 National Health Interview Survey (NHIS) were analyzed to examine the distribution of medical and dental insurance coverage by sociodemographic characteristics. Prevalence estimates and adjusted odds ratios with 95 percent confidence intervals were calculated using SUDAAN. RESULTS: Overall, 14.1 percent children were uninsured for medical care and 36.4 were uninsured for dental care; thus, there were 2.6 times as many children uninsured for dental than for medical care. Near-poor and Hispanic children were most likely to be without medical or dental coverage. Near-poor children were more likely to be uninsured for dental care than for medical care (43.8% vs 22.5%). CONCLUSION: Our findings, coupled with previous reports, suggest that the most serious problem concerning lack of dental insurance is among near-poor children. SCHIP has the potential to address dental coverage among near-poor children.

Adolescent↗
PubMed1977

The effect of physician-controlled health insurance. U.S. v. Oregon State Medical Society.

The trial record in an antitrust case against the Oregon State Medical Society, finally decided in 1952, was examined to reconstruct the behavior of a competitive market for health insurance coverage. Health insurers, called "hospital associations," were found to have engaged individually in cost-control efforts similar to, but possibly more aggressive than, today's utilization review under professional sponsorship. The subsequent disappearance of these insurer-initiated cost controls in Oregon is traced to the medical society's organization of a competing Blue Shield plan as a model of insurer conduct and to a simultaneous boycott by physicians of the hospital associations as long as they persisted in questioning doctors' practices. Some modern parallels are noted, and the advantages of fostering privately sponsored cost-control efforts are suggested.

Hospitals↗
PubMed1999

Enabling informed consumer choice in the long-term care insurance market.

Provisions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) may increase private long-term care insurance sales without imposing substantially more stringent consumer-protection features. The ability of consumers to make informed choices when purchasing this complex product is examined in light of these changes. Data were collected through detailed examinations of policies and interviews with industry experts, insurance companies, agents, consumer groups, and regulators. Because of the complexity of this product, the goals of expanding, consumer choice and ensuring that consumers are able to make informed decisions often work against each other. Mechanisms are discussed through which the government can facilitate informed choice and improve consumer protection. The authors contend that, because the government is providing tax incentives that encourage consumers to purchase the product, it has the responsibility to ensure that consumers understand the long-term care insurance they purchase.

Consumer Behavior↗
PubMed1995

The questionable value of medical screening in the small-group health insurance market.

Insurers perform medical screening to assess risk for health insurance in the small-group market. Most reform proposals eliminate screening because it denies coverage to those who need it. This DataWatch empirically analyzes the value of medical screening to insurers. We analyzed claims of two employed populations covered by a large insurer--one screened and the other not screened. We found no significant difference in the amounts claimed by these two populations over six years. This suggests that medical screening could be eliminated in the small-group market without an increase in premiums.

Data Collection↗
PubMed2005

Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program.

BACKGROUND: Racial/ethnic disparities are associated with lack of health insurance. Although the State Children's Health Insurance Program (SCHIP) provides health insurance to low-income children, many of whom are members of racial/ethnic minority groups, little is known about whether SCHIP affects racial/ethnic disparities among children who enroll. OBJECTIVES: The objectives of this study were to (1) describe demographic characteristics and previous health insurance experiences of SCHIP enrollees by race, (2) compare racial/ethnic disparities in medical care access, continuity, and quality before and during SCHIP, and (3) determine whether disparities before or during SCHIP are explained by sociodemographic and health system factors. METHODS: Pre/post-parent telephone survey was conducted just after SCHIP enrollment and 1 year after enrollment of 2290 children who had an enrollment start date in New York State's SCHIP between November 2000 and March 2001, stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic). The main outcome measures were usual source of care (USC), preventive care use, unmet needs, patterns of USC use, and parent-rated quality of care before versus during SCHIP. RESULTS: Children were white (25%), black (31%), or Hispanic (44%); 62% were uninsured > or =12 months before SCHIP. Before SCHIP, a greater proportion of white children had a USC compared with black or Hispanic children (95%, 86%, and 81%, respectively). Nearly all children had a USC during SCHIP (98%, 95%, and 98%, respectively). Before SCHIP, black children had significantly greater levels of unmet need relative to white children (38% vs 27%), whereas white and Hispanic children did not differ significantly (27% vs 29%). During SCHIP, racial/ethnic disparities in unmet need were eliminated, with unmet need at 19% for all 3 racial/ethnic groups. Before SCHIP, more white children made all/most visits to their USC relative to black or Hispanic children (61%, 54%, and 34%, respectively); all improved during SCHIP with no remaining disparities (87%, 86%, and 92%, respectively). Parent-rated visit quality improved for all groups, but preexisting racial/ethnic disparities remained during SCHIP, with improved yet relatively lower levels of satisfaction among parents of Hispanic children. Sociodemographic and health system factors did not explain disparities in either period. CONCLUSIONS: Enrollment in SCHIP was associated with (1) improvement in access, continuity, and quality of care for all racial/ethnic groups and (2) reduction in preexisting racial/ethnic disparities in access, unmet need, and continuity of care. Racial/ethnic disparities in quality of care remained, despite improvements for all racial groups. Sociodemographic and health system factors did not add to the understanding of racial/ethnic disparities. SCHIP improves care for vulnerable children and reduces preexisting racial/ethnic disparities in health care.

Adolescent↗
PubMed1992

Special report on liability and insurance. An update on assignment of patient benefits under ERISA.

While the holdings in Davidowitz and Arkansas Blue Cross & Blue Shield arose in different contexts, they both reflect the courts' increasing willingness to consider the importance of cost containment in the health insurance arena, even though patient accessibility to health care may be restricted as a result. If the holding in Davidowitz is not successfully appealed, providers may need legislative relief in order to retain their ability to take valid assignments of patient claims for payment from ERISA plans. It is uncertain whether such legislation can be sought at the state level or must instead come from Congress due to ERISA preemption of state legislation. Clearly, the district court decision on remand in Arkansas Blue Cross & Blue Shield will be closely watched for any light it may shed on this question. On a pragmatic note, providers who have not entered into "participation" agreements with insurers or other private payors may now have a greater incentive to do so, and "nonparticipating" providers who continue to obtain assignments from patients in order to collect directly from insurers or other private payors should determine on a case-by-case basis whether the source of the patient's benefits is a group health plan--which is likely to fall under ERISA and may contain nonassignment provisions--or some other form of coverage. For an additional perspective on insurers' responses to copayment waivers, see Newsletter, Vol. 6, No. 10, October 1991, at 7.

Arkansas↗
PubMed1989

Conventional health insurance: a decade later.

In this article, the 1987 conventional health plans are examined and 1987 group health insurance is compared with that of 1977. The source of information for 1987 is the national survey of 771 private and public employers conducted by the Health Insurance Association of America. Data for 1977 are from the National Medical Care Expenditures Survey. Findings show that conventional health plans' share of the group market declined from 95 to 73 percent during the decade; the majority of Americans covered by conventional group insurance are now enrolled in a plan that self-insures; prospective utilization review grew dramatically after 1984; and patient cost sharing increased, but not as significantly as conventional wisdom holds.

Data Collection↗
PubMed2000

Criteria for the future division of labor between private and social health insurance.

This article's point of departure is that the individual has to manage three stochastic assets, namely health, wealth, and wisdom (skills), which tend to be positively correlated. It shows that the unexpected components of insurance payments should be negatively correlated for minimizing total asset volatility. The empirical finding is that in the United States, Japan, and Germany, the lines of social insurance contribute less to diversification than do those of private insurance. The article concludes with suggestions for new, umbrella-type insurance contracts that in the future should help individuals in the efficient management of their assets.

Germany↗
PubMed2002

State regulation of private health insurance: prescription drug benefits, experimental treatments, and consumer protection.

This study analyzes the results of 2 surveys sent to state insurance commissioners that focused on policies regulating conventional health insurance and managed care organizations (MCOs) during 2000. Surveys were returned by 49 states and the District of Columbia. Several states have implemented regulations mandating prescription drug coverage. In addition, some states now require health insurers and MCOs to cover the medical care associated with experimental medications and treatments. Some states have also created laws allowing beneficiaries to sue their health insurer or MCO for damages caused by denial of care. These state policies provide a rich source of data for federal policy makers to analyze as they consider new patient protection legislation and amendments to the Employee Retirement Income Security Act.

Consumer Advocacy↗
PubMed1992

Use of medical insurance claims for surveillance of occupational disease. An analysis of cumulative trauma in the auto industry.

Medical insurance claims, linked with work histories for a large automotive manufacturer over a 3-year period, identified large numbers of cases of potentially work-related diseases, including 30,600 episodes of probable cumulative trauma disorders (CTD). CTD incidence rates were calculated within five plants, and high-risk areas identified, however, unknown differences in medical insurance coverage by exposure group limited interpretation. Case-control analyses, with controls also identified by insurance claims, addressed coverage and produced age-adjusted and sex-adjusted estimates of risks. All five plants had departments with statistically significant, elevated risks for one or more of the diagnoses carpal tunnel syndrome, CTD of other upper extremities, rotator cuff syndrome, CTD of the neck and of the lower back. Medical insurance claim data linked with work history provide the basis for practical and comprehensive surveillance for CTD and potentially a variety of other occupational diseases.

Accidents, Occupational↗
PubMed2004

Towards advanced risk-sharing in health care financing: with a focus on the potential of social health insurance in developing countries.

In this paper, we analyse the major health financing methods and the contribution they can make to improving access to health care among all of a country's population groups. Risk-sharing in health financing is proposed as a powerful method to achieve this improvement. The larger the degree of risk-sharing in a health financing system, the less people will have to bear the financial consequences of their own health risks, and the more they are likely to have access to needed care. Ideally countries should attempt to introduce 'advanced' risk-sharing aiming at equal access among individuals to an adequate package of health services. There are two major ways to implement advanced risk-sharing: general tax revenue may be main source of financing health services, or else social health insurance may be established. An important finding is that about 60% of the world's countries still need to pursue efforts towards the introduction of advanced risk-sharing. We further focus on the potential of social health insurance as an advanced risk-sharing method. In fact, there is recent interest in developing countries such as Côte d'Ivoire, Indonesia, Iran and Kenya in this particular health financing mechanism. Compared to health financing via general tax revenue, social health insurance spreads the immediate burden of financing among various groups, including the workers, the self-employed, enterprises and Government. Time and tedious discussions between these groups may be needed, however, before a consensus is reached, not only on the relative burden of financing but also on ways to achieve overall population coverage. It is suggested that action-research be used to test the adequacy of initial social health insurance policies.

Delivery of Health Care↗
PubMedDate not supplied

North Carolina high-risk insurance pools.

Imagine this: You are a 58-year-old man. You have worked all your life, paid taxes, and helped support your family. Two years ago you had a mild heart attack. Your wife has diabetes and high blood pressure. Luckily, you had health insurance through your job that helped you pay for the hospitalization, doctor's visits, and necessary medications for you and your wife. With a new diet, exercise, and the medications, you both are doing well managing your health problems. A little over a year ago, you lost your insurance when your company downsized. You found another job, but your current employer doesn't offer insurance. Your wife also works, but she works for a small employer that does not offer coverage. So, you pay approximately dollar 600/month for continuation coverage (COBRA) for your wife and yourself through your former employer. Last month, you found out your COBRA coverage is about to end. You want to continue to buy insurance coverage, but you were told that purchasing a comprehensive policy with a dollar 1,000 deductible (70% coinsurance) that covers your needed medications would cost more than dollar 4,000/month for your wife and yourself.

Fees and Charges↗
PubMed1980

Group life & Health Insurance Co. v. Royal Drug Co.: the McCarran-Ferguson Act and Health Service Plans.

Until recently, contractual relationships between health care providers and health insurers appeared to be immune from antitrust scrutiny. The Supreme Court ended this apparent immunity in Group Life & Health Insurance Co. v. Royal Drug CO., 440 U.S. 205 (1979), holding that insurance plans offering goods and services to policyholders are not exempted by the McCarran-Ferguson Act from the federal antitrust laws. By denying a McCarran-Ferguson exemption, the Court did not decide the ultimate issue--whether the insurers in fact had violated federal antitrust law. This Note reviews Royal Drug in light of precedent and of the purpose of the McCarran-Ferguson Act. This Note contends that the result in Royal Drug follows logically and consistently from the Court's earlier readings of the Act, but that the Court's reasoning is unclear and, even under its strongest reading, unconvincing; hence, an alternative approach to interpreting and applying the McCarran-Ferguson Act is suggested. Finally, this Note analyzes the application of Royal Drug by lower federal courts and discusses its implications for the interface of health law and antitrust law.

Commerce↗
PubMed1995

Genetic testing and insurance. The Ad Hoc Committee on Genetic Testing/Insurance Issues.

The rapid expansion of opportunities for genetic testing has been accompanied by complex questions about the appropriate relationships between providers, patients, and insurers. Some of these questions involve large public-policy decisions, such as whether the government should guarantee access to health care for all citizens. Universal access to health care, without regard to past, present, or future risk of disease, could eliminate risk-oriented underwriting in health-care coverage. A positive response to that question will ameliorate other problems. Until universal access is reality, genetic testing and genetic diagnosis will raise important issues for the practicing geneticist. How much does a client need to know about insurance implications before consenting to a genetic test? Should patients be counseled to purchase insurance before being tested? Should genetic information be excluded from medical records before their release to insurance companies for routine reimbursements or underwriting? What are the ethical and legal responsibilities of the geneticist?

Confidentiality↗
PubMed1997

Fraud worries insurance companies but should concern physicians too, industry says.

The amount of insurance fraud is increasing in Canada. This should worry physicians, because all personal-injury claims must be substantiated by a medical certificate. The vast majority of physicians are honest and ethical, fraud investigators say, but some are being duped as patients scheme to cheat the insurance industry. In one sensational auto-insurance-fraud case, some Ontario physicians are being investigated about possible involvement in a self-referral scheme. Nicole Baer looks at insurance fraud and the challenges it poses for doctors.

Automobile Driving↗
PubMed2007

Elasticities of market shares and social health insurance choice in Germany: a dynamic panel data approach.

In 1996, free choice of health insurers was introduced to the German social health insurance system. One objective was to increase efficiency through competition. A crucial precondition for effective competition among health insurers is that consumers search for lower-priced health insurers. We test this hypothesis by estimating the price elasticities of insurers' market shares. We use unique panel data and specify a dynamic panel model to explain changes in market shares. Estimation results suggest that short-run price elasticities are smaller than previously found by other studies. In the long-run, however, estimation results suggest substantial price effects.

Costs and Cost Analysis↗