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PubMed2004

[Public health research with statutory health insurance drug data].

Major well-organized data sources about medical services are accumulated by statutory health insurance companies. These data are sufficiently representative of drug prescriptions and constitute a potential basis for pharmacoepidemiologic research. Especially for pharmacovigilance tasks or when political decisions have to be prepared, fast and reliable answers are often necessary. These can be generated utilizing health insurances' databases. Legal requirements for the analysis of data from medical services in the framework of research projects are described in Article 287 of the SGB V (Code of Social Law Book V). An increasing number of such projects were conducted during the last few years. The Gesetz zur Modernisierung der gesetzlichen Krankenversicherung (Law on Modernization of Statutory Health Insurance Companies of 14 November 2003) will induce important progress for the development and quality of pharmacoepidemiologic research using health insurance data. Probably in the future the analysis of such data will become-in addition to analyses of other data sources such as survey data-a substantial field of pharmacoepidemiology in Germany. This article describes the background and development of using routine data from health insurance companies for scientific purposes and discusses potentials and limitations of such data for public health research.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? Results of a national population-based study.

STUDY OBJECTIVE: We determined whether having a usual source of care or health insurance is associated with the likelihood of an emergency department (ED) visit. METHODS: This was a multivariate analysis of the 2000 to 2001 nationally representative Community Tracking Study Household Survey to assess the independent association of usual source of care, health insurance, income, and health status with the likelihood of making 1 or more ED visits in the previous year. RESULTS: Based on a sample of 49,603 adults, an estimated 45.3 million adults reported 79.6 million ED visits in the previous year; 83.1% of these visitors identified a usual source of care other than an ED. Persons with poor physical health status made 48.4% of visits. Adults without a usual source of care were less likely to have had an ED visit than those whose usual source of care was a private physician (odds ratio [OR] 0.75). Uninsured individuals were no more likely to have an ED visit than insured individuals. Poor physical health (OR 2.41), poor mental health (OR 1.51), 5 or more outpatient visits during the year (OR 4.05), and changes in insurance coverage (OR 1.14) or usual source of care (OR 1.32) during the year were associated with an ED visit. Enrollment in a health maintenance organization and satisfaction with one's physician were not independently associated with ED use. CONCLUSION: ED users are similar to nonusers with regard to health insurance and usual source of care but are more likely to be in poor health and have experienced disruptions in regular care. The success of efforts to decrease ED use may depend on improving delivery of outpatient care.

Adult↗
PubMed2003

Even more extreme fertility insurance and the sex ratios of protozoan blood parasites.

Theory developed for malaria and other protozoan parasites predicts that the evolutionarily stable gametocyte sex ratio (z*; proportion of gametocytes that are male) should be related to the inbreeding rate (f) by the equation z*=(1-f)/2. Although this equation has been applied with some success, it has been suggested that in some cases a less female biased sex ratio can be favoured to ensure female gametes are fertilized. Such fertility insurance can arise in response to two factors: (i) low numbers of gametes produced per gametocyte and (ii) the gametes of only a limited number of gametocytes being able to interact. However, previous theoretical studies have considered the influence of these two forms of fertility insurance separately. We use a stochastic analytical model to address this problem, and examine the consequences of when these two types of fertility insurance are allowed to occur simultaneously. Our results show that interactions between the two types of fertility insurance reduce the extent of female bias predicted in the sex ratio, suggesting that fertility insurance may be more important than has previously been assumed.

Animals↗
PubMed2001

Rate of health insurance reimbursement and adherence to anti-hypertensive treatment among Japanese patients.

BACKGROUND: Although several studies have reported the effects of free medical care on compliance in patients with hypertension, no study has reported the effects of an economic incentive, such as subsidized medical costs, on compliance with medication protocol, in patients with hypertension. The unique characteristics of the Japanese health insurance system provide for a 10% decrease in the subsidy for medication immediately on retirement (approximately 60 years of age) for insured patients, and a 100% subsidy for insured patients who are 70 years of age or older. We examined the association between level of health insurance coverage and follow-up rate of medical treatment among Japanese patients with hypertension. METHODS: The subjects, from throughout Japan, were patients with hypertension (n=1236). The study was conducted in 1991. The odds of completing a 1-year treatment in relation to the rate of health insurance reimbursement were calculated using multiple logistic regression analysis. RESULTS: We found the following. (1) Compared with the base group, the odds of completing a 1-year treatment increased to 2.62 or 2.51 in the group whose reimbursement rate was 100%. (2) Compared with the base group, the odds of completing a 1-year treatment was no larger than 1 in the group whose reimbursement rate had been 100% for more than 6 years ('76-'). (3) Compared with the base level, the odds of completing a 1-year treatment increased to 1-1.81 in the group whose liability decreased to 80%. CONCLUSION: Although the results imply that even a small economic incentive might be effective in securing a patient's compliance with anti-hypertensive medical treatment, the effect appear limited in both duration and magnitude.

Aged↗
PubMed1998

Influence of insurance type on the use of procedures, medications and hospital outcome in patients with unstable angina: results from the GUARANTEE Registry. Global Unstable Angina Registry and Treatment Evaluation.

OBJECTIVES: The purpose of this study was to investigate whether or not there is an association between managed care insurance and the delivery and outcome of care in patients presenting with unstable angina. BACKGROUND: The proportion of U.S. patients with managed care health insurance is increasing. This may be associated with recent improvements in the control of health care costs. It is unknown whether or not there is a difference in process of care in angina patients presenting with managed care versus fee-for-service health insurance. METHODS: We compared baseline characteristics, process and outcome of care in 636 patients with managed care insurance (MC) and 1,404 patients with fee-for-service (FFS) insurance who presented with unstable angina to 35 hospitals participating in the global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry. RESULTS: Although, there was little difference in baseline characteristics and hospital treatments between cohorts, MC patients were more likely to be discharged on guideline-recommended medications (aspirin and beta-adrenergic blocking agents). In addition, FFS patients were more likely to undergo cardiac catheterization (odds ratio = 1.25 95% confidence interval = 1.1 to 1.5), but not revascularization during the hospitalization. There was no difference in hospital mortality (0.9% versus 1.2% in MC versus FFS; p = 0.60). CONCLUSIONS: In patients admitted with suspected unstable angina, MC patients are less likely to undergo coronary angiography, but are more likely to be discharged on indicated medications.

Adrenergic beta-Antagonists↗
PubMed2003

Effects of outcome-driven insurance reimbursement on short-term weight control.

CONTEXT: Although most health insurers exclude coverage of weight control therapy, one local insurer offered partial reimbursement of the cost of a weight control program, using an incentive plan. OBJECTIVE: To determine whether outcome-driven insurer-based reimbursement improves participation in a weight control program and short-term weight loss outcomes. DESIGN: Cohort follow-up study between January 1998 and February 2001. SETTING: Community weight management program operated by an academic medical center. SUBJECTS: Obese participants who had the potential for reimbursement (Group A, n=25) and participants in the same program classes (Group B, n=100) who had no possibility for reimbursement. Subjects in Group B were selected from among 206 potential participants using a propensity score to match them with subjects in Group A on age, gender, ethnicity, starting BMI, starting weight, and educational, economic, and demographic variables. INTERVENTION: Group lifestyle-based weight management program. The insurer reimbursed half the cost of the program to obese participants who met minimum weight criteria, paid the program fee at enrollment, attended > or =10 of the 12 classes, and lost > or =6% of initial body weight after 12 weeks. MAIN OUTCOME MEASURES: Participation rates and weight loss outcomes. RESULTS: Group A subjects attended significantly more classes (mean+/-s.d.: 10.1+/-1.8 vs 8.2+/-2.5, P<0.001) and lost more weight than Group B subjects (6.1+/-3.1 vs 3.7+/-3.6%, P=0.002). While 84% of Group A subjects attended > or =10 classes, only 37% of Group B subjects did so (P<0.001); 56% of Group A subjects lost > or =6% of body weight, but only 20% of Group B subjects did so (P<0.001); 56% of Group A subjects achieved both the class attendance and weight loss goals, but only 14% of Group B subjects did so (P<0.001). Logistic regression estimated that Group A subjects had 8.2 times the odds of attending > or =10 classes and 4.5 times the odds of losing > or =6% of body weight of Group B subjects, after controlling for class attendance. CONCLUSIONS: Insurer-based reimbursement that is contingent upon initial financial commitment on the part of the patient, consistent program participation, and successful weight loss is associated with significantly better short-term weight control outcomes.

Adult↗
PubMed2002

[Knowledge of "Hardship Exemptions" in statutory sickness insurance].

OBJECTIVES: The German Statutory Sickness Fund comprises about 90 % of the total population. There are special relief or 'hardship' regulations in the Statutory Sickness Fund (the 'Härtefallregelungen') exempting those insured persons from co-payment for whom the co-payments would be an undue financial burden. The most important research questions are: How many of the insured persons do actually know about the possibility of being exempted? How did this group learn about the possibility? How many insured are not exempted from co-payment although they are entitled to be exempted? Why didn't they apply? According to our knowledge there is no comparable national or international study in this field of research. METHODS: The data for the empirical study are collected in a Statutory Sickness Fund in the city of Augsburg (Southern Germany). 18 238 insured (pre-selected as not being exempted from co-payments, but probably entitled to be exempted) were addressed with a very short questionnaire in September 2000. They were asked about their household income, the number of the household members and the money spent for co-payments for medicaments, dental prostheses and other health-related services, in order to identify those entitled to be exempted, and a control group. Among those who responded 1.002 persons were interviewed by CATI (Computer Assisted Telephone Interview). RESULTS: Within the study group interviewed by CATI there was only limited knowledge about the "Härtefallregelungen". About two-thirds of the respondents (61.58 %) were unfamiliar with the possibility of getting an annual reimbursement of the co-payments. Less than one-third (27.78 %) knew nothing about the regulation of being totally exempted from co-payments. Most persons learnt about the regulations from friends and relatives, but few from physicians and other health professionals. One of the reasons most frequently mentioned for not applying for the "Härtefallregelungen" was a presumably too high income. Reasons which lie within the formalities of the application or refer to the potentially embarrassing situation were reported less often. CONCLUSION: Knowledge about the possibilities of being exempted from co-payments for medicaments and other health-related services and goods should be increased. With most of the respondents having learnt about the "Härtefallregelungen" from friends and relatives, patients could get relevant information from physicians and other health professionals more frequently. As financial aspects are the reasons reported most for not applying for the "Härtefallregelungen", the information policy could be enhanced e. g. by simplified examples for calculating the relevant income for being entitled. This way there is a chance that all insured persons who are entitled will actually benefit from the "Härtefallregelungen".

Eligibility Determination↗
PubMed2003

[Cost effectiveness evaluation of cataract patient care in respect of monofocal intraocular lenses from the perspective of German statutory health insurance].

BACKGROUND: Data on the cost effectiveness of cataract surgery with respect to the German statutory health insurance system are hardly available. Hence the increase in visual acuity as primary efficacy endpoint, order of posterior capsule opacification as primary complication endpoint and direct cost for supplementation with monofocal intraocular lenses have been assessed via meta-analyses to evaluate the procedure's cost effectiveness from the perspective of the German statutory health insurance system. MATERIAL AND METHODS: Using the medical internet database MEDLINE two meta-analyses on publications between 1995 and 2002 were carried out, one estimating the gained increase in visual acuity, the second to estimate the frequency of posterior capsule opacification 5 years after implantation of a monofocal lens. To estimate the direct cost of German health insurance current reimbursement rates were used. The primary objective of this investigation was the individual incremental cost effectiveness ratio (ICER) linking the direct cost with the cataract surgery-associated increase in visual acuity. RESULTS: 51 studies were included in the meta analysis regarding the increase in visual acuity after cataract surgery. The median increase in visual acuity was about 5 visual units (interquartile range 3.6 - 8.0 units) reaching a median postoperative visual acuity of 0.8. The median incidence rate of posterior capsule opacification during the observed period of 5 years was estimated 24 % (10 - 34 %). Computation of the current reimbursement rates of German health insurance resulted in a median incremental cost of 223.25 euro; per gained visual unit. CONCLUSION: Providing of cataract patients with monofocal intraocular lenses means median incremental costs of about 223 euro; to be refunded by the health insurance and is associated with a median visual acuity outcome of 0.8. Therefore the cost effectiveness of cataract surgery can be regarded quite encouraging compared to the outcome of other ophthalmological outpatient surgery.

Cataract↗
PubMed2005

[Quality assurance of outpatient nursing services in Baden-Württemberg -- overall view of 6 years of a total survey by the Medical Services of the Statutory Health Insurance (MDK)].

During the years 1997 to 2003 the medical services of the statutory health insurance in the German Federal State of Baden-Württemberg carried out a total survey regarding structure, process and outcome with regard to the quality of care of outpatients in the German long-term care insurance system. This survey provides information on the development of the quality of care. All outpatient nursing services licensed by the statutory long-term care insurance funds in Baden-Württemberg (n (1997 - 2000) = 863; n (2000 - 2003) = 779) were subjected to a uniform assessment based on a consented concept applied in all German Federal States. Our results demonstrate a tendency to fewer but larger nursing services providing care for an increasing number of patients. Qualification of head nurses and of caregiving staff in general has significantly improved. Information for the patient/consumer on the conditions of contracts which have to be made between a nursing service and the patient is still deficient in more than 20 % of cases. Adherence to proper procedures in the process of nursing has improved, especially with respect to taking a complete medical/nursing history and defining the individual resources of a patient and aims for therapy/nursing. However, only in (1/3) of the cases could we find a documentation of continuous adaptation of the planning of therapy. Efforts of in-house quality management and internal quality assurance by the outpatient nursing services have improved. Regarding the outcome of nursing there has been a decrease in the provision of stimulating care from 87 % of cases to 75 %. The majority of patients of outpatient nursing services do not receive benefits of the long-term care insurance system but of the statutory health insurance. This fact underlines the importance of a general conceptual framework for internal and external quality assurance.

Ambulatory Care↗
PubMed1999

Biodiversity and ecosystem productivity in a fluctuating environment: the insurance hypothesis.

Although the effect of biodiversity on ecosystem functioning has become a major focus in ecology, its significance in a fluctuating environment is still poorly understood. According to the insurance hypothesis, biodiversity insures ecosystems against declines in their functioning because many species provide greater guarantees that some will maintain functioning even if others fail. Here we examine this hypothesis theoretically. We develop a general stochastic dynamic model to assess the effects of species richness on the expected temporal mean and variance of ecosystem processes such as productivity, based on individual species' productivity responses to environmental fluctuations. Our model shows two major insurance effects of species richness on ecosystem productivity: (i) a buffering effect, i.e., a reduction in the temporal variance of productivity, and (ii) a performance-enhancing effect, i.e., an increase in the temporal mean of productivity. The strength of these insurance effects is determined by three factors: (i) the way ecosystem productivity is determined by individual species responses to environmental fluctuations, (ii) the degree of asynchronicity of these responses, and (iii) the detailed form of these responses. In particular, the greater the variance of the species responses, the lower the species richness at which the temporal mean of the ecosystem process saturates and the ecosystem becomes redundant. These results provide a strong theoretical foundation for the insurance hypothesis, which proves to be a fundamental principle for understanding the long-term effects of biodiversity on ecosystem processes.

Ecosystem↗
PubMed2004

How can a work rehabilitation process be improved?--a qualitative study from the perspective of social insurance officers.

PURPOSE: The aim of this study is to describe social insurance officers' experiences of a work rehabilitation process at a rehabilitation centre in the northern parts of Sweden. In Sweden the social insurance company has a key role to coordinate all efforts concerning work rehabilitation planning between all rehabilitation actors. METHOD: Ten social insurance officers at the social insurance company in a city in northern Sweden were interviewed using a narrative approach about their experiences of work rehabilitation processes in general. The interviews were analysed by qualitative content analysis with a focus on their experiences of goals, content and results of a work rehabilitation process. RESULTS: The social insurance officers' experiences of how a work rehabilitation process could be improved were described in six categories; (1) Early identification of problems, needs and interventions (2) clear goal formulations, (3) a focus on psychosocial factors (4) a greater variety of possible interventions, (5) activating employers to a higher extent in work rehabilitation and (6) a closer cooperation and information exchange with other rehabilitation actors. CONCLUSIONS: It is possible to improve a work rehabilitation process by focusing on early identification of problems, needs and interventions, with a variety of interventions to choose between and with clear goal formulations and recognizing psychosocial factors in the process. To activate employers to a higher extent in work rehabilitation and to make the information exchange between rehabilitation actors more frequent may also improve work rehabilitation processes.

Adult↗
PubMed1996

The Preventive Approaches of the Statutory Accident Insurance System and Their Effectiveness.

For decades, prevention has been an integral and important part of the German statutory accident insurance system. The very close link between prevention, rehabilitation, and compensation, which is so typical for the German system, had an extremely positive effect on the frequency of notifiable occupational accidents. What is more, if we compare benefits and costs of the system, it appears that prevention has also been successful in a strictly monetary sense. After a short outline of the basic principles of the German accident insurance system, the authors take stock of the last 33 years. The period between 1960 and 1993 also covers the repercussions of the German reunification in 1990. The trends in accident and disease frequency are presented together with the trends in costs and benefits. To allow a realistic comparison, all figures are indicated in terms of 1960. It can be shown that the average contribution rate to accident insurance decreased in the period under consideration. This is particularly remarkable if we look at the enormous increase in contribution rates that took place in all other branches of social insurance. It is also noted that the contribution rates of the different industrial branches are immediately dependent on the accident risks in those industries. The last part of the article contains a qualitative and quantitative description of the prevention measures available to the German accident insurance institutions.

accident frequency↗
PubMed1994

Retiree health insurance and pension coverage: variations by firm characteristics.

This study examined coverage by employer-sponsored retiree health insurance using the 1988 and 1989 Employee Benefits Surveys. The effects of firm characteristics on the probability of offering retiree health insurance and pension coverage are also estimated. We find that coverage by retiree health insurance varies across occupational groups, industries, and firm sizes. In addition, we find a strong relationship between a firm's decisions to offer retiree health insurance and pension coverage, with the retiree health insurance decision being more sensitive to specific firm characteristics.

Aged↗
PubMed1996

Seat belt use, insurance status, and hospital bad debt.

OBJECTIVES: Previous studies have shown that not wearing a seat belt is associated with both increased injury severity and higher hospital charges. In this article, we examine whether unrestrained motorists are also more likely (a) to be medically uninsured, and (b) to leave their hospital bills unpaid. METHODS: We reviewed the hospital clinical and billing records for all occupants in motor vehicle collisions admitted to the Massachusetts General Hospital Emergency Department during a 2-month period (n = 265). Using data on seat belt use, insurance status, bad debt, admission to the hospital, driver or passenger status, age and sex, we performed simple correlation and multiple regression analyses to determine the association between (a) seat belt use and insurance status and (b) seat belt use and hospital bad debt. RESULTS: Unrestrained patients were more likely both to be uninsured and, holding insurance status and other factors constant, to generate bad debt for the hospital. CONCLUSIONS: Our findings are similar to previous studies that show that the public pays a significant share of the medical care charges associated with risk-taking behavior. Propitious selection, an economic theory, may explain such findings. It asserts that risk-taking individuals are least likely to buy insurance voluntarily and will also be the ones most likely to deliberately place themselves in dangerous situations. Our findings show that people who do not use seat belts are more likely to have outstanding hospital bills; the public effectively pays for these bills in higher taxes or insurance premiums.

Accidents, Traffic↗
PubMed2004

Insurance knowledge and decision-making practices among Medicare beneficiaries and their caregivers.

BACKGROUND: The complexity of health plans and the Medicare program may require some beneficiaries to seek help when making health insurance decisions. However, there has been little research examining the Medicare-related knowledge and information gathering of beneficiaries who receive decision-making help and those who assist them. OBJECTIVES: We sought to compare the Medicare knowledge and information-gathering of beneficiaries who receive help with insurance decisions or their proxy respondents with beneficiaries who make their own decisions. RESEARCH DESIGN: Data were drawn from the 2000 Medicare Current Beneficiary Survey (MCBS), which includes a nationally representative sample of noninstitutionalized Medicare beneficiaries. SUBJECTS: We included a total of 11,978 beneficiaries and 1401 proxies who completed the MCBS. MEASURES: Measures were items and indices from the MCBS measuring the Medicare education campaign goals of access, awareness, and use of information sources, understanding of Medicare, and confidence in decision-making. RESULTS: Beneficiaries who receive help with health insurance decisions have lower knowledge of the Medicare program and are less likely to be aware of and use information sources than beneficiaries who make their own decisions. With few exceptions, proxy respondents had similar levels of access and knowledge as beneficiaries who make their own insurance decisions. CONCLUSIONS: Beneficiaries who receive help with their insurance decisions may be a particularly vulnerable population. They may have limited Medicare knowledge and not be aware of the resources that could help them.

Adult↗
PubMed1997

Older Medicare enrolees' choices for insured services.

OBJECTIVES: The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program. DESIGN: A cross-sectional survey using anonymous, inperson interviews and an innovative instrument to elicit choices. SETTING: General Internal Medicine outpatient clinic at a university teaching hospital. PARTICIPANTS: One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995. MEASUREMENTS: Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits. RESULTS: Subjects of various educational and economic backgrounds were able to carry out the selection process with relative case, and four-fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made. CONCLUSION: These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.

Aged↗
PubMed2004

Factors affecting missed appointment rates for pediatric patients insured by medicaid in a traditional hospital-based resident clinic and hospital-owned practice settings.

Missed appointment rates (MAR) of pediatric patients insured by Medicaid and seen in a traditional hospital-based continuity (teaching) clinic were compared to the rates for the same patients after their care had been transitioned to a community practice. The hypothesis is that when rewarded with shorter waiting times, a less chaotic environment, and more pediatrician continuity, the MAR for patients insured by Medicaid would be lower in the practice setting than it had been in continuity clinic. The MAR decreased from 33% in the continuity clinic in 1999 to 18% in the community practice in 2001 (p<0.01). It was also hypothesized that the MAR for patients insured by Medicaid would be higher in practices with a higher percentage of Medicaid appointments. Among 15 hospital-owned pediatric practices, the MAR for patients insured by Medicaid was positively correlated with the percentage of total appointments that were made by patients insured by Medicaid (correlation coefficient 0.706 [p<0.01]).

Appointments and Schedules↗
PubMed1988

Income redistribution effect of the Swedish sickness allowance insurance in a comparison of two concepts of social class.

Social insurances effect income distributions between social strata. Here, insurance returns in relation to income are studied on the Swedish sickness allowance insurance, which is intended to redistribute from higher to lower social strata. Two measures of social class are used, the socio-economic classification, the official index of Sweden, and a structural class concept, which in earlier results discriminates better for material factors such as income and work conditions. The material consists of all sickness cases of 1983 for 3,161 persons, sampled from insurance registers and cross-classified with registers at taxation authorities. Data on insurance returns, incomes, and occupation are used. Results clearly confirm the intended redistribution effect, but considerably clearer with the structural class concept. The effect is even stronger than intended for some strata, where the system seems to lack in implementation. The consequences for choice of class measure are finally discussed.

Adolescent↗