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PubMed2006

[Retrospective analysis of falls in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases].

AIM: To analyse the frequency and circumstances of falls in an inpatient rehabilitation centre. METHODS: In a survey all falls reported to the Austrian accident insurance carrier were analysed and external circumstances of falls were evaluated. The survey covers a period of 64 months (Jan 2000 to April 2005): 10 820 inpatients (234 502 patient days); mean age 52.8 years; 1,252 patients aged >/= 70 years; 47 % male, 53 % female. RESULTS: Of 223 accidents registered, 140 (62.8 %) were falls. Of these, 17 patients had to be referred to a surgical unit for further treatment. In total, 1.29 % of all patients fell during their stay (with report to the accident insurance carrier), 0.16 % suffered major injuries from falls (with referral to surgical unit). Females fell more frequently than males. 39 % of the falls were associated with physical therapy. Most falls occurred in daytime. The location in the centre or the day of week showed no major influence on the frequency of falls. Falls occurred slightly more often in the first part of the three-week inpatient stay. CONCLUSION: The high total number of falls shows that falls are important in an inpatient rehabilitation centre for rheumatic and orthopaedic diseases. The analysis did not reveal any special location inside the rehabilitation centre with an increased risk of falls calling for urgent interventions. The active and activating physical therapies do not seem to increase the number of falls significantly.

Accidental Falls↗
PubMed1986

Care of the ventilator-dependent patient: public policy considerations.

Because traditional cost-based reimbursement for acute hospital care has been replaced by the DRG system and other limited-payment approaches, hospital managers are seeking more cost-effective provision of care. This has shortened patient-stay periods in hospitals and increased demand for such alternatives as nursing home and private home care for chronically ill persons, including those dependent on ventilators. At the same time that hospitals seek to discharge patients earlier, patients themselves would prefer to remain in hospitals for long-term care because adequate financial coverage is not available to most of them for alternative-site care. In this setting of conflict between the financial policies of hospitals and those of Medicare and private insurance carriers, it is important to keep quality of care, not financial considerations, as the first consideration when a facility is chosen for long-term care. But the long-term patient, including the patient requiring ventilator support, is caught in the web of competing financial incentives and the fact that there is no consensus on how such care should be organized, delivered, or paid for. The only significant source of funding for long-term nursing home care is Medicaid, which requires the patient to give up his personal assets, including his home; this makes it nearly certain that he will always remain institutionalized. Private insurance carriers have not yet come to terms with the idea that long-term ventilator care can be made less expensive at sites other than hospitals--and thus many patients have no satisfactory answer to the problem of where to receive such care or how it can be financed.(ABSTRACT TRUNCATED AT 250 WORDS)

Health Policy↗
PubMed1992

A survey of state insurance mandates covering alcohol and other drug treatment.

This article reports the results of a survey of health insurance mandate legislation for alcohol and other drug treatment in the 50 states through spring 1991. A total of 23 states (including the District of Columbia) requires insurance carriers to provide coverage for alcohol and other drug treatment. This paper compares the provisions in these states at the present time and contrasts these provisions with those in effect in 1981. The paper concludes with a discussion of the policy objectives states pursue through enactment of such legislation and the outcomes brought about by the mandates.

Alcoholism↗
PubMed1988

Metamorphosis of dentistry. Update on alternative delivery systems.

In 1985, Americans spent $27.8 billion for dental care. Patients paid $18 billion out-of-pocket, while private health insurance paid about $9.2 billion. Public programs paid approximately $600 million primarily through Medicaid. Commercial insurance carriers have increased their market share to more than 80 million subscribers, or more than 70 per cent of the total market. Dental service corporations and Blue Cross/Blue Shield plans cover more than 30 million subscribers, while independent plans have policies with more than 6 million customers. Dentistry today is a big business, and Big Business wants to make it their business. What makes health care vastly different from the manufacture and sale of microwaves, furniture and clothing, or the production and serving of fast foods is that the provider is in a unique relationship with the consumer/patient and will always have a large measure of control for this reason. Receiving dental care is not the same as purchasing a new pair of tennis shoes, but good business practices from other business arenas can make it possible for greater numbers of people to have greater access to it. Over the past 25 years a metamorphosis of dentistry has been generated by a rather constant interplay between the various involved parties to obtain a position of least financial risk. Insurance carriers and/or administrative intermediaries want the risk placed on the dentist, employers want the administrators to take it, and dentists want employers, administrators, or patients to assume it. The future will see the gradual evolvement of equitable plans dividing the risk among the four principle parties. Plans are being put in place today that already reflect this. A viable alternative delivery system means: Dental care providers who have the knowledge and incentive to perform quality care; administrators willing to share some of the risk; and employers and consumers who are sophisticated and realistic in their demands in today's marketplace. All these factions are currently interacting to create the new dental picture we see today--and will see in the future.

Capitation Fee↗
PubMed1991

[Private accident insurance in Switzerland with reference to liability insurance as a part of social security].

On the Swiss market there exist various different accident insurance schemes and systems. Private accident insurance which is offered by the private insurers, date back to the middle of the 19th century. Since 1912 accident insurance is compulsory for all employees working in particularly dangerous industries, since 1984 it covers all employees in the country. In Switzerland there exists no general compulsory accident insurance. To perform as insurance carriers are qualified: private insurance companies, the Swiss Accident Insurance Company, and a number of the social health (sickness) insurers. Depending on the insurance system there are different approaches to renumerate the health costs. In the various social insurance systems the patient is rather free to chose his doctor and hospital (among those who have a contract with the insurer); in private insurance he is completely free. Yet the billing systems and the applicable rates and tarifs differ considerably. There are trends to simplify these systems and bring them more into mutual accordance. Due to the important rise of the health costs in Switzerland, there exists the danger that possible simplifications will bring about more public influence yet less private initiative and less incentives to really control costs without lessening the patients' possibilities.

Humans↗
PubMed2000

Finance, providers issue brief: insurer liability.

When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.

Humans↗
PubMed2002

Anticipating and controlling rising malpractice insurance costs.

The unprecedented proliferation of large jury awards and settlements in medical malpractice cases over the past few years is expected to continue in 2002 and beyond. As a result, most major malpractice insurance carriers have experienced a deterioration of their loss ratios. Malpractice insurance premiums have skyrocketed, and in some cases, carriers have withdrawn from markets. Healthcare providers are challenged by malpractice-insurance-related expenses. Although providers may find it difficult to negotiate malpractice premium price breaks over the next few years as carriers attempt to restore their profitability, there are some measures they can take to control their malpractice expenses, including selecting a knowledgeable agent or broker, self-insuring, preparing a high-quality renewal submission, reinforcing their commitment to patient safety, and paying attention to carrier financial ratings.

Cost Control↗
PubMed1978

[Prevention in medical services].

Report of a working party. The group agrees: 1. That the level of existing educational services in health care is not sufficient. New programmes with educational aims should be assisted by the creation of institutions, which would--develop programs and strategies--coordinate with existing services--assist with their realization--evaluate the programs. 2. That there is a sensible minimal program of early detection, which can be provided without expensive technology. Insurance carriers should finance such a minimal program within their policies.

Epidemiologic Methods↗
PubMed1985

Malpractice insurance options: claims-made vs. occurrence coverage.

Professional liability insurance is not the trivial matter it was once. Premium costs are significant, the threat of malpractice litigation is tangible, sources of coverage are diverse, and there has been a proliferation of insurance carriers of different genres. Such changes have elevated the choice of malpractice insurance policy to the status of a major decision about which practitioners must be well informed. Differences between claims-made and occurrence coverage are clarified, and the advantages and disadvantages of each type of coverage are canvassed. The benefits of insuring with a commercial carrier versus a physician-owned company are also discussed in the light of trends in the structure of the liability insurance industry.

Insurance, Liability↗
PubMed1951

Attitudes toward the dubious compensation claim.

Laws providing for compensation of workmen for occupational injury are a powerful socio-economic force. In settlement of compensation claims the goal, difficult to achieve, is fairness to employee, employer and insurance carrier. Often, medical, legal, economic and social considerations conflict with one another. A "fact" in one field may not be considered so in another. Since medical data and testimony often guide the ultimate decision of a compensation claim, the physician's attitude is a large factor not only immediately and directly in determination of the case at hand but, perhaps more important, in the ultimate direction of the socio-economic forces which spring from the sum of all such determinations. To perpetuate the good in workmen's compensation laws, the next generation of physicians-and of lawyers and business administrators as well, for they, too, are involved-ought to have basic training in the social sciences in order that they may have a broad rather than a segmental view of the problems with which they deal.

Attitude↗
PubMed1956

Workmen's compensation; emphasis on rehabilitation.

Since the first law was enacted in 1911 major emphasis has been placed on monetary satisfaction of liability with insufficient attention to rehabilitation of the occupationally disabled. An effective workmen's compensation program must have three basic goals: (1) Rehabilitation of the occupationally disabled; (2) assured, prompt, and adequate indemnity for the occupationally disabled or their survivors; and (3) minimal costs to employers and society commensurate with the first two goals. It is suggested that the medical societies of each state provide a broadly representative committee to advise the administrative agency on medical policies and practices. This committee would prepare registers of all physicians in each locality who are willing and qualified to accept calls for service to injured employees, would mediate complaints originating with the employee, the employer, the insurance carrier or the administrative agency, and would cooperate with the administrative agency in educational programs for all concerned. It is the physician's responsibility to help the administrative agency in shifting the emphasis from indemnity to rehabilitation. The disabled employee is entitled to all services available to restore him to an earning capacity.

Computer Systems↗
PubMed1988

Recent trends in financing long-term care.

There has been dramatic change in the financing of long-term care in the last few years. Major private insurance carriers have introduced long-term care insurance policies to meet some of the custodial care needs of a variety of consumer groups, including old and young retirees as well as current employees. Newer policies are tying coverages more closely to a measure of disability that reflect the ability of persons to live independently. Insurers, consumer groups, and policymakers have come to understand the importance of developing innovative financing mechanisms that emphasize prefunding and cash accumulation to make policies more affordable and more desirable to a broader spectrum of the aged and nonaged population.

Industry↗
PubMed1994

Dental fraud. A dental consultant's view.

Since most plans today are based on "cost plus", employers and unions, whose plans were negotiated a long time ago, cannot afford to pay an increase of $13 per amalgam as they were asked to do when new codes for bonded amalgams were added to the provincial fee schedule. Similarly, demanding strains were placed on drug plans when a $16 per tablet medication for migraine headaches was placed on the market. The plan says that if a physician prescribed it, it will be covered. But by whom? And for how long? Dental insurance is not, and has not been for a very long time, a source of profit for the insurance carriers. One large company, for whom I worked for a number of years, just sold all their group dental insurance to a large carrier. Another well-known company has placed their group insurance on the market and is anxiously seeking a purchaser. It is too much to ask of a dental plan (and let's face it, without the plan, the patient may not seek dental treatment) to pay $100 or more for an "examination and one periapical radiograph resulting from the referral of a patient by a general practitioner to a specialist for endodontic treatment." In the case of a difficult diagnosis, this might be entertained, but why charge this fee in every case, even when the patient is holding a radiograph? I am not suggesting that fraud is being committed by a large number of practitioners on a regular basis. At the same time, I think that we must realize that this type of activity may result in the removal of dental "insurance" from the benefits provided by companies to their employees. Most dentists are extremely honest, but the backlash produced by the few who are involved in fraudulent practices is disturbing.

Fraud↗
PubMed1986

Medical screening and monitoring as noted by the insurance industry.

Medical screening and monitoring have a long and varied history as part of the insurance industry's safety and health relations with its policyholders. Many workers' compensation insurance carriers have assisted policyholder management in understanding the requirements of cost-effective health programs, in planning and undertaking steps necessary to comply with state-of-the-art medical practices, and in locating knowledgeable physicians to supervise employee health systems. Managing employees' health and associated records has become, for many employers, a complex operational and regulatory problem because of the amount and type of health information being collected. Administration of group health and accident insurance plans, workers' compensation, treatment for the ill and injured employees, voluntary health screening and counseling programs, preplacement and periodic physical examinations, and control mechanisms for health hazard exposures all contribute to this huge pool of acquired and stored health information.

Humans↗
PubMed1954

Occupational aspects of coccidioidomycosis.

Infections with coccidioides immitis have been frequently associated with circumstances suggesting the likelihood of occupational origin. Some cases have been accepted as compensable by insurance carriers, the Industrial Accident Commission, and the courts. The factors considered in determining whether or not infection is of occupational origin are reviewed under the following headings.1. Laboratory infections.2. Other infections due to exposure to contaminated articles, arising outside endemic areas.3. Infections in employees entering endemic areas pursuant to their occupations.4. Primary cutaneous inoculation.5. Localization and/or aggravation of pre-existing coccidioidomycosis by occupational injury.6. Infections in agricultural workers imported into endemic areas.7. Infections in residents of endemic areas alleged to result from occupational exposures.

Accidents, Occupational↗
PubMed1998

Health promotion and managed care: surveys of California's health plans and population.

INTRODUCTION: The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS: A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS: California's HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION: For the majority of California's PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.

Adult↗