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PubMed1998

Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature.

CONTEXT: There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care. OBJECTIVE: To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians. DESIGN AND PARTICIPANTS: Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy. MAIN OUTCOME MEASURES: Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists. RESULTS: Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01). CONCLUSIONS: Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.

Body Height↗
PubMed1990

[Utilization and medical cost of patients with different insurance coverage among group practice centers].

In order to explore the utilization and medical cost of patients with different insurance coverage in group practice centers, we collected patient data in three centers from September 1, 1987 to February 28, 1988. We classified the payments as self-payment,partial-reimbursement and total-reimbursement. There were 42,234 visits by 8,111 patients. The average frequency of visits within 6 months was 6.1 in total-reimbursement patients, 5.2 in partial-reimbursement patients and 2.6 in self-payment patients. We found that the frequency of visits increased with age in patients with total-reimbursement and partial-reimbursement. On the other hand, the frequency decreased after the age of 65 in patients with self-payment; whether it was related to the economic problems of the elderly needs further study. The highest medical cost per visit was NT$. 343 in total reimbursement patients, followed by NT$. 281 in partial-reimbursement patients. The lowest cost was NT$. 208 in self-payment patients. Yet, the highest ratio of total drug cost by total medical cost per visit was 73.7% in partial-reimbursement patients followed by 63.6% in total-reimbursement patients. The lowest ratio was 56.7% in self-payment patients. Although the partial-reimbursement system could not decrease the ratio of total drug cost by total medical cost per visit, it would be beneficial in group practice centers to decrease the patients' visits and the medical cost per visit. Therefore, this system should be executed in the future.

Adolescent↗
PubMedDate not supplied

Expanding individual health insurance coverage: are high-risk pools the answer?

Thirty states operate high-risk pools intended to offer coverage to persons denied coverage in the individual health insurance market. But in most states the high-risk pool mirrors the individual market's problems: Coverage is expensive, the waiting period for coverage of preexisting conditions is long, and benefits may be limited. A few states with high-risk pools have addressed these problems by adequately funding high enrollment and comprehensive benefits; some also require the market to accept more risk. But most discourage enrollment in the high-risk pool in myriad ways and fall to ensure access to the individual market for persons with health problems.

Health Policy↗
PubMed1997

The demand for health insurance coverage by low-income workers: can reduced premiums achieve full coverage?

OBJECTIVE: To assess the degree to which premium reductions will increase the participation in employer-sponsored health plans by low-income workers who are employed in small businesses. DATA SOURCES/STUDY SETTING: Sample of workers in small business (25 or fewer employees) in seven metropolitan areas. The data were gathered as part of the Small Business Benefits Survey, a telephone survey of small business conducted between October 1992 and February 1993. STUDY DESIGN: Probit regressions were used to estimate the demand for health insurance coverage by low-income workers. Predictions based on these findings were made to assess the extent to which premium reductions might increase coverage rates. DATA COLLECTION/EXTRACTION METHODS: Workers included in the sample were selected, at random, from a randomly generated set of firms drawn from Dun and Bradstreet's DMI (Dun's Market Inclusion). The response rate was 81 percent. FINDINGS: Participation in employer-sponsored plans is high when coverage is offered. However, even when coverage is offered to employees who have no other source of insurance, participation is not universal. Although premium reductions will increase participation in employer-sponsored plans, even large subsidies will not induce all workers to participate in employer-sponsored plans. For workers eligible to participate, subsidies as high as 75 percent of premiums are estimated to increase participation rates from 89.0 percent to 92.6 percent. For workers in firms that do not sponsor plans, similar subsidies are projected to achieve only modest increases in coverage above that which would be observed if the workers had access to plans at unsubsidized, group market rates. CONCLUSIONS: Policies that rely on voluntary purchase of coverage to reduce the number of uninsured will have only modest success.

Adult↗
PubMed1998

Effects of state reforms on health insurance coverage of adults.

States have tried a number of strategies to reduce the growing number of uninsured people. These include Medicaid expansions and various insurance reforms, such as low-cost plans, subsidized insurance products, risk pooling, open enrollment and continuity of coverage requirements, and community rating. Using data from 1989 to 1994, we examine the impact of such policies on health insurance coverage for adults. We find that few state policies have succeeded in increasing health insurance coverage. For those that work, impacts are very modest or are accompanied by adverse effects such as crowdout. Implementing effective state policies to reduce the number of uninsured remains a great challenge.

Adolescent↗
PubMed2000

Health insurance coverage and the job market in California.

This Special Report examines why the uninsured rate is so much higher in California than it is in the rest of the United States; it focuses on labor market and demographic characteristics that may explain the differential in health insurance coverage. California has the third-highest rate of uninsured for the nonelderly population in the United States, accounting for 16.6 percent of the total U.S. uninsured population. In 1998, 24.4 percent of the nonelderly population in California (both workers and nonworkers under age 65) was uninsured, compared with 18.4 percent uninsured in the United States as a whole. Only Arizona (with 27.2 percent) and Texas (with 27.0 percent) had higher uninsured rates than California. Among California workers ages 18-64, nearly 24 percent (or 3.8 million workers) were uninsured in 1998. Eleven years earlier, in 1987, 19.3 percent (or 2.7 million workers) were uninsured. During the decade 1987-1997, the percentage of California workers with employment-based health insurance declined from 68.5 percent to 64.2 percent. But more recently, between 1997 and 1998, the percentage of workers with employment-based coverage increased slightly from 64.2 percent to 65.5 percent. Fifty-three percent of California workers employed in the agriculture sector were uninsured in 1998. Overall, agriculture accounts for 4 percent of the jobs in California; however, agricultural workers accounted for 8 percent of the uninsured. Demographics are a key factor affecting California's rate of uninsured. Twenty-seven percent of California workers are Hispanic, more than three times the proportion in the rest of the United States. Compared with the rest of the country, California has fewer workers who are white (54 percent vs. 76 percent) or black (6 percent vs. 12 percent), and more workers who are Asian (12 percent vs. 3 percent). More than 43 percent of Hispanic workers in California were uninsured in 1998, compared with 14 percent of white workers, 24 percent of black workers, and 21 percent of Asian workers. California workers--and Hispanic workers in particular--are more likely to be employed by small firms, which are significantly less likely to offer health benefits than large firms. Forty-four percent of the California work force was employed by firms with fewer than 100 employees, or was self-employed, compared with 40 percent of the work force in the rest of the United States. Sixteen percent of all workers in California did not graduate from high school. Among Hispanic workers, 44 percent did not graduate from high school; among white workers, 13 percent did not graduate. In comparison, 18 percent of Asian workers and 7 percent of black workers did not graduate from high school. In California, 60 percent of Hispanics earning less than $7 per hour were uninsured in 1998. In contrast, 26 percent of whites, 46 percent of blacks, and 41 percent of Asians earning less than $7 per hour were uninsured.

Adolescent↗
PubMedDate not supplied

New medical entities and delivery sites require specialized insurance coverage.

The addition of mid-level providers to the health care continuum and the development of off-site delivery has created new insurance coverage problems. Fran O'Connell, R.N., vice president of Shand Morahan & Company Inc., explains what to look for in coverage based on the level of care provided and the variety of care centers in use.

Group Practice↗
PubMed1998

Knowledge of health insurance coverage by adolescents and young adults attending a hospital-based clinic.

PURPOSE: To describe adolescents' and young adults' knowledge about their health insurance, and to identify factors associated with correct knowledge of health insurance in this population. METHODS: Data were analyzed from a confidential questionnaire administered to 830 patients at a hospital-based adolescent medicine clinic. The questionnaire contained items pertaining to insurance type, demographics, health status, and health-risk behaviors. Actual health insurance data and information regarding utilization of health services were obtained from the hospital billing data-base. Predictors of health insurance knowledge were determined through bivariate analyses followed by stepwise logistic regression. RESULTS: A total of 50.7% of respondents correctly identified their type of health insurance. Those who correctly identified their insurance had a higher mean age. Only 48.5% of participants who were 11-18 years old could identify their insurance type, versus 53.1% of 19-21-year-olds and 64.7% of 22-24-year-olds (p = 0.02). Sixty-five percent of Medicaid patients and 76.3% of hospital free care patients knew how their medical bills were paid, versus 17.9% of self-pay patients and 47.3% of patients with private insurance (p < 0.01). Greater utilization of health services was associated with increased rates of insurance knowledge among 19-24-year-olds on bivariate analysis; however, this factor was not significant when controlling for other factors. Regression analysis revealed that older age and insurance type other than self-payment were independent predictors of health insurance knowledge in adolescents (11-18 years old), while female gender and insurance type other than self-payment were independent predictors of insurance knowledge in young adults (19-24 years old). CONCLUSIONS: Approximately half of adolescents and young adults do not know how their medical bills are paid. Validation of self-reported insurance data is, therefore, critical both in clinical practice and health services research.

Adolescent↗
PubMed1986

Trends in private insurance coverage for mental illness.

The authors analyzed data from the U.S. Bureau of Labor Statistics Level of Benefits Surveys for the period 1979-1984 to examine coverage for psychiatric disorders in the private sector. While the overall number of employees with psychiatric benefits has increased, a greater percentage have more restrictions on those benefits. The extent of coverage is wide ranging, but there is little depth and the majority of psychiatric care expenses are not insured. Although the figures do not suggest a dramatic cutback in insurance coverage, the trends toward increased reductions in benefits for all health care threaten the more vulnerable psychiatric benefits.

Alcoholism↗
PubMed2001

The association between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer.

The objective of this study was to examine the effect of socioeconomic status and insurance status on health-related quality of life (HRQOL) outcomes in men with prostate cancer. The design was a retrospective cohort study using multiple sites, including both academic and private practice settings. A cohort of 860 men with newly diagnosed, biopsy-proven prostate cancer of any stage was identified within CaPSURE, a longitudinal disease registry of prostate cancer patients. HRQOL was assessed with validated instruments, including the RAND 36-item Health Survey (SF-36) and the UCLA Prostate Cancer Index. Covariates included insurance status, education level, annual income, age, stage, comorbidity, Gleason grade, baseline PSA, marital status, ethnicity and primary treatment. HRQOL measurements were taken at 3-6-month intervals. Analysis of covariance was used to determine the effect of SES and insurance status on the HRQOL domains at baseline and over time. Patients with lower annual income had significantly lower baseline HRQOL scores in the all of the domains of the SF-36 and four of eight disease-specific HRQOL domains. No relationship was seen between annual income and HRQOL outcomes over time. Conversely, health insurance status was associated with HRQOL over time, but not at baseline. Health insurance status appears to have a unique effect on general HRQOL outcomes in men after treatment for prostate cancer. This study confirms the commonly held belief that patients of lower SES tend to have worse quality of life at baseline and following treatment for their disease. These findings have important ramifications for clinicians, researchers and policy makers.

Activities of Daily Living↗