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PubMed2005

Do employers voluntarily include patient protections in self-insured managed care plans?

Managed care patient protection laws passed by states do not apply to health plans sponsored by self-insured employers, although 54% of workers who receive health insurance coverage through their employer are in self-insured plans. In-depth interviews conducted in five states with employers offering self-insured health benefits and with other knowledgeable market informants provide evidence that self-insured managed care plans nonetheless include important features that strengthen subscribers' access to medical providers. Less common in these plans were features providing for independent external appeal of coverage denials and for protecting network providers from undue influence by plan administrators.

Employee Retirement Income Security Act↗
PubMed1992

Expanding employment-based health insurance: is small group reform the answer?

Nearly two-thirds of all uninsured workers are employed in firms with 100 or fewer employees. Making insurance more affordable and available to small groups is high on the political agenda. Efforts to reform the small group market include making insurance more available by restricting the use of medical underwriting to deny access, and compressing rates to make it more affordable for high-risk groups. Other reforms pursued at the state level have focused on reducing the price of insurance facing all small employers. My analysis suggests that these proposals will have limited success in reducing the number of uninsured. Short of compulsory insurance, significant changes will occur only when insurance is organized around larger purchasing groups and not small employers.

Commerce↗
PubMed2006

[Factors affecting national health insurance mass screening participation in the disabled].

OBJECTIVES: As the disabled have higher prevalence rates and earlier onsets of chronic diseases than the non-disabled, their participation in mass screening is important for the early detection and intervention of chronic diseases. Nevertheless, in Korea, the disabled have lower participation rates in mass screening services than the non-disabled. The purpose of the study was to find determinants for the participation in the National Health Insurance (NHI) mass screening program among the disabled. METHODS: In this study, the NHI mass screening data of 423,076 disabled people, which were identified using the National Disability Registry (2003), were analyzed. Of the factors affecting the participation rates in mass screenings, the following variables were included for the analysis: socioeconomic stati, such as sex, age, category of health insurance program, region and income; disability characteristics, such as disability type, and severity. A multiple logistic regression analysis was used to evaluate the association between the participation rates, disability characteristics variables and demographic variables. RESULTS: The participation rate in mass screening of the disabled was 41.3%, but was lower in females, an age of more than 70 years, self-employed and for those with an average monthly insurance premium over 133,500 Won and in metropolitan regions. The participation rate was 1.31 times lower in females than males (95% CI=1.29-1.33); 3.50 times lower in the elderly (more than 70 years) than the younger (95% CI=3.33-3.67); 1.43 times lower in those who live in metropolitan areas (95% CI=1.40-1.46); 2.59 times lower for those in a health insurance program for the self-employed than for employees (95% CI=2.56-2.63); 1.19 times lower for the higher income (more than 133,500) than the lower income group (4,400-22,000) for the average monthly insurance premium (95% CI=1.15-1.23); 2.04 times lower for those with brain palsy and stroke disabilities than with auditory impairments (95% CI= 1.97-2.11) and 3.27 times for those with severe compared to mild disabilities (95% CI=3.15-3.40). CONCLUSIONS: The disabled with high severity, and locomotive and communication disabilities have lower participation rates in mass screening services in Korea.

Adolescent↗
PubMed1995

The impact of HMO competition on private health insurance premiums, 1985-1992.

A critical unresolved health policy question is whether competition stimulated by managed care organizations can slow the rate of growth in health care expenditures. We analyzed the competitive effects of health maintenance organizations (HMOs) on the growth in fee-for-service indemnity insurance premiums over the period 1985-1992 using premium data on 95 groups that had policies with a single, large, private insurance carrier. We used multiple regressions to estimate the effect of HMO market penetration on insurance premium growth rates. HMO penetration had a statistically significant (p < .015) negative effect on the rate of growth in indemnity insurance premiums. For an average group located in a market whose HMO penetration rate increased by 25% (e.g., from 10% to 12.5%), the real rate of growth in premiums would be approximately 5.9% instead of 7.0%. Our findings indicate that competitive strategies, relying on managed care, have significant potential to reduce health insurance premium growth rates, thereby resulting in substantial cost savings over time.

Cost Control↗
PubMed1995

[Work capacity evaluation in occupational disability (supplementary) insurance. What should the medical expert know about industrial practice?].

Up to now it has often been the responsibility of physicians to assess whether an insured person qualifies for disability benefits, although the insurance conditions in fact state that the problem is not purely a medical one. Indeed, it is advisable to take advantage of the expertise available in the field of Occupational Studies when assessing elibility for benefits. The spectrum of occupations is subject to constant change. The "classification of Occupations" published by the Federal Employment Agency in Nuremberg lists some 25,000 occupational designations. Further, several thousand agreements are concluded each year between employers and employees' representatives at various levels and these may need to be taken into account when assessing claims for disability benefits. Occupational Studies is a specialist area in its own right, requiring specific training and experience. The assessment of disability claims calls for close cooperation and teamwork: doctors, insurers and occupational consultants must each contribute their own particular skills to the decision-making process. In the final analysis, however, it is the insurer alone who must take responsibility for accepting or rejecting the disability claim. The present paper starts by discussing the term "Occupational Studies" and goes on to explain the tasks of the occupational consultant. Finally, reference is made to descriptions of occupations as well as workplace features and requirements which the medical expert should take into account when assessing and insured's ability to work in a given occupation.

Disability Evaluation↗
PubMed1994

Job loss due to health insurance mandates.

The proposed Health Security Act provides universal health insurance by extending the current employer-based health insurance financing system. It requires employers to pay approximately 80% of the health insurance premium for each of their workers. Experience with other legislation requiring employers to provide benefits to their employees indicates that most of the cost of a mandated benefit is shifted to employees in the form of lower wages. However, for workers without health insurance and with earnings close to the minimum wage, minimum-wage legislation prohibits employers from lowering wages in response to a health insurance mandate. These employers can be expected to respond by cutting employment. Recent evidence from employer reactions to increases in the minimum wage suggests that approximately 100,000 jobs would be lost due to the Health Security Act's employer mandate.

Employment↗
PubMedDate not supplied

Psychosocial consequences of inadequate health insurance for patients with cancer.

The psychosocial aspects of health insurance in general, and inadequate coverage in particular, have received scant attention from psycho-oncology professionals. However, with the dehospitalization of cancer treatment, and the longer survival time for patients with cancer, the economic and social burden of cancer has shifted to the patient and family. This article explores several domains of the life of the patient with cancer that can be affected by insufficient health insurance. These include the physical, emotional, financial, social, and employment consequences of inadequate insurance coverage, which can be far-reaching. Health insurance can influence the patient's decision making regarding treatment, choice of physician, and hospital. The unmet needs that arise from deficient insurance coverage can cause strain and distress for the family and the patient. These areas of concern are discussed, and recommendations are made for clinical, educational, and research activities.

Adult↗
PubMed1993

Personal characteristics and spells without health insurance.

People without health insurance differ not only in their personal characteristics and reasons for being without health insurance but also in the length of time they spend in uninsured spells. A hazard model of spell durations is used to estimate the relative effects of a person's characteristics in the month just before an uninsured spell begins on the duration of the spell. Using the Survey of Income and Program Participation, our analyses indicate that monthly family income, educational attainment, and industry of employment in the month prior to losing health insurance are the characteristics that have the greatest impact on the exit rate from being without health insurance. Because low-income people could end an uninsured spell with either private health insurance or Medicaid, findings from an exploratory competing risks model are also reported.

Adolescent↗
PubMedDate not supplied

The decline in health insurance and labor market trends.

Since the mid-1980s, there has been a reduction in the percentage of workers with employment-based health insurance. In 1993, 68.6 percent of workers had this insurance, compared with 72.9 percent in 1988. The decline was slightly more pronounced among workers obtaining their insurance indirectly, i.e., through someone else's employer. There was a decline in direct employment-based health insurance (coverage through one's own employer) with proportions dropping from 56.1 percent in 1988 to 54.1 percent in 1993. The model used in this analysis identified the factors associated with the decline in employment-based health insurance. The data used were those from the 1989 and 1994 supplements to the Current Population Survey (CPS) conducted by the U.S. Bureau of the Census. The data analyses identified about 55 percent of the factors influencing decreases in employment-based coverage between 1988 and 1993. These factors include decreases in real wages, a small movement toward the use of part-time workers, movements from the goods-producing sector to the service-producing sector, changes in unemployment rates, rising health care costs and the changing racial composition of the work force. The relative proportion each of the factors contributed to the decline, as well as the counterbalancing influence of age, education, firm size, occupation and marital status is discussed.

Adolescent↗
PubMed1997

[Morbidity estimates of beneficiaries of national health insurance for seven chronic conditions].

This work is aimed at providing improved coefficients applicable to the statistics of Health Insurance concerning the long-lasting conditions in order to assess morbidity of Health Insurance members concerning diseases invoked legislation on long-lasting conditions. To reach this objective, we have applied the consequences of successive equivalence (between diseases and their specific treatment, and between the use of special prescriptions for exempting diseases and the acknowledgment of long-lasting conditions by Health Insurance) to the results of a survey on medicines carried out by the Caisse Nationale d'Assurance Maladie des Travailleurs Salariés in 1993 on the basis of a representative sample. Improved coefficients were equal to the inverse of the proportion of special prescriptions within the whole of the prescriptions including specific treatment. Those coefficients and their confidence intervals have been calculated for seven affections: non-insulin dependent diabetes [1.56-1.67], coronary disease [1.51-1.61], Parkinson's disease [1.51-1.85], manic-depressive psychosis [1.49-1.89], haemorrhagic rectocolitis and Crohn's disease [1.49-2.04], insulin dependent diabetes [1.10-1.20] and tuberculosis [1.61-3.33]. The critical analysis of our work and its comparison with the rare literature on the same subject confirms the value of our results. The application of those improved coefficients to the figures of prevalence and incidence provided by Health Insurance makes it possible to set confidence bounds to the statistics of morbidity concerning the people who are affiliated to that system of Health Insurance and treated for these diseases however serious they are.

Adolescent↗
PubMed1997

Structural incentives and adoption of medical technologies in HMO and fee-for-service health insurance plans.

Recent literature has argued that conventional fee-for-service (FFS) health insurance, as compared to managed care (HMO) insurance, may lead to the adoption of new technology that raises costs and reduces patient welfare. In this paper, we show that this result depends on an increasingly unrealistic key assumption-that FFS insurers cannot refuse to reimburse new technology. We also show that, when the assumption is changed, HMO insurers may adopt costly technologies that FFS insurers do not.

Decision Making, Organizational↗
PubMed2005

Health insurance coverage during the years preceding medicare eligibility.

BACKGROUND: Adults in late middle age who lack health insurance are more likely to die or experience a decline in their overall health. Because most estimates of the uninsured are cross-sectional, the true number of individuals whose health is at risk from being uninsured is unclear. METHODS: We analyzed a nationally representative sample of 6065 US adults 51 to 57 years old who were interviewed in 1992, 1994, 1996, 1998, and 2000 as part of the Health and Retirement Study. Insurance coverage was determined at the time of each interview and classified as private, public, or uninsured. Longitudinal data were used to determine the proportion of individuals who were uninsured at any interview during the 8-year study period. RESULTS: The proportion of participants who were uninsured at the time of the 1992, 1994, 1996, 1998, and 2000 interviews was 14.3%, 10.8%, 9.7%, 8.8%, and 8.2%, respectively. People frequently transitioned between having insurance and being uninsured. As a result, despite the declining prevalence of being uninsured, the percentage who were uninsured at least once during the 8-year period rose to 23.3% by 2000; few participants (2.6%) were continuously uninsured. Only 60.1% of participants were continuously enrolled in private insurance across all 5 interviews. CONCLUSIONS: The proportion of US adults in late middle age at risk from being uninsured over a 10-year follow-up period was 2 to 3 times higher than cross-sectional estimates. At least one quarter of older adults will be uninsured at some point during the years preceding eligibility for Medicare.

Black or African American↗
PubMed1992

How will children and pregnant women fare under current national health insurance proposals?

OBJECTIVE: To compare the following five major national health insurance proposals and their implications for children and pregnant women: the MAtsui "play or pay" bill (HR 3393); the Russo Canadian-type bill (HR 1300); the Rockefeller "play or pay" bill (S 1177); the Stark Medicare-type bill (HR 650); and the president's market reform proposal. RESEARCH DESIGN: Using an analytic framework developed by the Association of Maternal and Child Health Programs, we examine the differences among the five proposals in basic approach, eligibility and enrollment, benefits, cost-sharing requirements, provider reimbursement, and cost-control measures. RESULTS: All of the plans, except for President Bush's, would provide coverage for virtually all children and pregnant women, using a combination of private and public approaches. President Bush's market approach provides financial incentives to purchase health insurance benefit plans that states can design within actuarial limits. The remaining four plans strive for uniformity in benefits, covering physician and hospital services in a manner similar to most plans today. Preventive care benefits extend beyond what has been offered in the past. The four plans differ sharply in their coverage of extended care services, with the Matsui and Russo bills covering the most generous package of benefits. The Rockefeller and Stark plans, on the other hand, require less cost-sharing for their basically preventive and primary care plans. CONCLUSIONS: Most of the health insurance proposals are aimed at extending preventive and primary care health insurance plans to more uninsured Americans. Only the Matsui bill devotes significant attention to developing a comprehensive benefit plan for children and pregnant women. Additional attention should be directed at extended care services for those with special health care needs, the future role of Medicaid, and the public health system infrastructure.

Child↗
PubMed2000

Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality.

Although the US health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians. Initiatives to provide access to health insurance have been a major policy tool to ensure that Americans receive high-quality health care. However, availability of insurance coverage does not automatically lead to high-quality care. This article explores points of vulnerability in the US health care system at which the potential to achieve high-quality care can be lost: (1) access to insurance coverage; (2) enrollment in available insurance plans; (3) access to covered services, clinicians, and health care institutions; (4) choice of plans, clinicians, and health care institutions; (5) access to a consistent source of primary care; (6) access to referral services; and (7) delivery of high-quality health care services. Ensuring high-quality health care requires that each of these "voltage drops" be recognized and addressed. JAMA. 2000;284:2100-2107.

Delivery of Health Care↗
PubMed1998

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort.

BACKGROUND: The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims. METHODS: Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes. RESULTS: There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001). CONCLUSIONS: The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Aged↗
PubMed2006

[The need for insurance coverage in Integrated Health Care].

Any health care provider who engages in contracts for Integrated Health Care should identify, evaluate, quantify and protect against the risks which can emerge from such agreements. Presently insurance companies do not offer insurance coverage for guarantees that are stated by such contracts. Only delict-dependent responsibilities are covered by common insurances. Insurance companies are presently preparing adequate agreements to cover guarantees of Integrated Health care contracts.

Contracts↗
PubMed2006

Risk management in radiotherapy: analysis of insurance claims.

PURPOSE: The purpose of this study was to analyse risk factors in radiotherapy with regard to those where protocols have been implemented for their prevention and those that are known but still present, thus requiring attention and remedial measures. MATERIALS AND METHODS: To demonstrate the existence of risk factors that have not been eliminated and that cause damage in radiotherapy practice, we examined insurance claims related to such radiotherapy procedures. Analysis of the claims made over a 10-year period was performed on the basis of radiotherapists (256 in 2004) insured with the professional association. The total number of claims in the 10-year period was 26. RESULTS: The type of claim was examined in each of the 26 cases, with as many as 15 being related to radiotherapy injury to tissues surrounding the neoplasm, thus confirming this to be the most frequent cause for insurance claims. The other 11 causes are also reported. CONCLUSIONS: Now that the historical causes of error that led to incorrect radiotherapy treatment have been eliminated through strict adherence to protocols, risk management in radiotherapy identifies side effects as the main source of risk for patients and physicians. Data analysis confirms the need to implement risk management procedures in radiotherapy in which insurance claims (15/26 cases) are motivated by side effects of treatment.

Clinical Protocols↗
PubMed1995

Consumer information surplus and adverse selection in competitive health insurance markets: an empirical study.

If premiums for health insurance are not risk related, there exists a consumer information surplus that may result in adverse selection. Our results indicate that insurers can greatly reduce this surplus by risk-adjusting the premium. We conclude that there need not be any substantial unavoidable consumer information surplus if consumers can choose whether to take a deductible for a one- or two-year health insurance contract with otherwise identical benefits. Therefore, adverse selection need not be a problem in a competitive insurance market with risk-adjusted premiums or vouchers and with such a consumer choice of health plan.

Actuarial Analysis↗