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PubMed1984

The cost of health care and health insurance in Australia: some problems associated with the fee-for-service system.

This paper reviews the health care system and the supporting health insurance framework in Australia. The importance of the health insurance mechanism is stressed in relation to the maintenance and growth of private fee-for-service medicine. The Medical Benefits Schedule, which is the negotiated basis for medical fees under insurance, is examined for the logic implicit in the fee structure. The high rewards for procedural medicine relative to consulting are suggested as part of the basis of the rapid growth in hospital admissions. It is also argued that the refund schedule has helped to determine the nature of the medical specialist manpower pool. Other problems associated with the complex nature of the refund schedule, such as fraud and wasteful over-servicing, are identified and discussed. It is asserted that the health insurance system and refund schedule are partly determining the nature of medical service provision and inducing inequities in the financing and delivery of medical care in Australia.

Australia↗

PubMed2006

The role of insurance data in setting priorities for netball injury prevention strategies.

The aim of this study was to investigate insurance records for a one-year period to determine the injury frequencies and costs associated with different age groups in netball. The insurance records for all netball claims made during 1999 in Victoria were obtained from the insurer and entered into a database. The overall injury rate was 9.49 injuries per 1000 players, with 829 claims for injuries filed with the insurance company. Of all injuries claimed for, 85.3% were to the lower limb, 8.7% to the upper limb, 3.1% to the spine/torso and 2.9% to the head and face. Lower limb injuries accounted for 85.4% of costs, upper limb injuries 10.7% and head/neck/torso injuries 3.9% of total injury costs. Knee injuries accounted for 56.9% of total costs, with ankle and calf/Achilles injuries costing 12.7 and 11.8% of total costs, respectively. Injury prevention strategies should therefore be directed to three main injuries taking into account costs and incidence. These injuries were: ankle sprains, knee ligament sprains and Achilles tendon strains. Specifically, the prevention program for Achilles injuries should be directed to the >25 years age groups.

Adolescent↗

PubMedDate not supplied

Health insurance for type 1 diabetes mellitus: US competition and French coverage.

Chronic diseases present a major challenge to individuals, health professionals, and policy makers. Disease burdens and fears of a lifelong condition are complicated by the volatility of health insurance. Individuals with type 1 diabetes mellitus face these challenges daily. Treatment needs persist despite changes in individual health insurance or health plan coverage, yet this costly and devastating disease does not discriminate economically. The demands for care are the same for the under- and uninsured as they are for the fully insured. As life expectancy lengthens for individuals with type 1 diabetes mellitus, a greater potential exists for significant variability in coverage. This article presents a review and analysis of health insurance issues among adults 18-64 years old and extrapolates the consequences for those in the United States (US) with type 1 diabetes mellitus. Comparisons are made with the French health care system, ranked 1st by the World Health Organization in 2000.

Diabetes Mellitus, Type 1↗

PubMed2006

Gender differences in the management of risk factors for cardiovascular disease: the importance of insurance status.

Despite cardiovascular disease (CVD) being the leading killer of both sexes in the US, there are indications that men and women have different experiences in the health system with prevention and treatment practices. Beyond largely descriptive findings, little research exists that addresses how men and women may differ in their response to certain key influences on CVD health services utilization. This paper examines gender differentials in the effect of insurance coverage on CVD preventive health services in the US. An economics framework is used to model individual demand for preventive services as a function of insurance status, while controlling for a comprehensive set of explanatory variables. The services analyzed include cholesterol and blood pressure screening, pharmaceutical use for hypertension and lipid disorders, and CVD-related physician visits. Both general and high-risk samples are evaluated. The results show that while a lack of insurance is associated with lower rates of utilization in both men and women, there are no observed gender differences in insurance-effects for recommended intervals of risk factor screening in the general population. However, for individuals with previously diagnosed heart disease or stroke, a lack of coverage is more strongly associated with lower rates of screening, pharmaceutical management, and physician contact in women than men. Potential reasons for these findings are discussed and policy implications are noted.

Cardiovascular Diseases↗

PubMed2006

Health insurance benefit packages prioritized by low-income clients in India: three criteria to estimate effectiveness of choice.

We applied a decision tool for rationing choices, with a predetermined budget of about 11 US dollars per household per year, to identify priorities of poor people regarding health insurance benefits in India in late 2005. A total of 302 individuals, organized in 24 groups, participated from a number of villages and neighborhoods of towns in Karnataka and Maharashtra. Many individuals were illiterate, innumerate and without insurance experience. Involving clients in insurance package design is based on an implied assumption that people can make judicious rationing decisions. Judiciousness was assessed by examining the association between the frequency of choosing a package and its perceived effectiveness. Perceived effectiveness was evaluated by comparing respondents' choices to the costs registered in 2049 illness episodes among a comparable cohort, using three criteria: 'reimbursement' (reimbursement regardless of the absolute level of expenditure), 'fairness' (higher reimbursement rate for higher expenses) and 'catastrophic coverage' (insurance for catastrophic exposure). The most frequently chosen packages scored highly on all three criteria; thus, rationing choices were confirmed as judicious. Fully 88.4% of the respondents selected at least three of the following benefits: outpatient, inpatient, drugs and tests, with a clear preference to cover high aggregate costs regardless of their probability. The results show that involving prospective clients in benefit package design can be done without compromising the judiciousness of rationing choices, even with people who have low education, low-income and no previous experience in similar exercises.

Choice Behavior↗

PubMed2003

Does insurance coverage decrease the risk for multiple births associated with assisted reproductive technology?

OBJECTIVE: To determine whether insurance coverage for ART is associated with transfer of fewer embryos and decreased risk of multiple births. DESIGN: Retrospective cohort study of a population-based sample of IVF procedures performed in six U.S. states during 1998. SETTING: Three states with mandated insurance coverage (Illinois, Massachusetts, and Rhode Island) and three states without coverage (Indiana, Michigan, and New Jersey). PARTICIPANT(S): Seven thousand, five hundred sixty-one IVF transfer procedures in patients < or = 35 years of age. MAIN OUTCOME MEASURE(S): Number of embryos transferred, multiple-birth rate, triplet or higher order birth rate, and triplet or higher order gestation rate. RESULT(S): A smaller proportion of procedures included transfer of three or more embryos in Massachusetts (64%) and Rhode Island (74%) than in the noninsurance states (82%). The multiple-birth rate in Massachusetts (38%) was less than in the noninsurance states (43%). The insurance states all had protective odds ratios for triplet or higher order births, but only the odds ratio (0.2) for Massachusetts was significant. This decreased risk in Massachusetts resulted from several factors, including a smaller proportion of patients with three or more embryos transferred, lower implantation rates when three or more embryos were transferred, and greater rates of fetal loss among triplet or higher order gestations. CONCLUSION(S): Insurance appears to affect embryo transfer practices. Whether this translates into decreased multiple birth risk is less clear.

Adult↗

PubMed2001

Health insurance and female labor supply in Taiwan.

We examine whether the availability of subsidized health insurance to the non-working population in Taiwan affected the labor force participation of married women. Our empirical identification exploits the fact that such insurance was first made available to wives of government employees, before being made universally available in Taiwan in 1995. We find that the availability of insurance for non-workers was associated with a 4 percentage point decline in labor force participation among married women, with larger declines among women from low income households. Countries considering universal health insurance as in Taiwan should anticipate similar declines in labor force participation.

Employment↗

PubMed1999

The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes.

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.

Bangladesh↗

PubMed1999

Regional variation in Russian medical insurance: lessons from Moscow and Nizhny Novgorod.

The implementation of Russia's 1993 legislation on obligatory medical insurance has been characterized by wide regional variation. Two areas in particular illustrate this phenomenon: for the last five years Moscow has enjoyed a sophisticated, well-developed insurance system, while the Nizhny Novgorod region has only recently taken the most rudimentary steps toward implementation of the law. Despite their radically differing approaches to the market-based insurance reforms, however, Moscow and Nizhny Novgorod continue to enjoy roughly the same quality of available health care services, at similar costs to consumers. They also suffer some of the same continued systemic defects inherited from the Soviet era. A comparison of the two regions demonstrates that, while reform of the Soviet health care system was desperately needed, the Russian version of obligatory medical insurance has not proved to be the panacea its architects intended. In fact, even its original pioneers are now moving forward with new schemes to correct some of its deficiencies.

Adult↗

PubMed1997

Review article: insurance risks for patients with ulcerative colitis or Crohn's disease.

Prospective population-based studies have allowed a re-evaluation of the risks of insuring patients with ulcerative colitis or Crohn's disease. Life expectancy, the risk of cancer and working capacity are very much better than previously recognised and are normal for many patients. Three population-based studies in ulcerative colitis have shown a mortality similar to or slightly less than the general population except in the first year after diagnosis, whilst two have shown a slightly higher mortality (standardized mortality ratio, SMR = 1.4), except for those with proctitis. In Crohn's disease, two population-based studies have also shown an increased mortality (SMR = 1.4), which is similar to that of unskilled manual labourers (SMR = 1.43) from all causes of death. Three other studies have shown no increase in overall mortality, except in the first 5 years after diagnosis, in those with proximal small intestinal disease and in some patients needing multiple operations. Insurance risks should be evaluated on an individual basis, after details of the extent and pattern of disease have been obtained. Although the 'standard life' in insurance terms differs from that of the general population, because people who seek life assurance are self-selected from a more affluent section of society, many patients can be identified who have a particularly good prognosis. These include patients with ulcerative proctitis, those with left-sided colitis in extended remission (> 12 months), and patients more than 30 years old with localized ileal or ileocaecal Crohn's disease that has responded to treatment. From the published data, it is difficult to justify increasing the insurance premium in such patients.

Activities of Daily Living↗

PubMed2002

Insurance coverage and outcomes of in vitro fertilization.

BACKGROUND: Although most insurance companies in the United States do not cover in vitro fertilization, a few states mandate such coverage. METHODS: We used 1998 data reported to the Centers for Disease Control and Prevention by 360 fertility clinics in the United States and 2000 U.S. Census data to determine utilization and outcomes of in vitro fertilization services according to the status of insurance coverage. RESULTS: Of the states in which in vitro fertilization services were available, 3 states (31 clinics) required complete insurance coverage, 5 states (27 clinics) required partial coverage, and 37 states plus Puerto Rico and the District of Columbia (302 clinics) required no coverage. Clinics in states that required complete coverage performed more in vitro fertilization cycles than clinics in states that required partial or no coverage (3.35 vs. 1.46 and 1.21 transfers per 1000 women of reproductive age, respectively; P<0.001) and more transfers of frozen embryos (0.43 vs. 0.30 and 0.20 per 1000 women of reproductive age, respectively; P<0.001). The percentage of cycles that resulted in live births was higher in states that did not require any coverage than in states that required partial or complete coverage (25.7 percent vs. 22.2 percent and 22.7 percent, respectively; P<0.001), but the percentage of pregnancies with three or more fetuses was also higher (11.2 percent vs. 8.9 percent and 9.7 percent, respectively; P=0.007). The number of fresh embryos transferred per cycle was lower in states that required complete coverage than in states that required partial or no coverage (P=0.001 and P<0.001, respectively). CONCLUSIONS: State-mandated insurance coverage for in vitro fertilization services is associated with increased utilization of these services but with decreases in the number of embryos transferred per cycle, the percentage of cycles resulting in pregnancy, and the percentage of pregnancies with three or more fetuses.

Ambulatory Care Facilities↗

PubMed2003

Agreement between insurance claim and self-reported hospital and emergency room utilization data among persons with diabetes.

As part of a retrospective evaluation of a diabetes management program, the agreement between self-reported and insurance claim data on hospitalization and emergency room utilization was examined. Data agreement on hospitalization or emergency room visits between the two collection modes was evaluated through the use of simple agreement proportions and the kappa agreement statistic. A total of 1,230 participant responses were studied. The proportions of patients with hospitalization or emergency room visits were indistinguishable between the self-reported and medical claims data, and kappa statistics also indicated good-to-excellent agreement between data sets. The percentages of participants whose self-reported hospitalization and emergency room utilization exactly matched data derived from insurance claims were high (89.1% and 87.2%, respectively). Furthermore, the kappa statistics of agreement for the number of hospitalizations (0.6366) and emergency room visits (0.5390) indicate good agreement between self-reported and insurance claim data. The results of this study suggest either self-reported or insurance claims data can be used to evaluate the impact of health care interventions on hospital or emergency room utilization.

Aged↗

PubMed1998

Private health insurance coverage and disability among older Americans.

OBJECTIVES: This study examines the relationship between the lack of private supplemental health insurance coverage and the development of disability among adults aged 65 and older. METHODS: Data are from the baseline and six follow-up waves of the Duke Established Populations for Epidemiologic Studies of the Elderly survey (N = 4,000). Discrete-time hazard models were used to estimate the impact of insurance coverage and other risk factors on the incidence of disability among those unimpaired at baseline. RESULTS: Controlling for education, income, and other potential confounders, the odds of developing disability were 35-49% higher among those without private coverage. Insurance coverage also statistically explained part of the increased risk of disability among low-income persons. DISCUSSION: The results indicate that changes in health insurance coverage as well as in individual behaviors may be needed to reduce disability generally and disability among the socioeconomically disadvantaged, in particular.

Aged↗

PubMed2005

The relationship of insurance status, hospital ownership, and teaching status with interhospital transfers in California in 2000.

PURPOSE: Public hospitals and academic medical centers may admit more poorly insured transfer patients than do other institutions. The authors investigated the relationship of patient insurance status, hospital ownership, and hospital teaching status with interhospital transfers in California. METHOD: In 2003, data were derived from the hospital discharge abstract database for the year 2000 from the California Office of Statewide Health Planning and Development. Hospitals were categorized by ownership and teaching status; patients were categorized as being "good" or "poor" payers depending on the level of expected insurance reimbursement. Descriptive and multivariate analyses were used to assess the number of poor payer transfers admitted by each hospital group. RESULTS: In 2000, there were 58,509 transfer and 2,320,479 direct admissions. All hospital groups admitted a higher percentage of good payer than poor payer transfer patients (85% vs. 15% respectively for all groups combined). Adjusted for total number of admissions and teaching status, the number of poor payer transfer patients admitted to county-owned and University of California hospitals was significantly higher than the statewide average (both p values < .001), while the number admitted to independent teaching hospitals was significantly lower than the statewide average (p < .001). The number of poor payer transfer patients admitted to independent teaching hospitals more closely resembled that of for-profit hospitals than that of University of California teaching hospitals. CONCLUSIONS: In 2000, the likelihood of a hospital admitting a transfer patient appears to have been affected by both the patient's insurance status and the hospital's ownership. In general, good payer patients were more likely to be transferred than were poor payer patients, with poor payer transfer patients more likely to be admitted to publicly owned hospitals.

California↗

PubMedDate not supplied

Patients' fear of genetic discrimination by health insurers: the impact of legal protections.

PURPOSE: The impact of laws restricting health insurers' use of genetic information has been assessed from two main vantage points: (1) whether they reduce the extent of genetic discrimination and (2) whether they reduce the fear of discrimination and the resulting deterrence to undergo genetic testing. A previous report from this study concluded that there are almost no well-documented cases of health insurers either asking for or using presymptomatic genetic test results in their underwriting decisions, either before or after these laws, or in states with or without these laws. This report evaluates the perceptions and the resulting behavior by patients and clinicians. METHODS: A comparative case study analysis was performed in seven states with different laws respecting health insurers' use of genetic information (no law, new prohibition, mature prohibition). Semistructured interviews were conducted in person with five patient advocates and with 30 experienced genetic counselors or medical geneticists, most of whom deal with adult-onset disorders. Also, multiple informed consent forms and patient information brochures were collected and analyzed using qualitative methods. RESULTS: Patients' and clinicians' fear of genetic discrimination greatly exceeds reality, at least for health insurance. It is uncertain how much this fear actually deters genetic testing. The greatest deterrence is to those who do not want to submit the costs of testing for reimbursement and who cannot afford to pay for testing. There appears to be little deterrence for tests that are more easily affordable or when the need for the information is much greater. Fear of discrimination plays virtually no role in testing decisions in pediatric or prenatal situations, but is significant for adult-onset genetic conditions. CONCLUSION: Existing laws have not greatly reduced the fear of discrimination. This may be due, in part, to clinicians' lack of confidence that these laws can prevent discrimination until there are test cases of actual enforcement. Ironically, there may be so little actual discrimination that it may not be possible to initiate good test cases.

Ethics, Medical↗

PubMed2007

Evaluation of race and insurance status as predictors of undergoing laparoscopic appendectomy in children.

OBJECTIVE: The objective of this study was to determine the relationship of race and socioeconomic factors and the method used for appendectomies in children (open vs. laparoscopic). SUMMARY BACKGROUND DATA: Previous studies have shown racial and insurance-related differences associated with the management of appendicitis in adults. It is not known whether these differences are observed in children. METHODS: Children (<15 years) undergoing appendectomy from 1996 to 2002 were identified in the Nationwide Inpatient Sample. Severity of appendicitis and underlying chronic illnesses were determined by ICD-9 codes. Hospital characteristics evaluated included teaching status and location, children's hospital status, and volume of appendectomies. Hierarchical unadjusted and risk-adjusted logistic regression analyses were performed. RESULTS: Among 72,189 children undergoing an appendectomy for appendicitis, 11,714 (16%) underwent a laparoscopic appendectomy. Multivariate analysis showed that whites were more likely to undergo a laparoscopic appendectomy than blacks (odds ratio, 1.14; 95% CI, 1.03-1.25, P = 0.01) but not other races. A significant interaction between payer source and children's hospital designation was observed, with the odds of children with private insurance undergoing laparoscopic appendectomy being significantly higher than those without private insurance at nonchildren's hospitals but not at children's hospitals. CONCLUSIONS: There are significant racial and insurance-related differences in use of laparoscopic appendectomy in children that are most evident at nonchildren's hospitals. These findings provide evidence that factors at hospitals dedicated to children may lead to better access to new technologies.

Adolescent↗

PubMed2006

Natural disasters and the challenge of extreme events: risk management from an insurance perspective.

Loss statistics for natural disasters demonstrate, also after correction for inflation, a dramatic increase of the loss burden since 1950. This increase is driven by a concentration of population and values in urban areas, the development of highly exposed coastal and valley regions, the complexity of modern societies and technologies and probably, also by the beginning consequences of global warming. This process will continue unless remedial action will be taken. Managing the risk from natural disasters starts with identification of the hazards. The next step is the evaluation of the risk, where risk is a function of hazard, exposed values or human lives and the vulnerability of the exposed objects. Probabilistic computer models have been developed for the proper assessment of risks since the late 1980s. The final steps are controlling and financing future losses. Natural disaster insurance plays a key role in this context, but also private parties and governments have to share a part of the risk. A main responsibility of governments is to formulate regulations for building construction and land use. The insurance sector and the state have to act together in order to create incentives for building and business owners to take loss prevention measures. A further challenge for the insurance sector is to transfer a portion of the risk to the capital markets, and to serve better the needs of the poor. Catastrophe bonds and microinsurance are the answer to such challenges. The mechanisms described above have been developed to cope with well-known disasters like earthquakes, windstorms and floods. They can be applied, in principle, also to less well investigated and less frequent extreme disasters: submarine slides, great volcanic eruptions, meteorite impacts and tsunamis which may arise from all these hazards. But there is an urgent need to improve the state of knowledge on these more exotic hazards in order to reduce the high uncertainty in actual risk evaluation to an acceptable level. Due to the rarity of such extreme events, specific risk prevention measures are hardly justified with exception of attempts to divert earth-orbit crossing meteorites from their dangerous path. For the industry it is particularly important to achieve full transparency as regards covered and non-covered risks and to define in a systematic manner the limits of insurability for super-disasters.

Disaster Planning↗

PubMed2006

Toward a more reliable federal survey for tracking health insurance coverage and access.

OBJECTIVE: Examination of the extent to which federal surveys provide the data needed to estimate the coverage/cost impacts of policy alternatives to address the problem of uninsurance. DATA SOURCES/STUDY SETTING: Assessment of the major federal household surveys that regularly provide information on health insurance and access to care based on an examination of each survey instrument and related survey documentation and the methodological literature. STUDY DESIGN: Identification of the data needed to address key policy questions on insurance coverage, assessment of how well existing surveys meet this need, definition of the critical elements of an ideal survey, and examination of the potential for building on existing surveys. DATA COLLECTION/EXTRACTION METHODS: Collection and critical assessment of pertinent survey documentation and methodological studies. PRINCIPAL FINDINGS: While all the federal surveys examined provide valuable information, the information available to guide key policy decisions still has major gaps. Issues include measurement of insurance coverage and critical content gaps, inadequate sample sizes to support precise state and substate estimates, considerable delays between data collection and availability, and concerns about response rates and item nonresponse. Our assessment is that the Current Population Survey (CPS) and the National Health Interview Survey could be most readily modified to address these issues. CONCLUSIONS: The vast resources devoted to health care and the magnitude of the uninsurance problem make it critical that we have a reliable source for tracking health care and coverage at the national and state levels and for major local areas. It is plausible that this could be more cost effectively done by building on existing surveys than by designing and fielding a new one, but further research is needed to make a definitive judgment. At a minimum, the health insurance information collected on the CPS should be revised to address existing measurement problems.

Data Collection↗