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PubMed1992

Diabetes patient education programs. Quality and reimbursement.

To inform health-care providers and third-party carriers of the national quality assurance systems in place for diabetes education programs and the health professionals who provide education services and to indicate the need for consistent reimbursement of essential outpatient diabetes education services. The components of an independent quality assurance mechanism were examined and a survey was conducted to determine reimbursement coverage of ADA recognized programs. A national program to evaluate whether programs meet national standards is in place. Many ADA approved programs were reimbursed and official recognition helped in the process of attaining reimbursement. Insurance coverage decisions made by third-party carriers, however, were inconsistent and largely unpredictable. Outpatient education and follow-up for diabetes is an integral component of care. These services need to be more clearly defined to enable appropriate coding and coverage decisions to be made by third-party payors.

Blue Cross Blue Shield Insurance Plans↗
PubMedDate not supplied

Health insurance trends are contributing to growing health care inequality.

A health plan chief medical officer comments on several trends underscoring the conclusion reached by Robert Hurley and colleagues that disparities in health care are widening. Growing use of new technology is driving up premiums, increasing the ranks of the uninsured and underinsured. Cost shifting by hospitals because of inadequate public program reimbursements drives premiums even higher. Although disparities in health care can never be eliminated, access to essential services can-and must-be made universal. That goal can be accomplished if insurance coverage is mandated and responsibility for its cost is spread broadly.

Health Services Accessibility↗
PubMed2005

Inequality decomposition and geographic targeting with applications to China and Vietnam.

How far are income-related inequalities in the health sector due to gaps between poor and less poor areas, rather than due to differences between poor and less poor people within areas? This note sets out a method for answering this question, and illustrates it with two empirical examples. The disproportionate accrual of health subsidies to Vietnam's better-off is found to be largely due to the fact that richer provinces have larger per capita subsidies, while pro-rich inequalities in health insurance coverage in rural China are found to be largely due to the fact that better-off villages have been more successful at preventing the collapse of their insurance schemes.

Catchment Area, Health↗
PubMed1980

Children's utilization of medical care.

Children's utilization of medical care remains unequal even after the implementation of policies such as Medicaid and Neighborhood Health Centers. Children in lower-income areas or from larger families are less likely to see a provider over a 1-year period. Sharper differences are found when one analyzes the type of providers used. Here income, race, marital status, family type, type of insurance coverage and community characteristics are all associated with type of provider used. Children to whom more resources are available (in terms of income, parents' time, community income and insurance) appear more likely than other children to use what is traditionally termed higher-quality care. The fact that the data used are from a community with generous Medicaid benefits and a university-sponsored pediatric project suggests that inequalities in utilization continue to exist even after substantial government intervention.

Adolescent↗
PubMed2005

Barriers to colorectal cancer screening: a comparison of reports from primary care physicians and average-risk adults.

BACKGROUND: Barriers to colorectal cancer (CRC) screening are not well understood. OBJECTIVES: We sought to compare barriers to CRC screening reported by primary care physicians (PCPs) and by average-risk adults, and to examine characteristics of average-risk adults who identified lack of provider recommendation as a major barrier to CRC screening. RESEARCH DESIGN: This was a comparative study using data from the 1999-2000 Survey of Colorectal Cancer Screening Practices and the 2000 National Health Interview Survey (NHIS). SUBJECTS: We recruited nationally representative samples of PCPs (n= 1235) from the SCCSP and average-risk adults (n = 6497) from the NHIS. MEASURES: We measured barriers to CRC screening identified by PCPs and average-risk adults who were not current with screening. RESULTS: Both PCPs and average-risk adults identified lack of patient awareness and physician recommendation as key barriers to obtaining CRC screening. PCPs also frequently cited patient embarrassment/anxiety about testing and test cost/lack of insurance coverage, but few adults identified these as major barriers. Of adults not current with testing, those who had visited a doctor in the past year or had health insurance were more likely to report lack of physician recommendation as the main reason they were not up-to-date compared with their counterparts with no doctor visit or health insurance. Only 10% of adults not current with testing and who had a doctor visit in the past year reported receiving a screening recommendation. CONCLUSIONS: A need exists for continued efforts to educate the public about CRC and the important role of screening in preventing this disease. Practice-based strategies to systematically prompt health care providers to discuss CRC screening with eligible patients also are required.

Aged↗
PubMed2000

The impact of managed care on substance abuse treatment: a report of the American Society of Addiction Medicine.

This report examines the impact of managed care (MC) and related developments on substance abuse treatment, and evaluates how it has been associated with a decline in the availability of proper treatment for many addicted patients. A trend toward carve-out and for-profit MC organizations is associated with lower financial incentives for intensive treatment than in earlier staff-model and not-for-profit MC organizations. The value of substance abuse insurance coverage has declined by 75% between 1988 and 1998 for employees of mid-to large-size companies, compared with only an 11.5% decline for general health insurance. The shift towards MC has also been associated with a drastic reduction in frequency and duration of inpatient hospitalization, and there is no clear evidence that this reduction has been offset by a corresponding increase in outpatient support. In a survey of physicians treating addiction, the majority felt that MC had a negative impact on detoxification and rehabilitation, and on their ethical practice of addiction medicine.

Cost-Benefit Analysis↗
PubMed2000

Medicaid and indigent care issue brief: Medicaid: access to health services.

Medicaid provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. According to the U.S. Census Bureau, Medicaid provided health insurance for approximately 14 million people in 1998. In that same year, however, 11.2 million poor people had no health insurance at all. In order to reduce the number of people without health insurance, states have expanded or clarified their eligibility standards to allow more people to enroll in Medicaid.

Forecasting↗
PubMed2002

Health insurance and discrimination concerns and BRCA1/2 testing in a clinic population.

The discovery of the breast cancer genes BRCA1 and BRCA2 has afforded those who seek breast and ovarian cancer risk counseling the option of genetic testing. Concerns about cost, confidentiality, and the potential for discrimination, however, may prevent some women from pursuing genetic testing. To determine the impact of these concerns on BRCA testing, we studied a cohort of 384 patients presenting de novo to a Breast and Ovarian Cancer Risk Evaluation Program, between January 6, 1997 and March 13, 2000. Of the 184 individuals who were themselves primary candidates for testing, 106 (58%) underwent BRCA1/2 sequencing. Of the 78 eligible patients who declined testing, 48 cited concerns about cost and insurance discrimination as their reason. On the basis of the number of positive results ascertained in the tested group, we estimate that approximately half of patients declining testing because of insurance coverage concerns would be positive for a BRCA mutation. We were unable to document any experiences of test result-based discrimination, although there were other negative insurance-related experiences. We conclude that in a high prior-risk clinic population, approximately one-quarter of patients eligible for BRCA testing may decline because of concerns about cost, confidentiality, and discrimination. Our research provides evidence that these fears may be discrepant with the actual experiences of patients in high-risk clinics.

Adult↗
PubMedDate not supplied

Why are employers prodding health-care providers to adopt new management systems?: reducing the cost of health care.

Increasingly concerned about the escalating costs of health-care insurance coverage, the quality of health-care delivery, and the escalating costs of delivering clinical services, employers are taking action. They are prodding health-care providers and insurers to adopt breakthrough management systems aimed at reducing costs related to poorly performing services and processes--and at the same time improving clinical outcomes. Doing this will require all members of the health-care value chain to work together to improve each and every process and procedure, whether clinical or administrative. This development presents formidable challenges to all health-care providers, insurers, employees, and patients.

Cost Control↗
PubMed2002

The influence of patient characteristics on ratings of managed behavioral health care.

Despite current emphasis on consumer-based performance measures, little is known about factors that influence consumer ratings of behavioral health care. This study examines the influence of patient characteristics, health care use, and insurance coverage on patients' ratings of their managed behavioral health care in both commercial and public plans. Older and healthier patients rated their behavioral health care and health plan more highly than did other patients. Patients with less education and those whose insurance paid all costs of care gave consistently higher plan ratings. Women and frequent users enrolled in commercial plans gave more positive care ratings. After adjusting for enrollee characteristics and coverage, there were no differences between ratings of patients in commercial and public plans. These results are consistent with other research that illustrates the importance of adjusting health care ratings for patient characteristics when comparing plans.

Adolescent↗
PubMed1999

Factors influencing enrollment in clinical trials for cancer treatment.

BACKGROUND: Recruitment of cancer patients to clinical trials is an ongoing challenge. In this study, we assess factors that may influence enrollment in clinical trials for cancer treatment. METHODS: Between June 1997 and January 1998, data were collected on all adult cancer patients evaluated for enrollment in National Cancer Institute-sponsored clinical trials at 15 medical facilities in the southeastern United States. RESULTS: More than 2,300 cancer patients were evaluated; 7% were enrolled. Neither patient sex nor race predicted enrollment. Patients with fee-for-service coverage were more than twice as likely to be enrolled compared with patients with other types of coverage, including managed care. Patient refusal accounted for the nonenrollment of nearly 40% of those clinically eligible. CONCLUSIONS: Although multiple factors influence enrollment in clinical trials for cancer treatment, results suggest that insurance coverage plays a role. Patient refusal, a substantial reason for nonenrollment, points to the need for continued efforts to educate physicians and the public in the value of clinical trials.

Adult↗
PubMed1999

Ethical aspects of genetic testing.

No research study or significant medical treatment can be done involving patients without their informed consent. In workplaces and environmental settings, individuals are often exposed to mutagenic or carcinogenic substances, usually without their knowledge, and not with their informed consent. Such exposures can lead to evermore easily documentable genetic changes. As genetic testing becomes more widespread, there are significant ethical implications regarding employment, insurance coverage, and confidentiality regarding medical information. With an increased ability to detect genetic changes, or 'unfavorable' genetic polymorphisms, this information should not be used to deny employment or increase insurance rates. Rather, such information should be used to increasingly provide appropriately safe workplaces, and place workers in less hazardous settings.

Confidentiality↗
PubMed1999

Securing insurance protection against fraud and abuse liability.

Healthcare organizations concerned about corporate compliance need to review securing appropriate insurance coverage as part of their corporate compliance program. Provider organizations often mistakenly expect that their directors and officers liability (D&O), malpractice, or standard errors and omissions (E&O) insurance policies will cover the cost of Medicare fraud and abuse fines. The insurance industry has developed a specific billing E&O insurance product to cover providers that run afoul of government fraud and abuse statutes.

Fees and Charges↗
PubMedDate not supplied

Programs that mitigate the effects of poverty on children.

This article reviews six federally funded in-kind public assistance programs that are intended to mitigate the effects of poverty on low-income children by providing access to basic human necessities such as food, housing, education, and health care. The evidence suggests that, while each program can be improved, these programs do achieve their basic objectives. In general, food stamps, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and school nutrition programs are successful at providing food assistance to low-income children, starting with the prenatal period and continuing through the school years. The Food Stamp Program provides food assistance nationwide to all households solely on the basis of financial need and is central to the food assistance safety net for low-income children. The WIC program has helped reduce the prevalence of iron-deficiency anemia in infants and children and has increased intakes of certain targeted nutrients for program participants. The school nutrition programs provide free or low-cost meals that satisfy the dietary goals of lunches and breakfasts to most school-age children. The Medicaid program has extended health insurance coverage to millions of low-income children. However, many children remain uninsured, and children enrolled in Medicaid do not have the same access to medical care as privately insured children. Relatively little is known about the effects of Medicaid on children's health status. For Head Start, empirical evidence suggests that participating children show enhanced cognitive, social, and physical development in the short term. Studies of the longer-term impacts of Head Start are inconclusive. Although housing assistance improves housing quality and reduces housing costs for recipients, there is a large unmet need for acceptable, affordable housing among poor families. Important gaps remain in our knowledge of the effects of these programs on the well-being of children. Questions regarding a program's effects over time on health and developmental outcomes particularly need more study.

Adolescent↗
PubMed2003

Health insurance and child mortality in Costa Rica.

This study uses a natural experiment approach to evaluate the effect of health insurance on infant and child mortality. In the 1970s Costa Rica adopted national health insurance, which expanded children's insurance coverage from 42 percent in 1973 to 73 percent by 1984. Aggregate infant and child mortality rates dropped rapidly during this period, but this trend had begun prior to the insurance expansion, and may be related to other changes during this period. We use county-level vital statistics and census data to isolate the causal insurance effect on mortality using county fixed effects models. We find that insurance increases are strongly related to mortality decreases at the county level before controlling for other time-varying factors. However, after controlling for changes in other correlated maternal, household, and community characteristics, fixed effects models indicate that the insurance expansion could have explained only a small portion of the mortality change. These results question the proposition that health insurance can lead to large improvements in infant and child mortality, and that expanding insurance to the poor can substantially narrow socioeconomic differentials in mortality.

Cause of Death↗
PubMed1994

Immunization status of 2-year-olds in middle/upper- and lower-income populations: a community survey.

Immunization rates of preschool children in the United States are well below recommended levels. Whereas low-income and minority groups have been targeted as at risk for inadequate immunization, the assumption is generally made that middle/upper-income children are adequately immunized through the private sector. We conducted a community-based survey that refutes this assumption. Only 31% of the 302 parents surveyed reported full immunization of their 2-year-olds. No significant differences were found in the immunization rates for middle/upper-income (34% immunized) versus lower-income children (28% immunized). Failure to receive the 18-month doses of DTP and polio was the most frequent cause of inadequate coverage for both groups. Barriers to immunization reported by middle/upper- and lower-income parents were similar, with over one-third of the parents identifying cost and lack of insurance coverage as problems. Additional barriers related to methods of operations of providers. Findings have immediate implications for public health nurses in terms of assessing coverage of their own preschool populations and introducing corrective actions to improve levels of immunization.

Adult↗
PubMed2005

Access to ambulatory medical and long-term care services among elderly Medicare and Medicaid beneficiaries: organizational, financial, and geographic barriers.

The comprehensive insurance coverage afforded low-income elders with both Medicare and Medicaid coverage (dual enrollees) has substantially reduced financial barriers to care. However, other studies show reduced and less appropriate utilization patterns among dual enrollees compared to Medicare beneficiaries with private supplemental insurance, suggesting access barriers remain. This study found that 59 percent of elderly dual enrollees needed an ambulatory medical or long-term care service in a 1-year period. One third of these individuals experienced barriers to access; organizational and geographic barriers were more prevalent than financial barriers. African American race, trouble paying basic living expenses, fair or poor health status, and an unfavorable assessment of physician information giving were significantly associated with an increased likelihood of organizational and geographic access barriers among elderly dual enrollees.

Black or African American↗
PubMedDate not supplied

The ABCs of HIPCs (health insurance purchasing cooperatives).

HIPCs, or health care purchasing cooperatives, are attracting widespread interest as a key element of the managed competition approach to health reform. HIPCs perform several useful roles for individuals and small employers unable to obtain health insurance coverage in the current system by spreading risk more evenly and purchasing coverage in a given region or market area. While HIPCs are generally associated with managed competition, they are also compatible with reform strategies that require employers to pay for coverage or those that provide incentives for expanded coverage.

Costs and Cost Analysis↗