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Hospitals looking to gain and maintain strong revenue cycle performance should avoid common mistakes, such as not verifying insurance coverage in advance and placing sole responsibility for correct documentation on physicians.
OBJECTIVES: The timing of cesarean sections is studied to examine how physician convenience and financial incentives play a role in the decision to perform a cesarean section. METHODS: Using birth certificate and hospital financial data from California, the likelihood of cesarean sections being performed at particular times of day was examined, controlling for maternal characteristics and the mother's insurance coverage. Two diagnoses associated with cesarean sections are examined separately: fetal distress and prolonged/dysfunctional labor. The hypotheses are that cesarean sections performed for physician convenience are more likely to occur in the evening hours and that type of insurance will affect the incentive to perform cesarean sections to obtain leisure. RESULTS: The probability of cesarean sections for patients insured by a group-model HMO is more stable during the course of a day than that for patients insured by all other insurance plans. Group-model HMO patients with previous cesarean sections are less likely to have cesarean sections in the evening hours and are less likely to be diagnosed with fetal distress or prolonged/dysfunctional labor. CONCLUSIONS: The differences in cesarean sections and diagnosis rates between group-model HMO patients and other patients could arise from several mechanisms: group-model HMOs provide consistent financial incentives to their staff, they may be better able to guide physician practice, and they might provide staff support to physicians so there is less leisure-based incentive to perform cesarean sections. In contrast, nongroup-model HMOs do not appear to reduce the incentive of physicians to maximize leisure relative to traditional insurance.
Studies of the demand for health insurance by elderly persons often inadequately address the distinctions between those who receive insurance through a former employer and those who purchase insurance on their own. The failure to distinguish these two modes of supplementing Medicare can lead to an inability to identify the effects of important independent variables. Using data from the Survey of Income and Program Participation this paper examines the demand for employer provided health insurance among retired pensioners using a bivariate probit model with partial observability and compares these results to other models of insurance demand among elderly persons. The results indicate that unobserved factors reducing the probability of being offered employer provided insurance are associated with increased acceptance. A comparison of the employer provided results with results from other models of the demand for privately purchased insurance indicates that different independent variables may determine the probability of having these types of insurance. Previous studies of insurance that have not distinguished between these two types of insurance may not provide reliable estimates of the relationship between independent variables and the probability of insurance coverage.
Outcomes research often requires estimating the impact of a binary treatment on a binary outcome in a non-randomized setting, such as the effect of taking a drug on mortality. The data often come from self-selected samples, leading to a spurious correlation between the treatment and outcome when standard binary dependent variable techniques, like logit or probit, are used. Intuition suggests that a two-step procedure (analogous to two-stage least squares) might be sufficient to deal with this problem if variables are available that are correlated with the treatment choice but not the outcome. This paper demonstrates the limitations of such a two-step procedure. We show that such estimators will not generally be consistent. We conduct a Monte Carlo exercise to compare the performance of the two-step probit estimator, the two-stage least squares linear probability model estimator, and the multivariate probit. The results from this exercise argue in favour of using the multivariate probit rather than the two-step or linear probability model estimators, especially when there is more than one treatment, when the average probability of the dependent variable is close to 0 or 1, or when the data generating process is not normal. We demonstrate how these different methods perform in an empirical example examining the effect of private and public insurance coverage on the mortality of HIV+ patients.
The study examined the feasibility of implementing treatment recommendations derived from the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in an urban addiction treatment program that offered a continuum of levels of care (LOC). A cohort of 281 applicants for alcoholism treatment were evaluated and the reasons for observed differences ("mismatches") between recommended and actual LOC placements were determined. Overall, 88% of the applicants entered treatment, and 72% of these were matched to LOC vs. 28% who were mismatched. Presumptive overtreatment (59%) was more common than undertreatment (41%) among the mismatched patients. The reasons for overtreatment were availability of Medicaid coverage for inpatient rehabilitation (93%), referral sources' treatment philosophy of gradually "stepping down" from inpatient detoxification (59%), social pressures on patients (28%), and mandated treatment (8%). The reasons for presumptive undertreatment were work schedule conflicts (72%), patient reluctance (48%), insurance coverage (15%), and interference with family or personal responsibilities (9%). These results indicate multiple barriers that need to be overcome to enable full implementation of the ASAM Criteria in real world program settings, even when a continuum of care is available.
This DataWatch examines trends in health insurance coverage of children using recent data from the Current Population Survey. The results indicate that the number and proportion of children who were uninsured changed little between 1988 and 1992. However, substantial changes occurred in the composition of the insured population: The proportion of children covered by employer-based private insurance declined from 60.7 percent in 1988 to 56.2 percent in 1992, while the proportion of children covered by Medicaid increased from 15.6 percent to 21.6 percent over the same period. These results indicate that a fundamental shift is occurring in responsibility for insuring the nation's children--from the private sector to the public sector.
Debates on health policy at the national level often overlook categorically the 19 million working-age persons with disabilities. Although this heterogeneous population with significantly diverse health statuses has higher than average rates of health care utilization, it remains questionable whether the demographic subgroup sufficiently receives needed types of care. As such, particular targeted solutions in health services delivery are warranted to meet the special requirements of working-age disabled persons. At the same time, access to mainstream health care financing is crucial for a population already excluded frequently from private health insurance coverage.
A questionnaire was sent in 1988 to all sites conducting mammographic studies registered with the radiologic licensing division of the West Virginia State Department of Health Laboratory Services to determine the number of women served and the costs of the procedures. The number of sites, 61, appears excessive in view of the small number of women many of them screened during the course of a year and the high charges. Copies of the report on the questionnaire results were sent to agencies and other groups within the state to urge initiation of a more cost-effective system; however, four years later the number of units had increased substantially, and no coherent plan had been formulated. The report was helpful to members of the state legislature in their decision to mandate insurance coverage for women according to the American Cancer Society guidelines.
Life insurance industry access to genetic information is controversial. Consumer groups argue that access will increase discrimination in life insurance premiums and discourage individuals from undergoing genetic testing that may provide health benefits. Conversely, life insurers argue that without access to risk information available to individuals, they face substantial financial risk from adverse selection. Given this controversy, we conducted a retrospective cohort study to evaluate the impact of breast cancer risk information on life insurance purchasing, the impact of concerns about life insurance discrimination on use of BRCA1/2 testing, and the incidence of life insurance discrimination following participation in breast cancer risk assessment and BRCA1/2 testing. Study participants were 636 women who participated in genetic counseling and/or genetic testing at a University based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January 1995 and May 2000. Twenty-seven women (4%) had increased and six (1%) had decreased their life insurance since participation in breast cancer risk assessment. The decision to increase life insurance coverage was associated with predicted breast cancer risk (adjusted OR 1.03 for each 1% absolute increase in risk, 95% CI 1.01-1.10) and being found to carry a mutation in BRCA1/2 (OR 5.10, 95% CI 1.90-13.66). Concern about life insurance discrimination was inversely associated with the decision to undergo BRCA1/2 testing (RR 0.67, 95% CI 0.52-0.85). No respondent reported having life insurance denied or canceled. In this cohort of women, these results indicate that information about increased breast cancer risk is associated with increase in life insurance purchasing, raising the possibility of adverse selection. Although fear of insurance discrimination is associated with the decision not to undergo BRCA1/2 testing, there was no evidence of actual insurance discrimination from BRCA1/2 testing.
Mammography screening continues to be under-utilized, especially among women from lower socioeconomic groups. In order to determine whether having direct access to health care services has an effect on mammography use among low income women, we conducted a randomized trial of two alternative letter reminders among 1,717 women who were enrolled at two locations of a multi-site inner city health department in Detroit. All participants were 39(1/2) years of age and older and were due for a screening mammogram at randomization. A physician-directed reminder form was placed in each of the participant's medical records at the beginning of the study. In addition participants were randomized to receive either a letter directing them to visit their primary care physician, a letter directing them to contact the clinic directly to schedule a mammogram, or no letter. Study participants were predominantly African-American, two-thirds of whom were over age 50, and who had minimal health insurance coverage. During the intervention year, mammograms were completed by 179 out of 967 study women at site one (18.5%), and 90 out of 750 study women at site two (12%). A multivariate model controlling for the simultaneous effect of age, insurance type, visit history and past mammography use, showed no significant independent effect of either type of letter reminder on mammography completion during the study year. In conclusion, letters targeted at women due for screening mammograms did not have a beneficial effect on mammography utilization above and beyond that of a physician medical record reminder.
Regional differences in Sweden in the prevalence of disability pension with a psychiatric diagnosis are unexplained, in spite of the significant impact on the population's health, rehabilitation systems, and the health care system. The purpose of this study was to describe the pattern of disability pensions with a psychiatric diagnosis and to analyze the impact of age and gender. We examined the incidence rates in one urban and one semi-rural region and compared these to national rates. The study sample was drawn from employed persons between 16-64 years of age who, because of their sickness insurance coverage, would be eligible to access disability pensions should it be necessary. Analysis of annual incidences and standardized morbidity ratios were made for 1980, 1985, 1990, 1995, and 1998. Data on disability pension cases were collected from the National Social Insurance registers. In the urban region we found that the proportion of men and women clearly outnumbered the national average: approximately twice the number of persons between 16-64 years of age with a psychiatric diagnosis were receiving a disability pension. In the semi-rural region there were fewer men overall on disability pensions with psychiatric disorders, but in 1980, 1985, and 1995 women clearly outnumbered men. Access to psychiatric care, unemployment, alcohol dependence, and previous sickness absence are suggested as possible factors that might affect the rates of disability pension in different geographical settings.
The purpose of our study is to assess the extent of racial differences in the access to simultaneous pancreas-kidney (SPK) transplantation and evaluate the potential influence of socioeconomic factors on access to transplantation. We performed a retrospective analysis of the US Renal Data System and United Network for Organ Sharing data on all patients with end-stage renal disease (ESRD) due to diabetes mellitus from 1988 to 1996 (n = 562, 814), including all dialysis, wait list, and transplant patients. Racial differences in incidence, prevalence, insurance coverage, employment status, and transplantation rates were calculated. Caucasians had the highest prevalence of ESRD caused by type 1 diabetes (73%), followed by blacks (22%), Hispanics (3%), Native Americans (2%), and others (<1%). Both blacks and Native Americans increased their annual incidence of ESRD caused by insulin-dependent diabetes mellitus by 10% compared with only a 3.5% increase in Caucasians, whereas incidence rates increased annually by almost 8% for both blacks and Native Americans compared with a 3% increase for Caucasians. However, Caucasians received 92% of all SPK transplants, whereas all other racial groups combined received a disproportionate minority of the remaining transplants. Lack of private insurance and unemployment status were associated with annual changes in both incidence of ESRD caused by type 1 diabetes and SPK transplant rates. In conclusion, we observed striking racial disparities for access to SPK transplantation in the United States today, which may be related to employment status, access to private insurance, and subsequent health care. Our preliminary data support current efforts to encourage Medicare and Medicaid coverage for all patients requiring SPK transplantation regardless of racial or financial status.
America is undergoing a profound age shift in its demographic make-up with people 55 and over comprising an increasing proportion of the population. Marketers may need to increase their response rate to this shift, especially in refining the application of marketing theory and practice to older age consumers. To this end, a survey of older couple buying behavior for health insurance coverage is reported here. Results clarify evaluative criteria and the viability of multiple market segmentation for health care coverage among older consumers as couples. Commentary on the efficacy of present health coverage marketing programs is provided.
This study examined injuries among farmers and farm family treated at two rural Vermont hospitals. Most involved dairy farming and woodlot activities. Livestock accounted for 38% of injuries among dairy farmers. Other injuries involved a variety of events, including equipment repair and use, haying, chemicals and biologicals, falls, and contacts with fixed objects. Half of woodlot injuries involved chainsaws. On average, livestock-related injuries resulted in 21.5 days of disability for work during the first 6 months after injury, whereas those not involving livestock averaged 16.2 days of disability. On dairy farms 14% of farming injuries were to family members, and at least a third of all injuries to farm family members were work related. Insurance coverage for medical care was sparse for all rural persons treated for injury, especially for woodlot operators.
A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 +/- 2.2) than those who did (8.0 +/-2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.
In a random sample of Medicare beneficiaries, multiple logistic regression was used to examine clinical, sociodemographic, and insurance coverage risk factors for readmission within 60 days of discharge. The patients most likely to be readmitted were those with poor health status or with chronic diseases and those who had not had surgery. Age, marital status, living situation, and having insurance to supplement Medicare were not independently predictive of readmission risk. The dominant roles of health status, diagnosis, and surgery as predictors of readmission provide evidence that risk-adjusted readmission rates can be equitably used for quality of care studies.
INTRODUCTION: The purpose of this study was to investigate the predictors of self-rated health status for Texas adults using the current 2003 Behavioral Risk Factor Surveillance System data. Self-rated health is generally accepted as a valid measure of health status in population studies, and understanding its correlates may help public health professionals prioritize health-promotion and disease-prevention interventions. METHODS: The two research questions addressed by this study involved the predictors of self-rated health: 1) "Do demographic characteristics, health care coverage, leisure-time physical activity, and body mass index predict self-rated health status for Texas residents aged 18 to 64 years?" and 2) "Does choice of interview language (English vs Spanish) predict self-rated health status for Texas residents of Hispanic ethnicity aged 18 to 64 years?" Key analysis variables were identified, and descriptive statistics were used to describe the major variables and determine whether the number of respondents for each variable was sufficient for analysis. Multivariate regression analysis was used to assess the variables. RESULTS: Multiple logistic regression analysis (controlling for diabetes and arthritis) of the self-rated health predictors indicated that older age, lack of health care coverage, lack of a college education, being Hispanic, having a lower income, obesity, and not exercising explained 19.4% of the variance of fair and poor self-rated health. The interview language (English or Spanish), age, sex, education, income, obesity, health insurance coverage, and physical activity (controlling for chronic illness) explained 22.8% of the variance in fair and poor self-rated health for Hispanic respondents. CONCLUSION: The results of this study suggest that a college education, a lower body mass index, non-Hispanic ethnicity, and participation in physical activity are associated with good, very good, or excellent self-rated health status. The finding that the interview language significantly predicted fair and poor self-rated health substantiates previous research and emphasizes the importance of culturally sensitive approaches to health care services.
Analysis of the National Medical Care Utilization and Expenditure Survey for persons with positive out-of-pocket expenses for one or more ambulatory mental health visits indicates that demand for such visits is responsive to price, and considerably more so than demand for health visits. Income, education, and insurance coverage interact in predicting demand, and price elasticity varies across income groups.