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The end of managed care.
Managed care embodies an effort by employers, the insurance industry, and some elements of the medical profession to establish priorities and decide who gets what from the health care system. After a turbulent decade of trial and error, that experiment can be characterized as an economic success but a political failure. The strategy of giving with one hand while taking away with the other, of offering comprehensive benefits while restricting access through utilization review, has infuriated everyone involved. The protagonists of managed care now are in full retreat, broadening physician panels, removing restrictions, and reverting to fee-for-service payment. Governmental entities are avoiding politically volatile initiatives to balance limited resources and unlimited expectations. By default, if not by design, the consumer is emerging as the locus of priority setting in health care. The shift to consumerism is driven by a widespread skepticism of governmental, corporate, and professional dominance; unprecedented economic prosperity that reduces social tolerance for interference with individual autonomy; and the Internet technology revolution, which broadens access to information and facilitates the mass customization of insurance and delivery.
The asbestos TLV: early evidence of inadequacy.
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Smoking cessation in a blue-collar population: results from an evidence-based pilot program.
BACKGROUND: Taft Hartley Funds provide group health care coverage for 10 million union workers as well as their dependents in industries such as construction and transportation. The adult smoking rate in these populations is estimated at approximately 40%, therefore, these funds include 9 million adult smokers. The absence of evidence demonstrating the effectiveness of smoking cessation programs has kept Taft Hartley Funds from investing in smoking cessation benefits. METHODS: A prototype for Taft Hartley Funds consistent with the Federal Clinical Guidelines for Smoking Cessation was designed and implemented in a pilot demonstration in the Carpenters Health and Security Trust of Western Washington. Participants chose a 1-call or more intensive 5-call smoking cessation counseling plan provided by the Group Health Cooperative's Free and Clear program. Medications were limited to the nicotine patch, nicotine gum, and Bupropion. Assessment of outcomes was performed by Free and Clear through a telephone survey 12 months following the enrollment date. RESULTS: Nine hundred thirty-five smokers participated in the program. This pilot evaluation covers 325 participants with at least 12 months since enrollment; 75% were male, the average age was 41.4 and 63% had smoked at least one pack per day for more than 20 years. Sixty-one percent selected 5-Call Counseling; 39% 1-Call. Seventy-five percent also used smoking cessation medications: gum, 4%; patch, 32%; Bupropion 21.5%; patch plus Bupropion, 15.7%. The point-prevalence-quit rates were: overall, 27.5%; 1-Call, 25.5%; and 5-Call, 28.9%. The cost of the program was $1025.28 per smoker who quit, or $11.78 per full-time equivalent employee covered by the Fund per year. The compounded savings in reduced lifetime tobacco-related medical costs for the participants who quit are estimated to be 15 times the cost of the program, yielding an annual return on investment of 27.6%. CONCLUSIONS: These results strongly suggest that smoking cessation programs can be effective even in such hard-to-reach populations as itinerant building trades workers, provided that the program is designed to their needs and environment. Based on these findings, health plans need to consider whether they are at risk of violating their fiduciary duties if they fail to offer smoking cessation benefits.
Disclosure, confidentiality, and families: experiences and attitudes of those with genetic versus nongenetic medical conditions.
Despite policy attention to medical privacy and patient confidentiality, little empirical work exists documenting and comparing experiences of persons with genetic versus nongenetic medical conditions concerning persons' disclosure to others as well as their views about appropriate confidentiality to and within families. The goal of this cross-sectional interview study with nearly 600 participants was to document and compare the experiences, attitudes, and beliefs of persons with strictly genetic conditions to those of persons with or at risk for other serious medical conditions in terms of the degree to which they have disclosed to others that they have the condition and their views about how others ought to maintain the confidentiality of that information. While almost all participants reported that family members knew about their condition, results suggest participants want to control that disclosure themselves and do not want doctors to disclose information to family members without their knowledge. Similarly, participants do not think family members should be able to get information about them without their knowledge but feel overwhelmingly that it is a person's responsibility to disclose information about hereditary conditions to other family members. Ambivalence about confidentiality was evident: while most participants did not mind doctors sharing information with other doctors when it was for their benefit, the majority also felt that doctors should be punished for releasing information without their permission. The views and experiences reported here generally did not differ by whether participants had genetic versus nongenetic conditions, suggesting that the extensive policy focus on genetic information may be unwarranted.
Ethics and the insurance broker.
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Minimizing risk through incident investigation and intervention.
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Risk equalization, competition and choice in Germany: a reply to Wysong and Abel.
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Competition and "cream skimming" in Germany: incentives and opportunities.
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[How does the Brandenburg general public health insurance company use the opportunity of Integrated Health Care?].
New laws on Integrated Health Care gives the opportunity to destroy unnecessary barriers within German social security systems. The aim is to optimally create health care supply so that the large potentials within these systems do not vanish in the chaos of these complex structures. The second most important aim is to reduce the cost of health care. The Brandenburg AOK (general public health insurance company) accepts the challenges and focuses on innovative potentials. Integrated Health Care provides ample opportunities for this purpose.
[Judicial opportunities and limitations of Integrated Health Care in cardiology].
Regulations of Integrated Health Care are capable of overriding the barriers of separated outpatient and inpatient health care. These regulations create a situation of competition among health care providers, but not among payers. Since the laws exclude common regulations of competition laws, antitrust laws and public procurement laws from Integrated Health Care, insurance companies gain a relatively strong position in the competition for contracts. This is even enforced by the fact that no health care provider is entitled to request a contract with a specific insurance company. The main result is that insurance companies can determine the contracts deliberately.
Genetic screening, health care and the insurance industry. Should genetic information be made available to insurers?
The potential use of genetic tests in insurance has raised concerns about discrimination and individuals losing access to health care either because of refusals to test for treatable diseases, or because test-positives cannot afford premiums. Governments have so far largely sought to restrict the use of genetic information by insurance companies. To date the number of tests available with significant actuarial value is limited. However, this is likely to change, raising more clearly the question as to whether the social costs of adverse selection outweigh the social costs of individuals not accessing health care for fear of the consequences of test information being used in insurance markets. In this contribution we set out the policy context and model the potential trade-offs between the losses faced by insurers from adverse selection by insurees (which will increase premiums reducing consumer welfare) and the detrimental health effects that may result from persons refusing to undergo tests that could identify treatable health conditions. It argues that the optimal public policy on genetic testing should reflect overall societal benefit, taking account of these trade-offs. Based on our model, the factors that influence the outcome include: the size of and value attached to the health gains from treatment; deterrent effects of a disclosure requirement on testing for health reasons; incidence of the disease; propensity of test-positives to adverse select; policy value adverse selectors buy in a non-disclosure environment; and price elasticity of demand for insurance. Our illustrative model can be used as a benchmark for developing other scenarios or incorporating real data in order to address the impact of different policies on disclosure and requirement to test.
Outcomes research collaborations between third-party payers, academia, and pharmaceutical manufacturers: What can we learn from clinical research?
Research collaborations between academic researchers, regulatory agencies, and pharmaceutical manufacturers have made the drug development process more efficient and have frequently supported the successful documentation of quality, safety, and efficacy of pharmaceuticals (the so-called three hurdles). Over recent years issues of drug cost, access, and utilization have moved to center stage, giving rise to a "fourth hurdle approval" process by third-party payers. This requires new forms of collaborative research among new players. This contribution highlights the need for a "triangular" relationship in the field of outcomes research between scientists in academia, third-party payer institutions, and pharmaceutical manufacturers. We discuss, and illustrate by case studies, how successful models of collaboration from the drug development process might be relevant to research activities related to the fourth hurdle. Case studies which may provide useful models for collaborative outcomes research include the "International Conference on Harmonization" process, the voluntary consultation procedures established by drug regulatory agencies, and the Quebec experience in database sharing.
Commercial insurers and all-payer regulation. Evidence on hospitals' responses to financial need.
This study explores commercial insurers' claims about cost-shifting in the broader context of hospitals' responses to revenue needs. It relies on hospital survey data from 1980 and 1982, a period that pre-dates Medicare's Prospective Payment System (PPS) for hospitals. While we find that limited amounts of cost-shifting occur, evidence does not support the notion that it is a perfect safety valve to control financial status. In addition, all-payer rate-setting does not appear to be related to hospitals' ability to shift costs. Instead, inpatient rate controls cause hospitals to contain costs, seek greater outpatient revenues and accept lower margins. Are the financial 'stresses' associated with PPS sufficient enough to kick off renewed concerns about cost-shifting? Some aggregate data from the PPS-era indicates that lower growth in Medicare payments has not resulted in cost-shifting on a widespread basis.
Medico-economic implications of industrial hand injuries in India.
625 five consecutive cases of industrial hand injuries attending the Employee's State Insurance Hospital, Jaipur, have been studied from 1983 to October 1986. The incidence of injuries was 36 per 10,000 workers per year. 47% were due to entrapment of the hand in active machines, 25% occurred during lifting and transportation of heavy objects and 12% while handling tools. The injuries resulted in residual deficit in 55% of cases and were serious enough to require absence from work of more than four weeks in 48% of cases. On an average 35 days were lost per injured worker. The average economic loss per injured worker was Rs. 6900 (approximately pounds 275) for workers in the wage-range of Rs. 5400 to 19,200 (pounds 216 to pounds 768) per annum.
Payment policy, quality of care and decision making with inadequate information.
The health care system in the United States is in chaos. The conflict is between containing costs on an aggregate level while, at the same time, not reducing services to the individual if the services are essential for quality care. There is little information on which to base decisions about the value of services. Health care organizations and delivery models must be restructured because current models are out of date. To accomplish this restructuring, better information is needed on why hospitals and doctors do what they do. Success in developing information and decision models that result in patients receiving only medically necessary services will contribute greatly to promoting high quality, cost-conscious care.
Disability insurance for emergency physicians.
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Managed care patient protection or provider protection? A qualitative assessment.
PURPOSE: Opponents of managed care regulation allege that a patient's bill of rights, in reality, represents provider protections motivated by the desire to curtail the economic onslaught of managed care. This claim is assessed through a large qualitative study of state managed care patient protection laws. METHODS: State laws were reviewed and categorized, and regulators in each state were surveyed, to determine the pattern and content of relevant enactments as of the end of 2001. In 2002, six states were selected for in-depth case studies to reflect a range of market, demographic, and legal characteristics. In each state, 16 to 24 key informants were interviewed, including provider advocates, physician practices, health plan managers, regulators, patient advocates, and various industry observers. Additional interviews were conducted from a national perspective, for a total of 138 interviews. Interviews were semistructured, and interview notes were analyzed using qualitative techniques. RESULTS: These laws are directed primarily to patients' rights and only secondarily to providers' interests. Enactment of these laws was rarely attributed primarily to provider advocacy. Instead, providers aligned with consumers, or the impetus came from legislators or regulators. There was little evidence that these laws, collectively or individually, have had much effect on providers' economic concerns. Health plans are still free to form and shape networks as they see fit, subject to competitive constraints. Provider due process laws might suppress deselection to some extent, but most subjects thought these laws only marginally restrain health insurers from removing providers who they no longer want. CONCLUSION: Managed care patient protection laws do not advance a self-interested provider agenda that disables features of managed care that are beneficial to consumers. Instead, these laws appear to embody a convenient alignment of interests among providers, patients, and lawmakers.