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PubMed2000

Initiation of and adherence to treatment for mental disorders: examination of patient advocate group members in 11 countries.

OBJECTIVE: Greater understanding of the help-seeking process is needed to reduce the level of unmet need for mental health treatment. DESIGN: Cross-sectional mail survey. STUDY POPULATION: The study population consisted of 3,516 respondents to a survey of members of 14 patient advocacy groups in 11 countries. Respondents reported whether they initiated and adhered to the treatment most recently recommended to them. OUTCOMES: Crude and adjusted likelihoods of initiating and adhering to recommended treatment were studied. RESULTS: The vast majority of respondents reported initiating the most recent treatment recommended to them (94%), and most of those who initiated treatment also adhered to such treatment (83%). Predictors of initiation by the respondents included higher levels of education, having pharmacotherapy recommended to the respondent, and having received explanations about the diagnosis and treatment. Predictors of adherence to therapy included male gender, receipt of pharmacotherapy, and presence of insurance coverage. Side effects were an important reported reason for treatment dropout, with 44% of respondents reporting lifetime treatment dropout due to side effects. CONCLUSIONS: Successful initiation and adherence to mental health treatments depend critically on patients' knowledge and awareness, clinicians' communication skills, treatment side effects, and barriers such as lack of insurance. Further study and intervention focused on these modifiable factors are needed to improve the adequacy of mental health treatment.

Adolescent↗
PubMedDate not supplied

Travel insurance claims made by travelers from Australia.

BACKGROUND: Little is known about travel insurance claims made by travelers returning from abroad. This study was designed to investigate travel insurance claims made by travelers from Australia, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when treatment was sought during travel or when the problem arose, use of emergency assistance, nature of claim, and claim outcome, including cost. METHODS: A random sample of approximately one in five claims reported during the period 1996 to 1998 to a major Australian travel insurance company were examined. RESULTS: A total of 855 claims were examined, of which 42.6% (356/836) were made by male travelers and 57.1% (477/836) were made by female travelers. The majority of claimants were in the 55 years and over age groups (445/836, 53.2%). Medical and dental conditions accounted for 66.6% of claims (569/854), with the remainder associated with loss, theft, and damage (285/854, 33.4%). The most common medical conditions were respiratory (110/539, 20.4%), musculoskeletal (90/539, 16.7%), gastrointestinal (75/539, 13.9%), ear, nose, and throat (67/539, 12.4%), and dental conditions (39/539, 7.2%). Only one case of venous thrombosis was reported, secondary to a lower limb infection. Use of the travel insurance company's emergency telephone service was reported in 17.1% of claims (146/853). Almost two-thirds (559/853, 65.5%) of claims were fully accepted. Those who claimed medical treatment, assault, and theft were significantly more likely to have their claims accepted compared to those claiming dental conditions, cancellation, curtailment, loss and damage (chi2 = 127.78, df = 40, p <.00001). The majority of medical and dental conditions did not require further medical investigations (427/569, 75.0%). The mean cost of claim refunds was Australian dollars (AUD)991.31 (standard deviation [SD] 6 AUD5400.76) for males and AUD508.90 (SD 6 AUD1446.10) for females. Claims for assault, cancellation, and curtailment were significantly more expensive than other types of claims (Kruskal-Wallis one way analysis of variance [ANOVA]; chi2 = 106.87, df = 8, p <.00001). Claims for treatment of gastrointestinal, cerebrovascular, cardiovascular, musculoskeletal conditions, and pyrexias of unknown origin were significantly more expensive than other medical and dental claims (Kruskal-Wallis one way ANOVA; x2 = 61.68, df = 15, p <.00001). CONCLUSIONS: This explorative study highlights the importance of travelers taking out appropriate travel insurance. Claims for medical and dental conditions represent the majority of travel insurance claims made by Australian travelers returning from abroad, although travel insurance also covers against such contingencies as loss, theft, and cancellation. The most common medical conditions claimed were respiratory, musculoskeletal, and gastrointestinal disorders. Travelers should be advised to take out appropriate travel insurance before departure overseas and to take care with preexisting medical and dental conditions, which may not be able to be claimed against travel insurance.

Adult↗
PubMedDate not supplied

How courts view experimental treatments.

The consequences of lawsuits brought by patients to obtain insurance coverage for autologous bone marrow treatment for breast cancer illustrate the problems that arise when health plans seek to exclude "experimental" treatments.

Bone Marrow Transplantation↗
PubMed2006

Patient's ethnicity does not influence utilization of effective therapies in rheumatoid arthritis.

OBJECTIVE: Biological agents have revolutionized the treatment of rheumatoid arthritis (RA). Given the previously documented ethnic disparity in the health service literature, we sought to determine if ethnic difference exists in the lag time between the diagnosis of RA and use of first biological agent. METHODS: RADIUS 1 and 2 are observational studies designed to document how rheumatologists treat RA across the United States. The sample analyzed here included early patients with RA who entered RADIUS with the initiation of the first biological agent. Ethnic status was categorized as White (W), African American (AA), and Hispanic (H). Lag time (months from RA diagnosis to initiation of the first biological agent) was the principal outcome variable. RESULTS: Compared to W (n=1616), AA (n=147) and H (n=116) were more likely to be female, younger, and have less than a high school education. Despite similar swollen and tender joint counts, AA and H had more active disease on the basis of Health Assessment Questionnaire and patient global assessments. Almost 97% of patients had some type of insurance coverage. On multivariable analysis, ethnic affiliation was not associated with lag time (14.5 months W vs 14.9 AA vs 14.3 H; p=NS). Similarly, there were also no significant ethnic differences in time to first DMARD (e.g., methotrexate) initiation. CONCLUSION: In a national sample of patients with RA, most of whom were insured, the length of time from diagnosis of RA to initiation of the first biological agent was not significantly different among Whites, African Americans, and Hispanics.

Adult↗
PubMedDate not supplied

Expanding Medicaid coverage for pregnant women: estimates of the impact and cost.

An estimated 361,000 pregnant women are expected to be newly eligible for Medicaid coverage when all states raise the income ceiling for such coverage to 100 percent of the federal poverty level by 1990, as Congress has mandated. According to a methodology for projecting the effects of recent congressional changes in the Medicaid program, about 64 percent of these women would be otherwise uninsured, at least for maternity care, and the rest would have some insurance, so Medicaid would be the payer of last resort. Congress has also given states the option to cover pregnant women with incomes from 100 to 185 percent of poverty. If all states were to do so, another 552,000 women would become eligible, 29 percent of whom would otherwise have no insurance coverage for maternity care. The estimate of newly eligible women with incomes below 185 percent of poverty represents 24 percent of the 3.8 million women who give birth in the United States each year. Under the 100-percent-of-poverty ceiling, the estimated number of poor women eligible for coverage ranges from 4,000 or fewer in 18 states and the District of Columbia to 41,000 in California and Texas. At 185 percent of poverty, the number ranges from 4,000 or fewer in 11 states and the District of Columbia to more than 90,000 in California and Texas. Eight states have already elected to extend Medicaid coverage to the 185-percent-of-poverty ceiling.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Medicare program; beneficiary counseling and assistance grants program--HCFA. Interim final rule with comment period.

This interim final rule establishes a minimum level of funding for grants made to States for the purpose of providing information, counseling, and assistance relating to the procurement of adequate and appropriate health insurance coverage to individuals who are eligible to receive benefits under the Medicare program. This rule implements, in part, section 4360(a) of the Omnibus Budget Reconciliation Act of 1990.

Counseling↗
PubMed1999

Explosion in the medicine chest.

This overview ties together the various articles by relating them to the current debate on whether, and how, the Medicare program can add outpatient drugs as a covered benefit. The unifying theme for most of the articles is that they outline possible ways of administering a drug benefit and discuss policy issues that will arise, based on Health Care Financing Administration (HCFA) experiences or State government experiences in efforts to administer existing drug benefits in a cost-effective manner while attempting to ensure the best medical outcomes. The articles provide information about drug utilization among Medicare beneficiaries with and without insurance coverage, among Medicaid beneficiaries, and among subpopulations for whom drug therapies can be considered essential.

Aged↗
PubMedDate not supplied

Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999.

We examine the roles that insurance coverage, the delivery system, and external factors play in explaining persistent disparities in access among racial and ethnic groups of all ages. Using data from the 1996-1999 Medical Expenditure Panel Surveys and regression-based decomposition methods, we find that our measures of health care system capacity explain little and that while insurance clearly matters, external factors are equally important. Employment, job characteristics, and marital status are key determinants of disparities in access to insurance but are difficult for health policy to affect directly. Much of existing disparities remains unexplained, presenting a challenge to developing policies to eliminate them.

Black or African American↗
PubMedDate not supplied

Diagnosis and procedure coding for bone mass measurement.

OBJECTIVE: To provide background information and practical advice about coding for submission of claims for reimbursement for performing bone mass measurement studies. METHODS: The current procedural terminology (CPT) codes for diagnoses and procedures related to reduced bone mass and osteoporosis are reviewed, and Medicare and other payer policies are discussed. RESULTS: Although considerable differences exist in payer policies relative to bone mass measurement, notable consistency is developing for Medicare patients. The CPT codes for pertinent outpatient and inpatient services, and applicable CPT modifiers, are outlined. In addition, examples are provided of criteria imposed for qualification for coverage. If a carrier or payer is not expected to provide coverage for the performance of a bone mass measurement study, an advance beneficiary notice (waiver statement) should be processed and the patient should be informed about the potential responsibility for payment before the test is done. CONCLUSION: Osteoporosis is an important and costly disorder that is rapidly increasing in prevalence in our society. Clinical endocrinologists have a critical role in the management of patients with this condition and an opportunity to contribute to high-quality care. Proper selection of patients for assessment and treatment and an understanding of certain restrictions and necessary documentation for insurance coverage may help obtain reimbursement for their care.

Bone Density↗
PubMed2006

Mandating coverage of biologic therapies for rheumatic disease: where evidence and politics meet.

In this issue of Arthritis Care & Research, we inaugurate an occasional series of commentaries entitled Policy Matters. In all of clinical research, our goal is to improve patient outcomes. Usually, that means focusing on the medical, demographic, and socioeconomic factors at the level of individuals with rheumatic diseases; sometimes, our scope of inquiry expands to encompass the impact of the communities in which they live. However, increasingly, the welfare of persons with rheumatic conditions is also affected by health policies through such diverse mechanisms as reimbursement decisions for specific treatments, insurance coverage, manpower, and NIH budgets (the foregoing list is hardly exhaustive).Recently, a piece of legislation was introduced in California (SB913) that has the potential to alter the availability of biologic response modifying agents (BRMs) by mandating that health plans that provide coverage for one such agent include all on their formularies (a revised version would preclude a trial of another disease-modifying antirheumatic drug before use of a BRM). In this state, the California Health Benefits Review Program (CHBRP) provides evidence reviews of the medical effectiveness, cost, and public health impact of proposed health insurance mandates for the legislature. The analysts from the University of California who conducted the medical effectiveness review of SB913 for CHBRP provide a legislative history of the proposed law in this article. We hope that the readership of Arthritis Care & Research find this article informative as an exemplar of the policies that could dramatically alter the welfare of our patients.

Biological Therapy↗
PubMed2005

Disparities in the financial burden of children's healthcare expenditures.

OBJECTIVE: To examine whether income-related disparities in the burden of children's out-of-pocket health care expenditures have diminished with the expansions in public insurance for children in low-income families. DESIGN: We compared absolute financial burden (out-of-pocket expenditures per child) and relative financial burden (out-of-pocket expenditures per child as a proportion of family income) among children aged 0 to 18 years in 6 poverty level groups using the 1980 National Medical Care Utilization and Expenditure Survey and the 2000 Medical Expenditure Panel Survey. Regression models were used to assess whether disparities in financial burden diminished between 1980 and 2000. RESULTS: There were significant reductions (P<.01) in absolute burden over time for children above 200% of the federal poverty level. Relative financial burden decreased significantly (P<.01) for all of the income groups, ranging from a reduction of 36.49% for those below 100% of the federal poverty level (95% CI, -49.54% to -20.07%) to a reduction of 46.69% for those at or above 300% of the federal poverty level (95% CI, -54.43% to -37.62%). For low-income children, relative financial burden was 49.49% less with public insurance (95% CI, -66.24% to -24.35%) and 79.14% greater with private insurance (95% CI, 9.31% to 193.59%) than relative financial burden for low-income children without insurance. CONCLUSIONS: While the financial burden of children's out-of-pocket health care expenditures has decreased for all of the income groups over time, socioeconomic disparities persist. However, public insurance coverage appears to mitigate the financial burden for low-income children.

Adolescent↗
PubMed1994

Breast cancer. Selected legal issues.

Several legal and ethical issues may arise during the course of screening for and diagnosis and treatment of breast cancer. Among the most active legal areas are reimbursement for therapies deemed experimental by certain insurance companies, such as high dose chemotherapy/autologous bone marrow transplantation (HDCT/ABMT) and off-label drug use; these reimbursement issues are discussed. Legal issues in mammography screening and insurance coverage and legal issues relative to informed consent in breast cancer treatment also are discussed.

Bone Marrow Transplantation↗
PubMed1991

Underinsurance for severe mental illness.

Mental health care for the severely mentally ill in the United States is financed by a combination of public and private funds. Both public and private health insurance programs handle mental illness differently than they do other illnesses. This article documents uninsurance and underinsurance for severe mental illness in the United States based on studies conducted during the last decade. The relationship between private insurance and public assistance is analyzed, and major arguments around equality in insurance coverage for severe mental illness are examined. Alternatives for reducing uninsurance and underinsurance for severe mental illness in order to avoid undertreatment are discussed.

Chronic Disease↗
PubMed2002

Social factors associated with prolonged hospitalization among diabetic children.

OBJECTIVE: To determine social factors associated with increased risk of hospital admission from diabetic ketoacidosis (DKA) or diabetic coma as well as risk of prolonged hospital stay. METHODS: A cohort of all children (</=21 years) with type 1 diabetes mellitus (DM) in the National Inpatient Sample admitted for DKA or diabetic coma during 1996 or 1997 was conducted. Patients' age, race, gender, and insurance coverage were identified. Length of stay and charges were examined; prolonged length of stay was defined as >/=7 days. RESULTS: A total of 8443 children with a primary hospital diagnosis of DKA and 123 children with type 1 DM and coma were identified; 55% of the children were girls, 32% were nonwhite, 29% received Medicaid insurance, and 33% resided in areas of poverty. Children with prolonged hospital stay were significantly more likely to be of nonwhite race (odds ratio [OR]: 2.0; 95% confidence interval [CI]: 1.6-2.5), to receive Medicaid insurance (OR: 1.4; 95% CI: 1.1-1.7), to live in areas of poverty (OR: 1.3; 95% CI: 1.1-1.7), and to be of younger age. CONCLUSIONS: When compared with state census data, nonwhite and poor children were more likely to be admitted with complications of DM and to have significantly prolonged and expensive hospital stays. These children should be targeted for intensive diabetes education and outpatient medical support both to improve their health and potentially to decrease total health care costs.

Adolescent↗
PubMed2005

Unmet need and problems accessing specialty medical and related services among children with special health care needs.

OBJECTIVES: To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN). METHODS: Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics. RESULTS: Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits. CONCLUSIONS: The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.

Adolescent↗
PubMed2000

Racial and ethnic differences in access to and use of health care services, 1977 to 1996.

This article focuses on racial and ethnic disparities in health care, describing both absolute differences and relative changes in access to care and the use of health services among whites, blacks, and Hispanics over the past two decades. Using data from a series of three nationally representative medical expenditure surveys, the authors present descriptive statistics on disparities in access and use between minorities and whites over time. They also use multivariate analyses to isolate the extent to which health insurance and income explain those disparities. The authors find that disparities increased between 1977 and 1996, particularly for Hispanic Americans. Results also show that approximately one half to three quarters of the disparities observed in 1996 would remain even if racial and ethnic disparities in income and health insurance coverage were eliminated.

Adolescent↗
PubMed2005

Patient involvement in medical decision-making and pain among elders: physician or patient-driven?

BACKGROUND: Pain is highly prevalent among older adults, but little is known about how patient involvement in medical decision-making may play a role in limiting its occurrence or severity. The purpose of this study was to evaluate whether physician-driven and patient-driven participation in decision-making were associated with the odds of frequent and severe pain. METHODS: A cross-sectional population-based survey of 3,135 persons age 65 and older was conducted in the 108-county region comprising West Texas. The survey included self-reports of frequent pain and, among those with frequent pain, the severity of pain. RESULTS: Findings from multivariate logistic regression analyses showed that higher patient-driven participation in decision-making was associated with lower odds (OR, 0.82; 95% CI, 0.75-0.89) of frequent pain, but was not significantly associated with severe pain. Physician-driven participation was not significantly associated with frequent or severe pain. CONCLUSIONS: The findings suggest that patients may need to initiate involvement in medical decision-making to reduce their chances of experiencing frequent pain. Changes to other modifiable health care characteristics, including access to a personal doctor and health insurance coverage, may be more conducive to limiting the risk of severe pain.

Aged↗
PubMed1978

Considerations in the design of mental health benefits under National Health Insurance.

The existing insurance coverage for mental health benefits provides incentives for hospital as compared with community care and reinforces a medical approach to psychological disability. Moreover, the structure of benefits favors the affluent as compared with the disadvantaged and provides little assistance for the community integration of the chronic mental patient. In considering mental health benefits under National Health Insurance we must be careful to avoid reinforcing these patterns. It is suggested that NHI include a mental health resource development fund intended for building a stronger network of community mental health care and that the pattern of insurance benefits under NHI be consistent with developing psychiatric services on a capitation basis.

Community Mental Health Services↗