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PubMed2002

Government mandates and employer-sponsored health insurance: who is still not covered?

We characterize employer-sponsored health insurance offering strategies in light of benefit non-discrimination and minimum wage regulation when workers have heterogeneous earnings and partially unobservable demand for (and cost of) insurance. We then empirically examine how earnings and expected medical expenses are associated with low wage workers' ability to obtain insurance before and after enactment of federal benefit non-discrimination rules. We find no evidence that the non-discrimination rules helped low wage workers (especially those with high own or children's expected medical expenses) to obtain insurance.

Adolescent↗

PubMed2003

Ethnicity, insurance type, and follow-up in a pediatric weight management program.

OBJECTIVE: To assess the characteristics of children and adolescents who drop out of a clinical weight management program. RESEARCH METHODS AND PROCEDURES: A retrospective survey of children and adolescents attending a pediatric weight management program [n = 518; mean +/- SEM: age 10.4 +/- 0.2 years, BMI z-score 4.9 +/- 0.1, 62% female, 41% African American and 57% white] was undertaken. Characteristics of children (age, relative weight, gender, and ethnicity) who dropped out of the program were compared with characteristics of those who continued beyond the initial assessment as a function of type of insurance. RESULTS: The children who dropped out of the program after the initial assessment differed by ethnicity from those who continued in the program: 63% of white children returned for more than one visit, whereas only 35% of the African-American children continued in the program. Indemnity insurance coverage was associated with more clinic visits, as compared with managed care insurance. The association between insurance type and clinic visit number was of borderline significance (p = 0.06), when ethnic group was added to this analysis. DISCUSSION: Ethnicity is associated with attendance in a Pediatric Weight Management Program. Given the epidemic of obesity in children and adolescents, issues related to program compliance must be assessed to improve overall outcome. This is especially important given the high rate of obesity among African Americans and the low rate of ongoing attendance observed among African Americans in the Weight Management Program.

Adolescent↗

PubMed1997

A health insurance scheme for hospital care in Bwamanda District, Zaire: lessons and questions after 10 years of functioning.

A voluntary insurance scheme for hospital care was launched in 1986 in the Bwamanda District in northwest Zaire. The paper briefly reviews the rationale, design and implementation of the scheme and discusses its results and performance over time. The scheme succeeded in generating stable revenue for the hospital in a context where government intervention was virtually absent and external subsidies were most uncertain. Hospital data indicate that hospital services were used by a significantly higher proportion of insured patients than uninsured people. The features of the environment in which the insurance scheme thrived are discussed and the conditions that facilitated its development reviewed. These conditions comprise organizational-managerial, economic-financial, social and political factors. The Bwamanda case study illustrates the feasibility of health insurance-at least for hospital-based inpatient care-at rural district level in sub-Saharan Africa, but also exemplifies the managerial and social complexity of such financing mechanisms.

Adult↗

PubMed2000

["Deficiencies in the mandatory health insurance system"--possibilities and limits of medical expert assessment].

In Germany, the Federal Committee of Physicians and Health Insurance Agencies is responsible for assessing which medical procedures are covered by the insurance agencies (therapeutic/economic value). The failure to evaluate certain medical procedures which promise therapeutic benefit may be considered a failure in the system of statutory health insurance as decreed by the German Federal Social Court. In cases of system failure the assessment of medical procedures is taken over by social courts. Evidence of therapeutic value will continue to be the decisive criterion of evaluation. In special cases, however, it may be replaced by the particular procedure's rate of incidence in everyday medical practice, as reflected by a widespread resonance in medical discussion and its use by a considerable number of physicians. Medical experts may face various difficulties in handling these alternative criteria. They usually lack reliable data on the frequency of the procedure, i.e. its distribution. Even if such data and data on secondary factors--such as disease incidence etc.--were available to them, they would still not be able to come up with a definite conclusion on the degree (widespread, considerable) of dissemination, as defined by the German Federal Social Court. Nevertheless, on request of statutory health insurances, social medical experts may investigate facts in order to establish basic knowledge for later decisions that are to be done by others. Factual investigation includes clarification of etiology, incidence, importance and natural history of the particular disease processes. Potential deficiencies in the medical services rendered for specific diseases as well as the characteristics of the procedure under scrutiny, and special requirements for evaluating the outcome have to be investigated as well. Additional attention needs to be paid to the quality of related publications (analysis of statistical data), possible recommendations for therapy (e.g. guidelines and their scientific basis), as well as to economic aspects. The result of such an investigation has to be stated without use of court criteria (widespread/considerable).

Evidence-Based Medicine↗

PubMed2006

[The Impact of Diseases (ICD-10) and Impairments of Activity and Participation (ICF) on the Long-Term Care Insurance in Germany (SGB XI)].

On the basis of a representative sample of expert records from the Medical Review Board of the statutory care insurance funds (MDK) it could be shown that in the year 2003 more diseases of dementia had been examined for the long-term care insurance. The diagnois of dementia is statistically significant as a determinat of exposition related to get benefit from the care insuance. Help assistance which is needed after suffering form fraturs of bones are significant too, but related to get no benefits. In Germany the expert records of the long-term care insurance investigate the help assistance defined by the Social Code (SGB XI) which is needed in the daily live of the disabled and handicaped people. The classification of the SGB XI for daily performances offers the required transparency by using the mulitvariate logistic regression analysis with the predictor to get benefits from the care insurance. The help assistance estimated in the sample was recoded with the International Classification of Functioning, Disability and Health (ICF). Within this classification activity and participation in daily life of disabled and handicapped people are investigated. It was found that there could be more subdivions for these performances. A new analysis of the body function recorded in the ICF could be of interest to explain significant variables relating to the amount of help assistance.

Disability Evaluation↗

PubMed1981

[Expertises on growth disturbances in children seen from the aspect of private accident insurance (author's transl)].

In private accident insurance, a degree of disability established for the insured and the insuring party for the first time in a binding manner, cannot be established as a new fact if more than 3 years have elapsed since the accident occurred. In private accident insurance for children, the right to confirm the disability as a new fact, is limited to a period of 5 years, but not beyond the age of 18. If post-traumatic disturbances in young children (following injuries of the epiphyseal cartilage, bone and articular infections etc..) do not supply sufficient pointers towards the possible or probable findings at the termination of growth, the physician writing the expertise should draw attention to this fact and should state that as far as the medical situation is concerned, determination of the first occurrence cannot be made now and is possible at the stage of termination of growth only.

Adolescent↗

PubMed1982

[Assessment of eye damage for private accident insurance].

Together with a team from the HUK association (an association of liability, accident, transport and legal protection insurance-companies) the authors discussed a new assessment table for diminution of vision and have recommended its use by private accident insurance companies. The table was worked out on the basis of guidelines issued by the Deutsche Ophthalmologische Gesellschaft in 1981. In cases of bilateral eye damage the total extent of the disability - based on the specific diminution of usability of each eye - should be calculated according to the conditions of the insurance companies and not by a medical expert. Further proposals for the assessment of visual field defects and other kinds of eye damage covered by private accident insurance were also brought into line with the recommendations issued by the Deutsche Ophthalmologische Gesellschaft in 1981.

Disability Evaluation↗

PubMed1989

Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986.

In this study of hospital discharge data on births to residents of an eight-county region of California, we found an increasing lack of health insurance that was associated with an elevated and increasing risk of adverse outcomes in newborns. Between 1982 and 1986, the percentage of newborns without health insurance increased overall by 45 percent (from 5.5 to 8.0 percent; P less than 0.001); the increases were larger among Asians (by 54 percent [from 7.8 to 12.0 percent]; P less than 0.001) and Latinos (by 140 percent [from 8.2 to 19.7 percent]; P less than 0.001). By 1986, the odds ratio for an adverse hospital outcome (defined as a prolonged hospital stay, transfer of the newborn to another institution, or death) was 1.31 (95 percent confidence interval, 1.17 to 1.46) in uninsured as compared with privately insured newborns, with control for race or ethnic group. There was a significant increase in risk over time (P less than 0.03); the comparable odds ratios in 1982 and 1984 were 1.11 (95 percent confidence interval, 0.93 to 1.33) and 1.19 (1.05 to 1.35), respectively. In 1986 the risks were especially elevated for uninsured as compared with privately insured blacks and Latinos (odds ratios, 2.24 [95 percent confidence interval, 1.60 to 3.13] and 1.56 [1.26 to 1.94], respectively); the increases in risk over time were the most marked in these groups. We believe that the elevated and increasing risks for uninsured newborns are explained at least in part by inadequate and diminishing access to care and that this burden is borne disproportionately by blacks and Latinos.

California↗

PubMed1994

Insurance-related differences in the risk of ruptured appendix.

BACKGROUND: We studied differences in the incidence of appendiceal perforation in patients with acute appendicitis according to their insurance coverage. METHODS: In a retrospective analysis of hospital-discharge data, we examined the likelihood of ruptured appendix among adults 18 to 64 years old who were hospitalized for acute appendicitis in California from 1984 to 1989. RESULTS: After controlling for age, sex, psychiatric diagnoses, substance abuse, diabetes, poverty, race or ethnic group, and hospital characteristics, we found that ruptured appendix was more likely among both Medicaid-covered and uninsured patients with appendicitis than among patients with private capitated coverage (odds ratios, 1.49 [95 percent confidence interval, 1.41 to 1.59] and 1.46 [95 percent confidence interval, 1.39 to 1.54], respectively). After adjustment for the above factors, the risk of appendiceal rupture associated with a lack of private insurance was elevated at both county and other hospitals, but admission to a county hospital was an independent risk factor. In all income groups, appendiceal rupture was more likely with fee-for-service than capitated private coverage (overall odds ratio, 1.20 [95 percent confidence interval, 1.15 to 1.25]). CONCLUSIONS: Among patients with appendicitis an increased risk of ruptured appendix may be due to insurance-related delays in obtaining medical care. Both organizational and financial features of Medicaid and various types or levels of private third-party coverage may be involved. The significant association between ruptured appendix and insurance coverage after adjustment for socio-economic differences suggests barriers to receiving medically necessary acute care that should be considered in current deliberations on health policy.

Adolescent↗

PubMed2002

Private health insurance uptake and the impact on normal birth and costs: a hypothetical model.

Recent Australian government policy has encouraged large numbers of women of childbearing age to enter private health insurance. This paper describes how increased uptake of private health insurance may impact on the rate of normal birth, caesarean section and the costs of providing maternity care in low risk primiparous women in New South Wales. A hypothetical model was developed using data from the NSW Midwives Data Collection. Costs were calculated using data established from previous research in NSW (Homer et al 2001). It suggests that, as the proportion of low risk primiparous women with private health insurance increases, the rate of normal birth may decrease with a subsequent increase in rate of caesarean section. As the rate of caesarean section rises, the cost of providing intrapartum and postpartum care may also increase. I argue that increased rates of private health insurance membership have the potential to increase the rate of caesarean section and the cost of providing maternity care to low risk women. It is evident that government policy can impact on the outcome of maternity care in Australia in ways that might not have been predicted. Paradoxically, the care of healthy childbearing women may cost the Australian government more to provide in the future.

Cesarean Section↗

PubMed2004

Why it is time to review the role of private health insurance in Australia.

The role of private health insurance (PHI) within the Australian health-care system is urgently in need of comprehensive review. Two decades of universal health cover under Medicare have meant a change in the function of PHI, which is not reflected in policies to support PHI nor in the public debate around PHI. There is increasing evidence that the series of policy adjustments introduced to support PHI have served to undermine rather than promote the efficiency and equity of Australia's health care system. While support for PHI has been justified to 'take pressure off the public hospital system' and to facilitate choice of insurer and private provider', and the incentives have indeed increased PHI membership, this increase comes at a high cost relative to benefits achieved. The redirection of hospital admissions from the public to private hospitals is small, with a value considerably less than 25% of the cost of the policies. The Commonwealth share of the health care budget has increased and the relative contribution from private health insurance is lower in 2001-02, despite an increase in PHI membership to nearly 45% of the population, compared with the 30% coverage in 1998. The policies have largely directed subsidies to those on higher incomes who are more likely to take out PHI, and to private insurance companies, private hospitals and medical specialists. Ad hoc policy adjustments need to be replaced by a coherent policy towards PHI, one that recognises the fundamental change in its role and significance in the context of universal health coverage.

Australia↗

PubMedDate not supplied

Public and private health insurance of US foreign-born residents: implications of the 1996 welfare reform law.

OBJECTIVE: US policy towards immigrants is undergoing considerable change, often in the absence of objective data. In this paper, the insurance status of the US foreign-born population is presented overall and disaggregated by race, ethnicity and length of residence in the USA. DESIGN: Data from the National Health Interview Surveys, a cross-sectional household survey representing the non-institutionalized US population, was used to identify respondents as foreign- or native-born and to determine the type of health insurance coverage. The surveys also collected race and ethnicity information from all respondents based on self-reports, and, for the foreign-born population, the length of residence in the USA. RESULTS: Compared to native-born residents, foreign-born residents are twice as likely to be uninsured (26.3% versus 13.0%), less likely to have private insurance (62.3% vs 78.8% and Medicare (88.6% vs 96.2%) and somewhat more likely to have Medicaid (6.5% vs 4.1%). A separate analysis of Hispanic and Asian foreign-born residents was conducted. Length of residence in the USA, race and ethnicity significantly impact the type and extent of health insurance coverage among the foreign-born population. CONCLUSION: Recent legislative initiatives restricting immigrants' access to public services could lead to adverse public health consequences including further exacerbation of the high rates of uninsuredness found in this study.

Adolescent↗

PubMed2005

Pharmaceutical insurance and the demand for prescription pharmaceuticals in Västerbotten, Sweden.

AIMS: The aim of this paper is to analyze the impact of pharmaceutical insurance on the demand for prescription pharmaceuticals in the county of Västerbotten, Sweden. As the patients do not bear the full marginal costs of the pharmaceuticals they consume when pharmaceutical insurance systems are present, this could induce patients to over-consume pharmaceutical treatments. METHODS: Data covering all prescription pharmaceuticals sold in the county of Västerbotten, Sweden during the year 2001 have been provided by the local county council. Data include information concerning the gender and age of the patient, the number of defined daily doses, total cost, and the patient's co-payment for the prescription. The hypothesis that patients will consume more (or perhaps more expensive) pharmaceuticals when there is pharmaceutical insurance is tested by means of regression analysis. RESULTS: The results show that both the quantities dispensed and the price of the pharmaceuticals consumed increase when the pharmaceutical insurance system pays part of the total cost of the pharmaceuticals consumed. CONCLUSIONS: The findings suggest that introducing a small patient co-payment for all prescriptions should be an effective measure to decrease pharmaceutical consumption.

Adolescent↗

PubMed2005

Sickness certificates as a basis for decisions regarding entitlement to sickness insurance benefits.

BACKGROUND: The sickness certificate is a major instrument for establishing contact and conveying information between two authorities that have a substantial impact on the life situation and work situation of the patients, as well as on the economic costs of the society. AIM: A study was undertaken to assess the quality of physicians' sickness certificates as a basis for social insurance officers' decisions regarding entitlement to sickness benefits. METHOD: Information on all 2,449 sickness certificates for sick-leave periods exceeding 28 days' sick leave period received at the social insurance offices in one Swedish county during one week in 2002 was coded and analysed. RESULTS: Information provided in the certificates was often not sufficient to allow social insurance officers to determine eligibility for sickness benefits. Qualitative analyses of certificates from general practitioners (GPs) revealed that 21% contained ambiguous statements about the medical disorder, 30% were unclear regarding the assessment of functional capacity, and 22% required additional information on both those aspects. Sickness certificates issued by GPs and physicians under specialist training, as compared with other categories of physicians, more often provided essential data, for example concerning the patient's occupational tasks and type of employment. CONCLUSIONS: Physicians often fail to contribute required information concerning functional capacity and other important aspects when issuing sickness certificates. This limits the use of these documents as a basis for decisions regarding sickness insurance benefits. The practical consequences of incomplete certificates might be delayed payment of benefits and delayed initiation of return to work measures.

Decision Making↗

PubMed2000

Breast self-examination in women in two primary care settings: an evaluation of the impact of insurance status.

Breast cancer is one of the most common cancers diagnosed among women in the United States. Screening tools available for breast cancer detection include breast self-examination (BSE), clinical breast examination, and mammography. Various studies have indicated that women may inconsistently perform BSE. This investigation evaluated the potential impact of insurance status on BSE. Women with health insurance receiving primary healthcare at a health maintenance organization (HMO) and women without health insurance receiving primary healthcare at a free clinic completed anonymous questionnaires that obtained information about the frequency of BSE performance, whether instruction was given about performing BSE, age at learning BSE, and confidence in performing BSE. One hundred fifty-five (82%) of 200 questionnaires at the HMO and 92 (92%) of 100 questionnaires at the free clinic were completed. Thirty-five percent of women (32% at the HMO, 39% at the free clinic) reported performing BSE. There were no significant differences in the rate of monthly BSE, receiving instruction about performing BSE, age at learning BSE, or confidence in performing BSE in women at the HMO and free clinic. Insurance status did not affect BSE. However, further study is needed to evaluate factors that potentially influence performance of BSE and could encourage compliance with BSE recommendations.

Adolescent↗

PubMedDate not supplied

Complementary and alternative provider use by insured patients with diabetes in Washington State.

OBJECTIVES: The authors investigated whether insurance coverage for complementary and alternative medicine (CAM) providers is associated with increased medical care use among diabetes patients. Predictors of CAM use and how CAM affects health care use and expenditures under insurance coverage were examined. DESIGN: Claims data from two large insurers in Washington State were obtained for 2002. Types of providers used, comorbid medical conditions, number of visits, and expenditures were calculated for the study sample and compared to a nondiabetic matched group. RESULTS: Of the 20,722 adults with diabetes, 3605 (17.4%) had one or more visits to any licensed CAM provider (mostly chiropractors). This was lower than the 20% CAM use in the comparison group. Diabetes patients who used CAM were more likely to have multiple other medical problems than CAM nonusers. CAM users had a higher average number of annual outpatient visits compared to nonusers (28 versus 16), and higher average annual expenditures (8,736 dollars versus 7,356 dollars); however, after adjustment for disease load and other factors, CAM use was not a significant predictor of expenditures. CAM use was <2% of the overall mean medical expenditures for diabetes patients. Quality of conventional care was similar for CAM users and nonusers. CONCLUSIONS: CAM provider usage when covered by insurance is lower among diabetes patients than in adults without diabetes and represents a small proportion of diabetes care costs. Very few CAM visits were related directly to diabetes care. CAM-using patients often have heavy disease burdens and high total expected resource use compared to those not using CAM.

Adult↗

PubMed2005

Race/ethnicity and insurance status as factors associated with ADHD treatment patterns.

Using data from the 1997-2000 Medical Expenditure Panel Survey (MEPS), disparities in different stages of attention-deficit/hyperactivity disorder (ADHD) health care were investigated, from initial detection to follow-up physician visits and psychotherapy appointments. Differences in ADHD diagnoses, stimulant usage, and health-care visits were examined by age, race/ethnicity, region, and type of insurance. Major significant findings were: (1) children without insurance had lower levels of care in all stages relative to children with insurance, (2) Hispanic-American and African-American children were less likely to be diagnosed with ADHD by parent report than were white American children, and (3) African-American youths with ADHD were less likely to initiate stimulant medication relative to white American children. Implications for expanding childhood health insurance coverage, and for future work on minority mental health care in regard to ADHD, are discussed.

Adolescent↗

PubMed1997

The effect of type of hospital and health insurance on hospital length of stay in Irbid, North Jordan.

The study aimed at examining the effects of type of hospital and health insurance status on hospital length of stay for three identified medical and surgical conditions. Medical records of 520 patients for the year 1991 were reviewed in one public and one private hospital. Comparison of hospital length of stay for the private (n = 185) versus public sector patients (n = 335) was carried out. The effect of presence of health insurance (n = 189) and the lack of it (n = 325) was also studied. It was found that the average length of stay in the public hospital was significantly longer than the private one (3.3 versus 2.7 days). In addition, insured patients had significantly longer hospital length of stay (3.3 versus 3.0 days). The results of the multi-variate analysis showed that after socioeconomic factors and clinical conditions of patients were adjusted for, the influence of hospital type and health insurance on hospital length of stay was about one day. The paper also discusses the need to base hospital cost-containment strategies on studies of hospital behaviour and performance.

Adolescent↗