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PubMed1994

Notes from the insurance underground: how the chronically ill cope.

This report from the field is an account of the experience of individuals with multiple sclerosis (MS) in Indiana in getting and keeping private health insurance. The report presents the findings of a telephone survey of individuals with MS in Indiana. While survey respondents were generally able to obtain health insurance through the Medicare program or employer-based private health insurance plans, many experienced formidable barriers to adequate and affordable health insurance, such as preexisting exclusions, cancellations, high premiums, and coinsurance. Respondents adopted a variety of strategies to keep private health insurance, including selectivity in submitting claims, which worked to reduce their health insurance coverage. Our findings raise two crucial questions: (1) to what extent are the chronically ill forced to take extraordinary measures to get and keep health insurance? and (2) to what extent do insurer practices in pricing insurance and determining coverage of benefits actually make health insurance even more inadequate and unaffordable for the chronically ill? These two questions are critical in understanding the full dimensions of the health insurance crisis in the United States today.

Actuarial Analysis↗
PubMed2002

Compensation for medical injury in New Zealand: does "'no-fault" increase the level of claims making and reduce social and clinical selectivity?

The issues of patient safety and quality of care have gained policy attention with a growing appreciation of the scale and impact of medical injury in health systems. While the focus is clearly on the prevention of iatrogenic injury, the question of patient compensation is now also considered important, if only because in fault-based tort systems the fear of litigation may itself be a barrier to the disclosure and open discussion of medical error. No-fault systems, by contrast, do not require proof of culpability, and thus may both reduce barriers to compensation and increase disclosure of error. Little evidence, however, is available on the performance of such systems. This article reports on the analysis of two data sources-a sample of hospital admissions and a complete set of compensation claims for medical injury. Both are for the same year and region of New Zealand, a country that has maintained a no-fault system of accident compensation for a quarter of a century. Just over 2 percent of hospital admissions were associated with an adverse event that was potentially compensable under scheme criteria. While the claims process was well targeted, the level of claims making and receipt was low, with the ratio of successful claims to potentially compensable events being approximately 1:30. Comparison of social and clinical characteristics of the two data sets revealed a degree of selectivity. Compared with the hospital events, the typical successful claimant was younger and female and was much more likely to have experienced a surgical adverse event that, while unexpected, was not due to substandard care. It is concluded that, in interpreting these results, account needs to be taken of a number of features unique to the New Zealand system. These include: the limited payoff for a compensation claim (no pain and suffering or lump sum, free hospital care); the relative complexity of the grounds for claim (either rarity and severity or practitioner error); and a history of limited litigation for medical error. This suggests that, while the New Zealand system is well targeted, cheap, and free of financial and legal barriers, a change in legal doctrine alone has not in itself been sufficient to remove completely the selective and low level of claims making traditionally associated with patient compensation under tort.

Adult↗
PubMed2003

Has solidarity survived? A comparative analysis of the effect of social health insurance reform in four European countries.

Social health insurance reform has evolved as an important public policy issue in several European countries. Some of the most important reform programs have been the introduction of managed competition, a shift from full retrospective reimbursement of health insurers to prospective reimbursement, an increase of private payments, and a change in the health benefits of social health insurance. The article investigates the widespread assumption that reform programs have adverse effects on solidarity in social health insurance by looking at the concrete experience of four European countries (Belgium, Germany, The Netherlands, and Switzerland) over the past decade. A distinction is made between risk solidarity and income solidarity, and the scope of solidarity is shown to have two dimensions: entitlements and membership. The analysis consists of three parts: description of the structure of health insurance of each of the four countries in the early 1990s; discussion of health insurance reform; determination of the impact on each dimension of solidarity. The findings are mixed. There are indeed some examples of solidarity having declined as the result of health insurance reform. But, more important, many examples also were found of an increase in solidarity due to health insurance reform. In some cases, reform was explicitly intended to improve solidarity. If a reform program had a negative impact on solidarity (e.g., an increase in private payments), accompanying measures often were taken to keep solidarity intact as much as possible. Thus the assumption of a negative impact as a result of health insurance reform is not confirmed.

Belgium↗
PubMed2004

Differences in facilities' acceptance of patients under long-term care insurance in Japan.

OBJECTIVES: In April 2000, Japan launched a public, long-term care insurance (LTCI) plan for elderly people who need support. This study describes how medical support for the elderly is delivered at LTCI care facilities in Japan now and gaps between system goals and current activity. Recommendations are made for enhancing the implementation of LTCI. METHODS: We mailed questionnaires to all health service facilities for the elderly (HSF) and special nursing homes for the elderly (SNH) located in the Kyushu area of Japan, asking whether they would accept patients with nine specific conditions. RESULTS: We found that HSFs, which are required to employ a full-time doctor and are reimbursed at a higher rate, accept significantly fewer patients with four conditions that need medical support than are accepted by SNHs, which are not required to employ a full-time doctor. DISCUSSION: In this study, we find discrepancies between system goals and current activities at LTCI care facilities. For the Japanese LTCI system to work well in the limitation of medical resources, we must understand how it really works and to reform the system continuously.

Aged↗
PubMed2004

A comprehensive snapshot of States' small group market reforms on insurer pricing & rating practices, 1999.

This paper presents a qualitative analysis of states' small group health insurance reforms that impact small group premiums, mostly enacted by the states during 1996-99, following the federal Health Insurance Portability and Accountability Act in 1996. It draws from an intensive review of statutes of 48 states and the District of Columbia as of 1999. It analyses regulations related to insurer pricing and rating practices concerning rating criteria and rating bands, pricing incentives, premium stability from year to year, minimum loss rations, reinsurance and carve-out coverage for the medically uninsurable. It also covers regulations targeting employer purchasing and coverage practices such as pooled purchasing and adverse selection. This is the second of a two-part series analyzing states' small group market reforms, the first being devoted to state reforms to promote access and improving the value of health plans offered in this market (Xirasagar et al. 2004). The variety in pricing and rating reforms illustrate the differences in the depth of reforms across states, and represent a far wider range of potential actuarial combinations than the sample of reforms documented in past literature.

Health Care Reform↗
PubMed2001

Insurance against germ theory: commerce and conservatism in late-Victorian medicine.

This article highlights the role played by commercial life insurance companies in determining the response to tuberculosis in Britain between 1865 and 1920. Late-Victorian life offices hired two sorts of physicians to help them screen out high-risk proposals: provincial medical examiners, who collected fees for examining candidates; and salaried medical advisors, who developed guidelines for the medical examination and interpreted the examiners' findings for the head office. The latter set of physicians, many of whom worked at specialist consumption hospitals in London, established an orthodoxy among life offices that privileged hereditarian explanations for the cause of tuberculosis. The provincial examiners resisted that orthodoxy, arguing that advances in public health and treatment rendered irrelevant any apparent correlation between family history and tuberculosis. In adjudicating this internal dispute, life offices stood by their salaried advisors, but in the process pushed them away from viewing disease in terms of specific causes and toward viewing disease in terms of statistical correlation. This victory of statistics over etiology preserved, at least for the rest of the twentieth century, the institutional prominence of insurance as a technique for coping with medical uncertainty.

Attitude of Health Personnel↗
PubMedDate not supplied

Prescription drugs and the elderly: issues and options.

This paper examines the elderly's need for prescription drug insurance, the extent and depth of current coverage supplementary to Medicare, the characteristics of those who have coverage and those who do not, and the problem of adverse selection in individual insurance for prescription drugs. It also discusses the issues that must be resolved in choosing the direction public policy should take if more of the elderly are to be covered and examines the advantages and disadvantages of four illustrative public policy options, ranging from small expansions of Medicaid benefits through "Medigap" regulation to Medicare coverage for all elderly.

Aged↗
PubMedDate not supplied

The politics and economics of mental health 'parity' laws.

The enactment of the Domenici-Wellstone amendment in September 1996, which calls for the elimination of certain limits on coverage for mental health care under private insurance, is being hailed as a major step forward in the quest for "parity" in mental health coverage. Parity legislation is being introduced in a number of state legislatures and is finding new enthusiasm in Congress. In this paper we consider the efficiency rationale for these laws and examine their likely impact in the era of managed care. We conclude that although such successes represent important political events, they may offer only small gains in the efficiency and fairness of insurance markets.

Health Services Accessibility↗
PubMedDate not supplied

The ethics of Pharmaceutical benefit management.

Efforts to limit pharmacy costs raise both ethical and economic considerations. Six values should inform pharmacy benefit management: (1) accepting resource constraints; (2) helping the sick; (3) protecting the worst off; (4) respecting autonomy; (5) sustaining trust; and (6) promoting inclusive decision making. Direct controls, such as formularies, step therapy, and prior authorization, can focus limited resources on the sick and worst off. However, direct controls limit autonomy and are administratively burdensome. Indirect controls, such as physician capitation, tiered copayments, and drug benefit caps, align physicians' and patients' interests with resource constraints, respect autonomy, and are administratively efficient. Unfortunately, they deter use based on cost, not medical need; they do not focus cuts on unnecessary or marginal drug use or focus resources on the sick. Budget caps are the least defensible, while tiered copays and physician capitation can be justified if implemented with safeguards. Formularies and step therapy are ethically justifiable if they can be efficiently instituted.

Capitation Fee↗
PubMedDate not supplied

How health insurance inhibits trade in health care.

A range of health care services are tradable, in that consumers can travel abroad for treatment. In this paper we first estimate the gains from trade. An international price comparison of fifteen procedures reveals that there could be savings of around 1.4 billion dollars annually even if only one in ten U.S. patients choose to undergo treatment abroad. We then identify a key impediment to realizing these gains: the nature of existing health insurance plans, which discriminate explicitly or implicitly against treatment abroad. We propose that coverage should be neutral to provider location and that reimbursement should include travel costs.

Commerce↗
PubMedDate not supplied

Implications of Part D for mentally ill dual eligibles: a challenge for Medicare.

Through the Part D drug program, Medicare has assumed responsibility for the prescription drug needs of beneficiaries and, consequently, for an important component of mental health treatment: psychotropic drugs. Managing the prescription drug benefits of mentally ill dual eligibles could challenge this new program. Efforts to balance quality assurance and cost-effectiveness will be complicated by this population's vulnerability and high level of health care need, the uncertainties surrounding optimal psychotropic drug use, and the economic incentives of prescription-only insurers. We discuss the details and policy implications of this challenge.

Cost Sharing↗
PubMedDate not supplied

The costs of mental health parity: still an impediment?

Parity in mental health benefits rectifies unfairness in health insurance coverage and reduces financial risk for those with mental illness. However, increased coverage for mental illness has been seen as creating inefficiencies and increasing total spending, based largely on results from the RAND Health Insurance Experiment conducted in the 1970s. Newer evidence suggests that cost control techniques associated with managed care give health plans alternatives to discriminatory coverage for containing costs. We review both eras of research on mental health insurance and conclude that comprehensive parity implemented in the context of managed care would have little impact on total spending.

Cost Control↗
PubMedDate not supplied

The relationship between health plan advertising and market incentives: evidence of risk-selective behavior.

Medicare beneficiaries are now facing advertising from an unprecedented number of health plans that are offering prescription drug coverage. Previous Medicare managed care efforts have been undermined by risk selection, the practice of enrolling healthier and therefore less costly patients. In this study we explore how the content of health plan advertising is related to the competitiveness of the health plan market. We find that increased competition is associated with greater use of advertising that targets healthier patients.

Advertising↗