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PubMed2006

Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform.

SETTING: Seven public hospitals in a southern province of Thailand. OBJECTIVES: To measure delays in tuberculosis (TB) diagnosis and to examine the factors associated with these delays, with special focus on the effect of drug store utilisation and health insurance coverage on patient delay. DESIGN: A total of 202 newly diagnosed smear-positive and smear-negative pulmonary TB patients were interviewed using a structured questionnaire. RESULTS: The median patient, health system and total delay were 4.4, 2.8 and 9.4 weeks, respectively. Risk factors for patient delay were age 31-60 years, having mild illness, previous similar symptoms and first presenting to non-qualified providers. Health insurance was not associated with a shorter patient delay. Health system delay was significant longer for patients with health insurance and first presenting to low-level public health facility (i.e., community hospital, health centre, primary care unit or private clinic/hospital). CONCLUSIONS: The public should be informed how to recognise TB symptoms to shorten patient delay. The Thai National Tuberculosis Control Programme needs to supervise the private health sector, including drug stores, for better TB control. Drug store personnel need to be trained to recognise and refer TB suspects. The capacity of low-level public health facilities and private doctors in TB diagnosis needs improvement. A proper referral system should be developed.

Adolescent↗
PubMed1997

Unemployment in inner-city renal transplant recipients: predictive and sociodemographic factors.

Studies of dialysis patients report unemployment rates of 60% to 75%; however, it is generally believed that following transplantation, improvement in well-being and removal of time constraints imposed by the dialytic regimen afford improvement in employment status. We studied 58 stable renal transplant recipient attending an outpatient transplant clinic by questionnaire, administered anonymously. Only 25 (43%) of the patients were currently employed. Employed and unemployed patients did not differ when compared for age, gender, race, cause of renal disease, type of transplant or prior dialysis, time on dialysis or time since transplantation, years of education, or prestige score or classification ("blue collar" v "white collar") of prior job. In the employed group, 24 (96%) patients had worked before developing kidney disease compared with 23 (70%) patients in the unemployed group (P < 0.05). While on dialysis, 19 (79%) of the employed patients continued working compared with 10 (30%) of the unemployed patients (P < 0.005). Major reasons for discontinuing work after starting dialysis for both groups were subjective illness (feeling too sick, 51%), followed by interference of the dialysis regimen with time necessary for work (32%). Only 15% of the previously employed patients did not work after transplantation because of feeling too sick. By multiple logistic regression, the strongest predictors of employment posttransplant were being more than 1 year posttransplant (odds ratio, 2.35; 95% confidence interval, 1.01 to 5.5) and having been employed before transplantation (odds ratio, 3.79; 95% confidence interval, 1.60 to 9.02). Over half of the unemployed patients (20 [61%]) expressed interest in job training. Eighty percent to 90% of patients in both groups were insured by Medicare, with the second greatest number insured by Medicaid. Of the 15 unemployed patients insured by Medicaid, 67% reported that their decision not to work was related to fear of losing Medicaid benefits because they could not afford medications without it. Despite no difference in actual type of insurance carried, 17 (51%) of the unemployed patients believed their health insurance coverage was inadequate compared with four (12%) of the employed patients (P = 0.005, chi-squared test). Unemployment remains a significant problem for our population of inner-city renal transplant recipients. Attention to job retention or retraining during the early renal disease and dialysis therapy period may promote better rehabilitation following transplantation. However, for this population, with limited employment opportunities, removal of disincentives to work, including loss of Insurance and Inability to pay for medications, will be necessary before we can provide optimal rehabilitation for renal transplant recipients from all social strata.

Adult↗
PubMed1989

The politics of employment-based insurance in the United States.

Analyses of the corporatization of U.S. health care typically focus on the political struggle between corporations and traditional health care providers, e.g., physicians. A neglected area of study is the struggle between corporations and their employees over the employment-based health insurance system. Yet, since this system is currently the primary mechanism for financing health care in the United States, an analysis of its historical development is critical to any understanding of the corporatization of U.S. health care. It is argued here that the employment-based health insurance system was a part of a political compromise between capital and labor that emerged after World War II. In exchange for control over production and increased worker productivity, corporations agreed to provide workers with steady wage increases and an expanded system of fringe benefits, or "corporate welfare." But, by the late 1970s, rising health care costs created a corporate health care financing crisis that has prompted corporations to cut back employee health insurance coverage. The relative inability of workers to resist such cutbacks reveals the extent to which, by linking health care to wage labor, the "corporate welfare" system has made the U.S. working class more vulnerable to corporate power.

Economics↗
PubMed1996

Current prevalence of asthma-related symptoms in San Diego's predominantly Hispanic inner-city children.

Ethnic minorities of low socioeconomic status are disproportionately represented in the trends of increasing asthma prevalence, morbidity, and mortality. We surveyed a cohort of 998 fourth-grade students in an impoverished area of southeast San Diego with a high percentage of Hispanic Mexican-Americans. Of the 654 Hispanic 9-12-year-olds, 14.4% were categorized as probable current asthma (within the past year), based on symptom of wheezing or physician diagnosis of asthma [with respiratory symptom(s) or medication]. An additional 13.5% had respiratory symptoms indicating possible asthma. Differences by ethnic group in the percentage of probable asthma or related symptoms were highly significant (p < 0.0001). Among Hispanics with a category of probable asthma, only 57.4% had a physician diagnosis versus 80.6% of black and 85.7% of white students. The frequency of health insurance coverage differed significantly between ethnic groups (p < 0.0001), with Hispanics among the lowest (37.2%).

Absenteeism↗
PubMed1991

Uncompensated care provided by private practice physicians in Florida.

While a great deal of attention has been paid in recent years to establishing the magnitude and characteristics of uncompensated care in hospitals, comparatively little research has been undertaken to study physician uncompensated care. This article reports the results of a prospective patient-specific study of uncompensated care in Florida. Of 4,042 cases examined, 26.2 percent had charges voluntarily reduced below the usual and customary charge at the time of service. However, only 13.5 percent of those reductions were attributed to charity. Overall, 10.4 percent of the total billed amount was left unresolved. When payment source was considered, it was found that self-pay patients accounted for 30.6 percent of the cases but accounted for 52.0 percent of the unresolved amounts. Further analysis indicated that the self-pay patients were 35.5 times more likely to leave an outstanding balance than individuals with some type of insurance coverage. Odds of unresolved balances were also calculated as a function of income, specialty type, practice size, and type of visit.

Adolescent↗
PubMed1978

Why do HMOs seem to provide more health maintenance services?

Greater use of preventive services by enrollees of HMOs than of other health plans is often assumed to reflect differences in philosophy about "health maintenance." But organizational forms are less important than extent of insurance coverage in influencing use of preventive services. Policy options for improved health status will have to challenge ideologies of prevention and financing.

Adolescent↗
PubMed2005

Genetic effects on physical health: lower at higher income levels.

Given the robust finding that people in higher income groups tend to experience better physical health, there is interest in identifying mechanisms underlying this gradient. Using a nationwide sample of 719 twin pairs from the National Survey of Midlife Development in the United States, we investigated the possibility that gene-environment interaction underlies the income-health gradient. We observed that genetic variance associated with 2 measures of physical health, number of chronic illnesses and body mass index, each declined significantly with increasing income. This interaction effect could not be removed by adjusting income for the presence of health insurance coverage and education, suggesting that the interaction is not simply a result of differences in levels of those characteristics with income.

Adult↗
PubMed1996

[Quality assurance in trauma surgery--meaning, characteristics and methods].

For trauma surgeons the compliance with and keeping to well organized and planned courses of action is obligatory. This is valid as well for the highly sensitive areas of preclinical emergency treatment, the primary treatment in the hospital and the exceptional management in polytrauma, as for treatment of solitary injuries of the musculo-skeletal system. Despite considerable activities--so far voluntarily--(optimization of courses of action, classification systems for injury grades, algorithms and close-meshed further education) control mechanisms are demanded by politicians and insurance companies. Therefore, comprehensive quality control is strived for in all different types of insurance coverage systems. In spite of justifiable restraints against control mechanisms, which oppose increasingly medical freedom in diagnostics and treatment, only cooperation with and proficient guidance of the often self-appointed quality assurance personnel is useful.

Algorithms↗
PubMed1987

The importance of distinguishing Hispanic subpopulations in the use of medical care.

Rather than analyzing Hispanics as a homogeneous population, this paper uses the 1977 National Medical Care Expenditure Survey in order to make separate national estimates for Cubans, Puerto Ricans, and Mexicans. Utilization of various health services by these three groups is discussed, as well as their insurance coverage, mean annual expenses by source of payment, and health status indicators. The analysis has a descriptive as well as multivariate component and focuses specifically on the use of physician and hospital services and prescribed medicines. It is found that Puerto Ricans are almost twice as likely as Mexicans, and over four times as likely as Cubans, to be covered by Medicaid; Cubans, on the other hand, are most often privately insured. Of the three groups, Puerto Ricans have the highest annual expenses and are most likely to have at least one physician visit. The number of visits for those with a visit, however, is identical across the groups. The paper discusses the policy implications of these findings, as well as the methodologic implications of classifying various Hispanic subgroups into one all-encompassing category.

Adolescent↗
PubMed1984

Peer review, third-party payment, and the analytic situation: a case report.

The complexities of insurance coverage and peer review as they intrude into the analytic situation were discussed. The basic question was raised of whether becoming acceptable to major health providers through the peer-review program is truly a compromise of the analytic pact and a threat to the future of psychoanalysis. Practical as well as technical considerations facing the analyst when he is confronted with having to write a report to the patient's insurance company were elucidated. Countertransference feelings were emphasized. A detailed case illustration was presented to demonstrate that peer review, as it relates to third-party payment, need not compromise an analysis.

Adult↗
PubMed1983

Depression, problem recognition, and professional consultation.

Data are from a 1979 community sample (n = 1000) of adults in Los Angeles County. The analysis examines how depressive symptoms, measured with the Center for Epidemiologic Studies Depression (CES-D) scale, and a variety of other factors influence problem recognition and use of mental health services. Of those people with a high level of depressive symptoms, nearly one third view themselves as having a nondepressive problem, while another third view themselves as having no personal problem. After controlling for demographic and other factors, depressive symptoms emerge as the most important element enhancing problem recognition; being female and having more education also enhance recognition of depressive problems and enable people to distinguish depressive from other problems. Among those with a high level of depressive symptoms, only one third had consulted a mental health service in the prior year. Factors promoting use of mental health services among those who acknowledge a personal problem include depressive symptoms, prior use of mental health services, use of services by friends and relatives, and discussion with friends and relatives about counseling; no significant effects emerge for sex, age, education, income, or insurance coverage. Data from the untreated show that a self-reliant attitude and some practical barriers prevent people with depressive symptoms from obtaining professional help.

Adult↗
PubMed2003

Racial and ethnic disparities in the purchase of nongroup health insurance: the roles of community and family-level factors.

OBJECTIVE: To evaluate the influence of community- and family-level factors on racial/ethnic disparities in the uptake of nongroup (individual) health insurance. DATA SOURCES: Responses to the 1996-1997 Community Tracking Study Household Survey plus community-level descriptors from several sources including census data, the Area Resource File, and community and migrant health center Medicare cost reports. STUDY DESIGN: Logistic regression was used to compare families in which at least one person had nongroup health insurance to families without nongroup insurance in which at least one person was uninsured. Sequential models were constructed examining family- and community-level factors. RESULTS: Twenty-three percent of families with otherwise-uninsured persons purchased nongroup insurance, ranging from 11% to 41% among the 60 communities sampled. Disadvantaged minority group members, especially Spanish-speaking Hispanics, had half or less the odds of whites of purchasing nongroup insurance. Education had a weaker association with purchasing nongroup insurance among minority group members than among whites. Community-level factors had minimal effect on disparities in uptake, although greater housing segregation was associated with lower uptake among blacks. CONCLUSIONS: Minority group members are much less likely to purchase nongroup insurance than whites. Family income and community factors do not explain this gap. Programs aimed at stimulating voluntary insurance purchase will continue to underenroll disadvantaged minorities if nonfinancial barriers to acquiring insurance coverage, including the interplay between race/ethnicity and education, are not better understood and addressed.

Black or African American↗
PubMed1990

Maternity care financing: universal access or universal care?

In an era of fiscal constraint, growing poverty, increased uninsuredness, medical liability problems, and increasing costs of maternity care, public and private financing mechanisms are changing rapidly and the service delivery system is increasingly fragmented. Despite the almost mercurial changes in the system, data from national studies show that access to care is a major problem affecting all childbearing women. This paper describes the three groups of women who require comprehensive maternity care, their insurance coverage, and the gaps for each group. It describes proposals which are currently under development to reduce uninsuredness and produce universal access and, in addition, presents an alternative plan for universal maternity care.

Costs and Cost Analysis↗
PubMedDate not supplied

Why physician groups are self-insuring.

Given the medical malpractice crisis in a number of states, many physicians are looking at alternatives to conventional insurance coverage. These options typically involve some form of risk sharing where the medical group assumes additional risks based on experience. This article identifies several options-retrospective payment plans, risk retention groups, captives, and rent-a-captives--and their associated risks and opportunities.

Humans↗
PubMedDate not supplied

Comorbidities of HIV-1/AIDS in adults.

The comorbid diagnoses associated with illness due to human immunodeficiency virus type 1 (HIV-1) are cumulative, multiple, and varied. These diagnoses start with primary infection, then progress to symptomatic illness and finally to AIDS-indicator diseases. The author reviews this progression and additional variables such as preexisting health problems, socioeconomic status, health insurance coverage, and educational level. Based on an understanding of the preexisting problems, as well as the HIV-1 trajectory, the author outlines the implications for future nursing education, practice, and research.

AIDS-Related Opportunistic Infections↗
PubMed1995

Preschool children. Need and use of dental services.

There have been major decreases in dental diseases, but many youngsters are still in need of care, especially low-income and medically compromised children. Additionally, family structure and economic changes are placing children at increased risk for dental diseases. Although there is a progressive increase in the use of services, many children don't have insurance coverage and do not receive preventive and restorative dental care. The preschool years are a foundation period for children, but many continue to receive an uncertain start.

Child, Preschool↗
PubMed1994

Changes in employment, insurance, and income in relation to HIV status and disease progression. The Multicenter AIDS Cohort Study.

While patterns of health care financing for HIV have received considerable attention in the literature, the financial impact of disease on individuals living with HIV infection has been underexplored, particularly in relation to disease progression. Therefore, we sought to document changes in employment, income, and insurance coverage over time among HIV-negative, HIV-positive, and AIDS-diagnosed gay and bisexual men participating in the Multicenter AIDS Cohort Study (MACS) and to document measures of financial hardship. Persons with AIDS (PWAs) were 2.7 times more likely to lose full-time employment over a 6-month period than seronegative persons (p < 0.05), and loss of employment was strongly associated (p < 0.001) with both loss of private health insurance and loss of income. Twenty-seven percent of PWAs reported having financial difficulty meeting their basic expenses, compared with 10% of seronegative (p < 0.001), and 15% of PWAs, compared with only 9% of seronegative persons, said that, for financial reasons, they had not sought medical care that they thought they needed (p = 0.028). When 27% of PWAs in a cohort such as this report financial difficulty meeting their basic expenses, it is clear that the response of our public health and social welfare systems has not been adequate. Given that the problems experienced by most persons infected by HIV are considerably more severe than those experienced by MACS participants, the imperative for action is even greater.

Acquired Immunodeficiency Syndrome↗
PubMed1997

An attempt to withdraw coverage by the insurance company in the event of gross negligence. Costs totalling US $ 4.5 million.

In its judgement of 11 June 1993, the Court of Appeal of Brussels upheld the personal liability of a trainee and the in solidum liability of the hospital in a case where an erroneous spinal injection caused permanent paraplegia and incontinence. Although the attempt of withdrawal coverage by the insurance company on base of the concept of gross negligence, did not succeed in this case, it is clear that under the new insurance law of 25 June 1992, several risks will not be covered by the insurance companies in the future. The exemplary list of gross negligence cases, which may be used by the insurance companies, involves predominantly anesthesiology practice. The coverage of several insurance contracts exclude e.g., damages resulting from simultaneous anesthesia, or from the absence of an anesthesiologist during the full course of the surgery and damages resulting from anesthesia in the absence of necessary monitoring and reanimation equipment.

Anesthesia, Spinal↗