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Mandated mental health benefits in private health insurance.

Eleven states mandate coverage of inpatient and outpatient mental health care in private health insurance. Health insurers have objected to these laws on the grounds that they interfere with consumer choice of health insurance benefits and are too costly. This paper analyzes the benefits and costs of mandates for psychotherapy. The potential benefits considered have to do with adverse selection in insurance markets and the offset effects of psychotherapy. Arguments based on economic efficiency are presented to justify the possible appropriateness of overriding individuals' choice of health insurance benefits. Mandates are estimated econometrically to increase the cost of psychotherapy in a state by about 10-20 percent. We conclude that mandates for mental health benefits in private health insurance may be reasonable state policy.

Actuarial Analysis↗

The Mazankowski Report: can we fix medicare with more private financing.

The Mazankowski Report is a very important contribution to the debate washing over Canada with regard to the future of its most cherished social program, medicare. While a complete analysis of the report is not possible in this brief comment, several observations and arguments should be made. First, the report's recommendations for a greater role for private financing undermines the other excellent recommendations made with regard to greater accountability, the rigorous pursuit of quality and greater flexibility regarding the role of the private sector in delivery (as opposed to financing). Second, the report's specific recommendation to establish a permanent, independent panel to determine what services should and should not be publicly funded is a worthwhile reform, but not for the reasons envisaged by the report's authors - that is, because it will result in a reduction in the range of services funded and save public dollars. Rather, it is a worthwhile initiative because engaging in a transparent and explicit determination of what is in and out of the publicly funded basket is likely to result in more political support for publicly funding a wide range of care rather than less.

Alberta↗

Providing therapy when managed care organizations deny reimbursement: are private practitioners and their clients taking the fall?

Sampled private practitioners from the Register of Clinical Social Workers, American Psychological and Psychiatric Associations were used to evaluate what percentage of these practitioners' caseloads are made up of clients who have been denied reimbursement by managed care organizations for ongoing therapy. The results indicate that 39% of the respondents' caseloads are of managed care insured clients, of whom nearly one-third have been denied reimbursement for ongoing therapy, and of whom 42% later reenter therapy with an acute exacerbation of symptoms. The results have potential ethical and legal complications for private practitioners treating clients insured by managed care organizations.

Analysis of Variance↗

Office abortion services for women: private physician providers.

Research suggests that private physician providers of office abortions and the women who seek their services are not included in nationwide surveys of abortion statistics. This study describes the demographic characteristics of private physicians and the prevalence of abortions performed in their offices in Los Angeles County, California, a state in which office abortions are prohibited by law. Factors that influence physicians' decisions to provide the service, as well as the age and ethnicity of the office abortion recipients, are examined. Of 1,004 California Medical Association members who practiced obstetrics and gynecology in Los Angeles County during 1990, 49% returned anonymous, confidential surveys. Seventy percent of physicians had performed at least one abortion in California, and 29% were currently providing this service in their offices. Physician gender, age, ethnicity, and religion were associated with performing abortions. The average abortion patient was not young and ethnic, but White, middle-class, and in her mid- to late twenties. The implications of these findings are discussed.

Abortion, Legal↗

Evaluation of 4 years of clinical pharmacist anticoagulation case management in a rural, private physician office.

OBJECTIVES: To evaluate patient outcomes after 4 years of anticoagulation case management by a pharmacist and to document patient and provider satisfaction with the service. SETTING: Rural, private physician office in Mt. Vernon, Iowa. PRACTICE DESCRIPTION: Clinical pharmacist anticoagulation clinic. PRACTICE INNOVATION: Under a protocol reviewed annually, a clinical pharmacist faculty member from the University of Iowa College of Pharmacy provides on-site, point-of-care anticoagulation dose adjustment and monitoring 1 day per week. MAIN OUTCOME MEASURES: Data on anticoagulation outcomes from 1998 to 2002 were obtained through retrospective review of medical charts of patients served by the clinic. A survey of patient satisfaction with the clinic was mailed to all currently active patients enrolled in the anticoagulation clinic, and a second satisfaction survey was distributed to providers and ancillary staff of the physician office. RESULTS: Eighty patients met the criteria for evaluation of therapeutic outcomes. The mean +/- standard deviation percentage of international normalized ratios in the therapeutic range ("percent therapeutic") for the anticoagulation clinic population was 57.5 +/- 17.4. The percent therapeutic for patients who had been on warfarin before enrolling in the pharmacist case management anticoagulation clinic (defined as the usual medical care group) was 37.6%, compared with 57.8% for those patients receiving care in the pharmacist case management anticoagulation clinic (P < .001). In nearly all instances, responses to the surveys indicated that patient and provider satisfaction with the anticoagulation service was extremely high. CONCLUSION: A clinical pharmacist can provide anticoagulation case management services safely and effectively in a private physician office, and the service is highly valued by both patients and providers. We believe case management is an optimal method for systematically monitoring outpatient anticoagulation therapies and is preferable to usual medical care.

Adult↗

Comparing Medicare and private insurers: growth rates in spending over three decades.

Over the past three decades both Medicare and private insurers have initiated cost containment mechanisms to control the growth of spending on personal health care. To compare spending growth between these two payers, we present four measurement principles that should be implemented when drawing such comparisons, and we apply them to the National Health Accounts data files. We attribute Medicare's ability to equal--and using our measures, actually exceed-the private sector in controllingthe rate of health spending growth to Medicare's ability to price aggressively for the services it covers.

Health Care Surveys↗

Private health insurance in developing countries.

A joint Wharton School-World Bank conference called attention to the high proportions of medical care spending paid out of pocket in most developing countries. One of the reasons for this, attendees said, is the problem in such economies of generating high tax revenues in a nondistortive way. Since people are paying out of pocket, they should be able to afford some private insurance that can spread the risk of above-average out-of-pocket payments. The potential efficiency gains from greater use of voluntary private insurance seem large, but there are a number of possible impediments to the emergence of such insurance.

Developing Countries↗

Clinical and economic impact of enterovirus illness in private pediatric practice.

OBJECTIVE: To characterize the acute clinical course and economic burden of nonpolio enteroviral (NPEV) illness in the summer/fall season as seen in private pediatric practice. METHODS: We prospectively studied 380 children aged 4 to 18 years with systemic NPEV syndromes presenting to private suburban pediatric practices. Seventy-three asymptomatic controls were concurrently enrolled. Clinical diagnosis of NPEV illness was based on the presence of fever plus at least one of the following: headache and stiff neck (n = 2); myalgia and malaise (n = 105); nonpuritic maculopapular rash (n = 10); papulovesicular stomatitis (n = 214); papular rash of the hands, feet, and mouth (H/F/M) (n = 30); or pleurodynia (n = 11). Study participants were enrolled during a 4-month time span (July-October, 1994) and followed daily for 14 days. A parent symptom diary card and twice weekly phone contacts by study nurses characterized the illness to include the frequency of health care contacts, the necessity for laboratory tests, medication use, and school/work absenteeism. RESULTS: Three hundred seventy-two (98%) children completed the study; 122 (33%) of the patients were confirmed to be infected with NPEV. Confirmed NPEV infection was more frequently observed in Rochester, NY (85/147 = 58%) than in Scottsdale, AZ (32/224 = 14%). The age group 4 to 12 years comprised 79% to 90% of the enrollees, depending on the syndrome. Median duration of illness and median number of missed days of school/summer camp/work for the enrolled patients was: meningitis (7 days ill, 2 days missed), myalgia/malaise (9 days ill, 3 days missed), rash (6 days ill, 4 days missed), stomatitis (7 days ill, 2 days missed), H/F/M (7 days ill, 1 day missed), and pleurodynia (8 days ill, 3 days missed). Direct medical costs varied from $69 per case to $771 per case and indirect costs, attributable primarily to parent missed work and/or sick-child care, varied from $63 per case to $422 per case for H/F/M and meningitis, respectively. In households, H/F/M spread to 50% of siblings and 25% of parents. CONCLUSIONS: In our study population, NPEV infection: 1) caused sufficient illness to prompt physician visits in summer and fall; 2) occurred more frequently in 4 to 12 year olds than in adolescents; 3) produced various clinical syndromes concurrently during the same months in the same season of a given year; 4) varied in occurrence geographically; 5) was characterized by numerous symptoms of longer duration than previously recognized; and 6) produced a significant economic impact by generating both direct and indirect costs.

Absenteeism↗

Does gatekeeping control costs for privately insured children? Findings from the 1996 medical expenditure panel survey.

OBJECTIVE: Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking. METHODS: We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. RESULTS: Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% (887 dollars vs 881 dollars, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were 636 dollars versus 595 dollars by indemnity plans. Out-of-pocket payments were on average 62 dollars less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees. CONCLUSION: In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately 8 dollars less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.

Child↗

[The experience of inservice education in a private institution].

The experience was developed in a private hospital of the Rio de Janeiro, with 60 patients, in the period of 1987 to 1988. The objective are: To report the experience of the service education cordenation in a private institution. To contributer to the practice and scientific improvement of the brazilian nursing. The service education happened in the following areas: 1) Personnel recruitment; 2) Training; 3) Recycling and continuous education; 4) Case study; 5) Improvement and development through the incentive in talking part of nursing meetings.

Brazil↗

[Cost of osteoporotic hip fracture in the Brazilian private health care system].

OBJECTIVE: To assess the direct cost during hospitalization for an osteoporotic hip fracture in Brazilian private health care system, by health plan companies' perspective. METHODS: We conducted a cross-sectional and retrospective study on costs of medical resources in patients above 50 years with an osteoporotic hip fracture, under hospital treatment, between July 2003 and June 2004. The study sample was collected from electronic claims databases of patients enrolled in Brazilian health plans. RESULTS: There were 129,611 patients with osteoporosis diagnosis. The incidence of osteoporotic hip fracture was 4.99% (women). The mean length of hospital stay was 9.21 days (2.13 days in ICU). The total mean cost of hospitalization was R$ 24,000. The largest cost component was attributable to medical device (61%). The economic burden of osteoporotic hip fracture to health plan companies was estimated in R$ 12 million. CONCLUSION: The costs of treating osteoporotic hip fracture are substantial in Brazilian private health care system. This study highlights the savings to health plan companies if an osteoporotic hip fracture can be avoided.

Acute Disease↗

Demographic and anthropometrical analysis and genotype distribution of chronic hepatitis C patients treated in public and private reference centers in Brazil.

Hepatitis C virus (HCV) infection is a serious public health problem, since 80% to 85% of HCV carriers develop a persistent infection that can progress into liver cirrhosis and hepatocarcinoma. Considering that the response of hepatitis C patients to combination therapy with interferon and ribavirin depends on HCV characteristics as well as on host features, we made a retrospective analysis of demographic and anthropometrical data and HCV genotype distribution of chronic hepatitis C patients treated in public and private reference centers in Brazil. The medical records of 4,996 patients were reviewed, 81% from public and 19% from private institutions. Patients' median age was 46 years, and there was a higher prevalence of male (62%) and white patients (80%). The analysis of HCV-infecting strains showed a predominance of genotype 1 (64%) over genotypes 2 and 3. The patients' mean weight was 70.6 kg, and 65% of the patients weighed less than 77 kg. Overweight and obesity were observed in 37.8% and 13.6% of the patients, respectively. Since a body weight of 75 kg or less has been considered an independent factor that significantly increases the odds of achieving a sustained virological response, the Brazilian population seems to have a more favorable body weight profile to achieve a sustained response than the American and European populations. The finding that 65% of chronic hepatitis C patients have a body weight of 77 kg or less may have a positive pharmacoeconomic impact on the treatment of genotype 1 HCV patients with weight-based doses of peginterferon.

Adolescent↗

Government and private insurance medical programs as well as MDVIP, an update.

On November 19,1945, President Truman outlined a Prepaid Medical Insurance Plan for all people through the Social Security System. Because of its comprehensive nature, it was coined "National Health Insurance." On July 30,1965, President Johnson signed the Medicare and Medicaid bill (Title XVII and Title XIX of the Social Security Act). Today, many groups of people are covered by Medicaid. However, there are strict requirements that may vary from state to state. Medicare offers the following types of medical heath care plans to include the original Medicare plan that is a "fee for service" plan. The individual may stay in the original plan unless he/she chooses to join a Medicare+ Choice Plan or a Medigap Plan. Most individuals will receive Medicare Part A when they are 65 without paying a premium because it has been deducted annually through their tax payments before the age of 65. Medicare Part A helps pay for the following: inpatient hospital care, skilled nursing facility, hospice care, and some home health care. Medicare Part B, however, must be paid by the individual through premiums to the Federal government. Medicare Part B medical insurance pays for doctors' services, outpatient services, and some other services that Medicare Part A doesn't cover. In an effort to supplement one's health care coverage, the individual may select either a Medicare+ Choice Plan or a Medigap Policy. The Medicare+ Choice Plan has four different types: Medicare Managed Care Plans, Medicare Private Fee for Service Plan, Medicare Preferred Provider Plans, and Medicare Specialty Plans. If one selects a Medigap policy, one may choose either a Medigap SELECT Policy or the standard Medigap policy. The front of a Medigap Policy must clearly identify it as a "Medicare Supplement Insurance." One must be carefully advised of the selection of the Medigap Policy. The Medicare Part B has a wide range of preventative services, including tests for breast cancer, cervical cancer, vaginal cancer, and colorectal cancer; bone mass measurements; diabetes monitoring and diabetes self-management; flu, pneumonia, Hepatitis B shots, and prostate cancer screening tests. It is important to emphasize that Medicare and Medicare supplemental insurance policies do not pay for home health care, such as durable medical equipment. Because of the enormous complexity of the wide variety of health insurance plans and their billing strategies, many physicians are electing to charge their patients an additional fee for being part of their practice. In return for their annual fee, their patients receive immediate cell phone access to their doctor 24 hours a day, 7 days a week. In addition, they receive same-day appointments and on-time appointments. They also spend as much time with their doctors as they wish. It is not surprising that there is growing evidence that the privately insured patient with a life-threatening illness will live longer than those individuals who have the same disease but have public insurance only. Legislatures are well aware of this crisis in medical care that must be corrected immediately.

Aged↗

A comparison of the success of root resected molars and molar position implants in function in a private practice: results of up to 15-plus years.

BACKGROUND: When faced with a furcated molar, today's clinician must decide between a number of treatment options, including root resection, tooth removal, and implant placement. This paper assesses the results in one private clinical practice of root resection and subsequent restoration or molar implant placement and subsequent restoration. Clinical considerations in treatment selection are discussed. METHODS: A retrospective analysis of treated patients was carried out by examining active and inactive patient charts. When patients had discontinued therapy, every effort was made to determine the reason for leaving the private practice, so as to assess the impact of previously undocumented treatment failure on the statistics in question. RESULTS: A total 701 root resected molars and 1,472 molar implants were evaluated after > or = 15 and 13 years in function, respectively. Resection of the distal root of a mandibular molar demonstrated the lowest success rate (75%). All other success rates for various root resected molars in function ranged from 95.2% to 100%. Lone standing implants in second molar positions demonstrated the lowest success rate (85%). All other implant use in molar positions demonstrated a success rate ranging from 97.0% to 98.6%. Root resected molars and molar implants demonstrated the highest degree of failure when they were lone standing terminal abutments. Seven out of 23 (30.4%) root resected molar failures, and 17 of 45 (37.8%) of the molar implant failures were associated with untreated parafunction. Cumulative success rates were 96.8% for root resected molars and 97.0% for molar implants. Success and failure are discussed by tooth and/or implant position, and resected root, where applicable. Possible ramifications of these findings upon treatment planning are also reviewed. CONCLUSIONS: Both molar root resection and appropriate restoration and molar implant placement and restoration demonstrated a high degree of success in function. However, this success rate is markedly affected when either the root resected molar or molar implant is a lone standing terminal abutment. Care must be taken to choose the appropriate treatment modality for a given patient scenario.

Adult↗

The privatization of risk.

The privatization, or individualization, of risk factor knowledge has been largely responsible for a rising tide of criticism of epidemiology. The current debate seems polarized into 2 sides, those who support and those who attack "risk factor" epidemiology. This commentary aims to reinvigorate some of Geoffrey Rose's central arguments and show that this debate may miss a key point: a risk factor is a probabilistic concept that applies to an aggregate of individuals, not to a specific individual. Risk factor knowledge compels those in public health to seek actions that shift population distributions of these factors and, to do so, to understand their social, economic, and political determinants. The author links Rose's qualitative distinction between the causes of cases and the causes of incidence to an examination of the conceptual and quantitative limits of "individual risk" estimation. The attempt to predict individuals' futures on the basis of risk factor profile is especially prominent now with breast cancer. The author suggests reasons why a policy promoting private decision making about risk, while likely ineffective from a population standpoint, is viewed as the only feasible primary prevention option against this disease.

Breast Neoplasms↗

Income, social stratification, class, and private health insurance: a study of the Baltimore metropolitan area.

Most studies of inequalities and access to health care have used income as the sole indicator of social stratification. Despite the significance of social theory in health insurance research, there are no empirical studies comparing the ability of different models of social stratification to predict health insurance coverage. The aim of this study is to provide a comparative analysis using a variety of theory-driven indicators of social stratification and assess the relative strength of the association between these indicators and private health insurance. Data were collected in a 1993 telephone interview of a random digit dialing sample of the white population in the Baltimore Metropolitan Statistical Area. Indicators of social stratification included employment status, full-time work, education, occupation, industry, household income, firm size, and three types of assets: ownership, organizational, and skill/credential. The association between social stratification and private health insurance was strongest for those having higher household incomes, having attained at least a bachelor's degree, and working in a firm with more than 50 employees, followed by being an owner or manager, and by being employed. The addition of education and firm size improved the prediction of the household income model. The authors conclude that studies of inequalities in health insurance coverage can benefit from the inclusion of theory-driven indicators of social stratification such as human capital, labor market segmentation, and control over productive assets.

Adult↗

Should we abolish the private health insurance industry?

Health care financing can be based on one of two conflicting principles: health care as a right versus the insurance principle. The former assures equal access to care for all people regardless of income, while the latter requires each grouping in society to pay its own way. In the United States, health financing has utilized both principles, with employer-sponsored group health insurance approximating health care as a right. However, the insurance principle is increasingly eroding this right. In five major areas, the private health insurance industry has serious flaws: it has contributed to health care inflation; it wastes billions in administrative and marketing costs; it is unfair to many groups in society; it has undermined the positive features of health maintenance organization reform; and it has far too much political and economic power. In order to establish health care as a right as the guiding principle of U.S. health care financing, the private health insurance industry and the insurance principle should be abolished.

Blue Cross Blue Shield Insurance Plans↗

Health care in the Spanish social security system: public-private relationships.

The Spanish socialist regime is faced with the decision of whether to operate its own health facilities or to pay private entrepreneurs for this function. This paper analyzes four policy areas of the Spanish social security system: contracting arrangements, primary care, pharmaceuticals, and methods of financing. The implications of the public-private question in Spain for the United States are discussed.

Contract Services↗