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Changing the method for calculating quarters of coverage: the impact on workers' insured status.

The 1977 Social Security Amendments specified that, beginning in 1978, a worker would be credited with one quarter of coverage for a designated amount of annual earnings. For 1978, a worker received one quarter of coverage (up to a total of four) for each $250 in annual earnings from employment or self-employment. Before 1978, a worker who was paid $50 in wages in a calendar quarter was credited with a quarter of coverage. A person who had $400 or more in self-employment income in a year was credited with four quarters of coverage. Some workers received more quarters of coverage under the new provisions than they would have under the old, and other workers received less. Since a worker's receipt of benefits depends on his or her insured status, which is based on quarters of coverage, this change can affect a worker's eligibility for benefits. This study indicates that if $250 in annual earnings had been required for one quarter of coverage in 1977, more than 2.1 million workers would have had a change in their insured status for disabled worker benefits, and about 700,000 workers would have had a change in their insured status for survivor benefits. Those whose insured status was affected were most likely to have had marginal earnings records--for example, they had four to seven quarters of coverage when six were needed. (This effect was expected when the legislation was passed.) This article examines those whose eligibility for benefits was most likely to have been affected.

Adolescent↗

Hospital-sponsored groups offer viable malpractice insurance.

Hospital - sponsored insurance organizations can offer their members many advantages, especially reasonable and stable malpractice insurance coverage and premium rates. To do so, they must ensure their financial stability through the support of the insured and through adequate reinsurance, compete effectively with commercial insurance companies, comply with federal regulations regarding reimbursement to hospitals for premiums, and develop effective internal management.

Bermuda↗

[The concept of including psychiatry in insurance medicine].

Arguments for restructuring of psychiatric service on the principles of medical insurance are given. Because mental disorders are characterized by chronic development and high disability rate, the necessity of mixed budget-insurance financing of psychiatry is grounded. Obligatory state insurance must be conducted for all mentally ill persons. However, only a certain part of outpatient care and the treatment period in hospital are to be insured, while the remaining part of outpatient visits or hospital stay will be financed from the budget. The method of calculation of the incurred number of the doctor's visits and the length of hospital stay during the year is discussed.

Adult↗

[Analytic study of the hospital self inspection results with the medical insurance inpatient fee from the viewpoint of the hospital management--based on one university hospital pre-discharge inspection].

The purposes of this study were to evaluate the results of the hospital self inspection with the medical insurance and to offer basic materials to the medical insurance inspection and the education of medical insurance. The study was undertaken with 4,730 cases among the total 13,810 medical insurance in patients from Jan. 1990 to Dec. 1990 at one university hospital in Pusan. The major contents of the inspection were the omission of diagnosis and medical fee, curtailment, application mistake, the rates of inclusion, subtraction and total accumulation. The data were collected using patients charts and bills. The results of the paper analysis were as follows. 1. From the pre-discharge hospital self inspection, major omission were treatment and material fee but medication fee were moderately high and high curtailment was operation fee. 2. Decreasing order of operation fee adjustment were digestive (22.4%) muscular (22%) and neuro system operation (21.4%). Majority of the medication fee adjustments were injection form of medication (95.7%). 50% of the treatment fee adjustments were composed of injection fee (27.9%) and dressing or post-operative dressing fee (22.3%). 74.7% of material costs were composed of oxygen (30.6%), blood and the blood composed materials (44.1%). 3. Pre-discharge inspection showed 6% adjustment rate, 4.3% addition and 2.1% curtailment rate. Most of the adjustment were omission (66.1%). 4. Omission were divided by event omission (92.6%) and application mistake (7.4%). The decreasing order of omission fee were operation (21.84%), treatment (18.71%) diagnosis (18.68%), medication (14.53%) and material costs (10.84%). So operation and treatment part were the major part of the total omission fee (40.55%). 5. The average omission of diagnosis were 1,800 per month.

Fees, Medical↗

Does employment-related health insurance inhibit job mobility?

Most private health insurance in the United States is an employment-related, nonportable fringe benefit. As a result, severing an employment relationship can lead to a loss of such coverage. The risk of losing coverage has been identified as a primary reason for not changing jobs and has shaped the debate over health care reform. This paper examines the relationship between employment-related health insurance and job mobility. We model the likelihood that a worker voluntarily changes employment, based upon insurance status and wages at an initial job, expected insurance status and wages at alternative employment, other fringe benefits, and worker and dependent health status. Analyses of data from the 1987 National Medical Expenditure Survey support the "job lock" hypothesis.

Adult↗

Insuring Latinos against the costs of illness.

OBJECTIVE: To examine the determinants of health insurance coverage for Latinos in the United States and how different targeted strategies for health care reform differentially affect the country's major ethnic groups, focusing on the implications for the Latino population. DESIGN: Data from the 1980 and 1990 Current Population Surveys were used to compare the insurance status of nonelderly (< 65 years) Latinos with the Anglo (non-Hispanic white), black, and Asian and other populations by estimating the attributable fraction for selected covariates. The effects of health care reform strategies on the coverage of the major ethnic groups were simulated from these data. MAIN OUTCOME MEASURES: Percentage uninsured, percentage insured by Medicaid, and attributable fraction for covariates. RESULTS: Latinos have the worst health insurance coverage of any ethnic group in the country. Approximately 39% of Latinos are uninsured compared with 13.8% for the Anglo and 24% for the black population. Providing coverage to all the poor could reduce the uninsured rate for Anglos by about 23%, whereas the reduction among Latinos could be about 37% and among blacks about 42%. Similar reductions could be achieved by covering all workers and their minor dependents. Regardless of the approach to reform, however, Latinos would remain with high absolute rates of uninsured. CONCLUSIONS: Differences in Medicaid eligibility, labor force characteristics, and family composition between Latinos and other ethnic groups suggest that policy initiatives may affect Latinos differently. Targeted strategies, such as employer mandates, "pay-or-play" programs, or Medicaid expansions, can improve coverage, but many Latinos could still remain uninsured.

Adolescent↗

[Legal aspects of health insurance claims and their potential use as a data source for epidemiological research].

Health insurance claims are legal documents for the purpose of billing health care cost and not intended for medical certification. They contain valuable public health data as well as sensitive personal information which must be kept confidential. Conflicts arise between the public interest and the privacy protection when public health researchers attempt to perform studies using health insurance claims. This article examines the legal aspects of health insurance claims and proposes legitimate procedures and forms for using claims data in public health research: researchers should act as "contractors" to perform survey under the auspices of insurers instead of requesting the "disclosure" of the personal information.

Confidentiality↗

Genetic testing: employability, insurability, and health reform.

Presently, 85%-90% of individuals with private health insurance are covered under group health insurance, with most covered through employment. Under virtually any system of health care reform likely to be enacted in the near future, employers will continue to play a major role in the funding of private health care. As costs of health care are increasing dramatically, employers and insurance carriers are examining alternatives for controlling health care expenditures. Not all consumers of health care are equal in their rates of consumption. Tremendous savings could be realized by parties responsible for paying for health care if the most expensive (or potentially most expensive) health care users could be identified and their costs shifted to another payer. Genetic testing could play a major role in predictive health screening to identify individuals with the potential for developing cancer. This prospect raises three major problems regarding employability and insurability. First, individuals could be subject to discrimination in employment, with the responsibility for their health coverage shifted to the public sector. Second, privacy and confidentiality could be compromised through the compilation, storage, and release of non-job-related, sensitive medical information. Third, the fear of employment discrimination through employer access to medical records generated in the clinical setting might discourage at-risk individuals from undergoing medically indicated genetic testing. This report reviews these issues and emphasizes that these concerns must be addressed in the context of health care reform as well as through the interpretation of existing legal proscriptions on employment discrimination.

Cost Control↗

The role for regional autopsy centers in the evaluation of covered deaths. Survey of opinions of US and Canadian chairs of pathology and major health insurers in the United States.

OBJECTIVE: To evaluate the advantages and disadvantages of, as well as the attitudes of health care professionals and insurers toward, the development of regional autopsy services. DESIGN: Survey of 150 medical school departments of pathology in the United States and Canada and 12 representative major health insurers in the United States. RESULTS: Of the 25 respondents from the pathology departments, most were in favor of regionalization of autopsy services, if properly underwritten. Of the five respondents from the health insurers, most were disinterested in the autopsy as a measure of outcome and unwilling to provide support. CONCLUSIONS: Health care is being regionalized around networks of insurers rather than hospitals. The networks are defined by a mixture of hospitals, physician groups, and other health care professionals. Within networks, the goal is to subscribe groups of patients, covered lives, for all medical needs from primary to complex care. As the economic risk of caring for patients is shifted to physicians, the incentive to provide service at the lowest possible cost grows, as does the need to assure that medical mismanagement does not occur. To provide quality care at affordable costs, it is necessary that outcomes, including deaths, be professionally evaluated. The present system of death investigation involves hospital colleagues and is potentially biased. Regional autopsy centers that provide timely expert information should be part of the health care system. Medical schools are potential sites for regional autopsy programs because they have the personnel needed to conduct appropriate death-related studies. Most schools are affiliated programmatically and economically with surrounding hospitals and physicians in a manner in which outcomes, costs, and quality of clinical service are of common interest.

Attitude of Health Personnel↗

[Fatal post-traumatic alcohol delirium--compensation responsibility in private accident insurance?].

While several case reports about fatal posttraumatic alcohol withdrawal deliriums after minor traumas and compensation by legal insurance have been published this problem has been hardly addressed regarding private accidance insurance. Based on the very comprehensive definition of an accident in the private insurance law posttraumatic deaths by alcohol withdrawal deliriums can be causally related even to minor traumas and compensations by private insurance are justified. However according to section 8 AUB 88 the contribution of preexisting alcoholism and alcohol related organ damage to the lethal outcome must be subtracted.

Adult↗

Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors.

BACKGROUND: Appropriate utilization of primary and specialty care has stimulated substantial debate, but the portion of the discussion focused on policies that restrict or discourage direct access to specialists has been largely uninformed by empirical analysis. Using data from the National Ambulatory Care Survey (1985 to 1992 surveys), we examined the associations of patient and physician demographics and health maintenance organization (HMO) insurance status with the utilization of primary compared with specialty care. METHODS: Office visits for adult patients seen by primary care physicians and specialists were analyzed for: (1) patient-initiated utilization of specialists (patient self-referral) compared with that of primary care physicians; and (2) utilization of specialists compared with that of primary care physicians, stratified by HMO insurance status. RESULTS: After multivariate adjustment, patient self-referral was less likely among black patients (adjusted odds ratio [AOR] = 0.67; 95% confidence interval [CI] = 0.59 to 0.76), self-pay (AOR = 0.81; 95% CI = 0.74 to 0.88), or patients with Medicaid (AOR = 0.51; 95% CI = 0.43 to 0.61). The proportion of non-HMO patients seeing specialists remained stable (44.9%). For HMO patients, the proportion of total visits made to specialists increased from 27.6% in 1985 to 41.3% in 1991, then dropped to 33.2% in 1992. Disparities in utilization of specialists by women, blacks, and patients with Medicaid observed among non-HMO patients were not found in the HMO population. Specialists were more likely to see HMO patients for follow-up of a known problem, whereas non-HMO patients were more likely to have specialist follow-up visits for new problems. CONCLUSIONS: The results suggest greater utilization of specialists by male, white, and privately insured patients. The findings may partially account for disparities in specialty procedure use, and suggest that HMO insurance may reduce some of these disparities. The less frequent and more selective use of specialists among HMO patients suggests an evolving role for specialists in managed care.

Adult↗

State-specific prevalence of lapses in health-care-insurance coverage--United States, 1995.

Lack of health-care-insurance coverage has been associated with decreased use of preventive health services, delay in seeking medical care, and poor health status. In 1995, an estimated 30.5 million persons aged 18-64 years in the United States did not have health insurance. To determine state-specific estimates of the prevalence of persons aged 18-64 who reported either short-term (i.e., <12 months) or long-term (i.e., > or = 12 months) lapses in health-care coverage, CDC analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and indicates that among adults who reported having no health insurance in 1995, most were without insurance for > or = 1 year and that long-term lapses were more prevalent among men than women.

Adult↗

Breast cancer treatment choice and mastectomy length of stay: a comparison of HMO and other privately insured women.

This study uses hospital discharge abstract data from five states (Massachusetts, New York, New Jersey, Maryland, and California) for two years (1988 and 1991) to investigate whether enrollment in an HMO affects nonelderly breast cancer patients' treatment choice (breast-conserving surgery or mastectomy) and hospital length of stay for women who have a mastectomy. Since HMO insurance creates financial incentives that differ from other types of insurance coverage, it is important to assess whether the type of insurance coverage affects the care received by breast cancer patients. Although the results vary from state to state, they suggest that HMO enrollees are less likely to receive breast-conserving surgery (relative odds =.93). However, an unambiguous interpretation of this findings requires better data on patients' opportunity costs and preferences, which also may vary with type of insurance coverage. Among women who had a mastectomy, HMO enrollment was generally associated with a 4.5% shorter average length of stay and a greater likelihood of a short stay (one or two days, relative odds = 1.21-1.29). A much higher proportion of mastectomy patients in California than in other states had a short stay. Follow-up of these women may indicate whether short stays lead to adverse long-term health effects.

Adult↗

From assurance to insurance in Russian health care: the problematic transition.

OBJECTIVES: Given the declining health status of the Russian population and the negative social impact of ongoing economic reforms, it is important to understand the nature and scope of Russia's innovations in health care financing. METHODS: Data on Russian health care and its financing were gathered from Russian newspapers and journals. US government agency reports, recent press accounts, and the authors' observations and interviews in Russia. RESULTS: The 1991 statutory basis for the Russian mandatory medical insurance system replaced the traditional, state-funded medical care system with a regional system principally reliant on an enterprise-based with-holding tax plus supplementation by local government and, to a minor extent, federal funds. The regional agent for distribution and management of these funds is a series of Territorial Health Insurance Funds. Implementation thus far has been highly uneven among territories. CONCLUSIONS: An insurance model patterned after the Western example may not be the optimal solution to Russia's current health financing problems. Given the chaotic nature of political and economic reform, Russia may simply not be ready for market-based medical insurance.

Health Care Reform↗

Insurance type and choice of hospital for coronary artery bypass graft surgery.

OBJECTIVE: To examine the effect of insurance type on the relationship between hospital attributes and patient flows, with particular attention to whether HMO enrollees are more or less likely than other patients to receive care at high-quality hospitals and whether HMO enrollees travel farther to receive care. DATA SOURCES/STUDY SETTING: Data on patient flows, taken from discharge abstracts compiled by the California Office of Statewide Health Planning and Development. Our sample consists of patients undergoing coronary artery bypass graft surgery (CABG) in 1991 who resided in three California markets. Only patients under the age of 65 and insured by HMOs, Blue Cross/Blue Shield, or other commercial insurance were included. Hospital quality is based on hospital-specific measures of excess mortality from CABG. Other hospital attributes were taken from American Hospital Association survey data. STUDY DESIGN: Conditional-choice models were used to estimate the probability that patients would receive care at any given hospital as a function of their insurance type and the hospital's attributes. PRINCIPAL FINDINGS: Patients were more likely to receive care from hospitals closer to their residence. However, HMO patient flows were less sensitive to proximity. In general, the likelihood that an HMO enrollee received care at a given hospital was positively related to hospital quality. Moreover, quality had a greater effect on patient flows for HMO enrollees than for non-HMO enrollees. However, the evidence suggests that the effect of quality on patient flows is neither uniform across markets nor across HMOs. CONCLUSIONS: HMOs do not appear to direct patients to low-quality hospitals. However, heterogeneity among HMOs and across markets suggests that buyers must recognize that choosing an HMO involves greater scrutiny than simply picking a plan labeled "HMO."

California↗

Is insurance for children enough? The link between parents' and children's health care use revisited.

Parents' own use of physician services is known to be a strong predictor of their children's use of such services. This paper contrasts the relationship between parents' and children's use of services among uninsured and privately insured children. Parents' utilization is found to have a larger impact upon service use among privately insured children than among uninsured children. Even if all children were universally insured, parents' health care utilization would remain a key determinant in children's use of services. Policies that integrate financing and delivery systems for all family members deserve attention among efforts to foster better access for children. Neglecting financial access to care for adults may have the unintended effect of diminishing the impact of targeted health insurance programs for children.

Adolescent↗

Basic insurance concepts for dentists.

Dentists cannot afford to be ignorant about insurance. Insurance is an important risk-management tool, minimizing the exposure for catastrophic claims and losses. Patient insurance is also a major source of revenue for most dental practices.

Insurance↗

Using tax credits and state high-risk pools to expand health insurance coverage.

There are practical proposals now on the public policy table to reduce the number of Americans without health coverage. While they won't make health care free or eliminate the forty million uninsured persons, they would help millions of Americans acquire or improve their health insurance. Practical strategies can also be taken to address access issues for unhealthy persons in the nongroup market through federal assistance to states to establish and improve state high-risk health insurance pools, as well as to make health insurance more affordable for low-income Americans.

Health Policy↗