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PubMedDate not supplied

Options and opportunities for individuals and families in the private health insurance market.

A variety of options exist for coverage in the individual health insurance market. Coverage is state-regulated; this provides consumers with important access and benefit protection and ensures stability of insurers. Coverage for individuals is based on health history in most states, and most individuals either qualify for coverage or are able to find it through state high-risk pools and other state mechanisms. Since individual-market purchasers do not have an employer contribution to offset the cost of coverage, proposals for refundable tax credits offer great potential for making health insurance coverage more affordable for eligible persons.

Chronic Disease↗
PubMed2001

The full cost of dental insurance: who's really minding the store?

A private practitioner describes the evolution of control of practice by insurance companies. The effects of assignment of benefits have been to limit patients' demand for care to what will be covered by insurance, postponement of needed care, damaging the relationship between patients and dentists, and erosion of patients' sense of responsibility for their own oral health. Current trends toward electronic filing of insurance claims are seen as an acceleration of these practices. Educating patients regarding their role in their own care is proposed as a needed response.

American Dental Association↗
PubMed2006

The big squeeze. Insurers point to slower growth in premiums in past few years to show progress, but providers say they're paying the price.

While insurers last week were trumpeting the third straight year of slower growth in premiums, providers weren't exactly celebrating. That's because of huge mergers, which give insurers far more leverage and have led to reimbursements being cut back even more. "What's worrying us is that there's a growing segment (of insurers) that aren't going to budge an inch, no matter what," says Russ Weaver, left.

Cost Savings↗
PubMed2000

Cross-subsidization in the market for employment-related health insurance.

This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of equilibrium in the market for employment-related health insurance. We examine coverage generosity, premiums, and insurance benefits net of expenditures on premiums, showing that despite a degree of market segmentation, there was a substantial amount of pooling of heterogeneous risks in 1987 among households with employment-related coverage. Our results are largely invariant to (i) firm size and (ii) whether or not employers offer a choice among plans. Our results suggest the need for caution concerning incremental reforms that would weaken the link between employment and insurance without substituting alternative institutions for the pooling of risks.

Adult↗
PubMed1998

Cream-skimming in deregulated social health insurance: evidence from Switzerland.

Policymakers fear that health insurers when exposed to competition will engage in cream-skimming (i.e. selection of good risks) rather than trying to improve their benefit to premium ratio. This fear surfaced also when Swiss federal government proposed pro-competitive Law on social health insurance, which barely passed a popular referendum in 1994. While a risk equalization mechanism based on age, gender, and place of residence has already been created, there is a considerable interest in improving its formula. This paper shows that a dummy variable indicating an individual's death during the period of observation causes the coefficient of determination to jump from 0.039 to 0.111. More-over, simulations of the risk selection process suggest that risk equalization should be made a permanent institution rather than being limited to a life of 10 years as prescribed by present legislation. In fact, the formula in use, with all its shortcomings, can be shown to neutralize to a great extent insurer interest in cream skimming provided he takes a longer-run view.

Actuarial Analysis↗
PubMed1992

Adverse selection with a multiple choice among health insurance plans: a simulation analysis.

This study uses simulation methods to quantify the effects of adverse selection. The data used to develop the model provide information about whether families can accurately forecast their risk and whether this forecast affects the purchase of insurance coverage--key conditions for adverse selection to matter. The results suggest that adverse selection is sufficient to eliminate high-option benefit plans in multiple choice markets if insurers charge a single, experience-rated premium. Adverse selection is substantially reduced if premiums are varied according to demographic factors. Adverse selection is also restricted in supplementary insurance markets. In this market, supplementary policies are underpriced because a part of the additional benefits that purchasers can expect is a cost to the base plan and is not reflected in the supplementary premium. As a result, full supplementary coverage is attractive to both low and high risks.

Actuarial Analysis↗
PubMed1992

Competitive bidding for health insurance contracts.

The determination of the payment or premium to be paid to the insurer by a large purchaser of care must accurately represent the risk of the enrolled persons. One approach is a risk-adjusted payment established by a mathematical formula, which estimates the effect of many variables on total care costs, and for different groups of persons determine an average cost. This method has several problems, and an alternative is competitive bidding. Market forces pressure providers to offer the lowest possible bids while attempting to remain fiscally viable and provide high-quality services. Research from the U.S. demonstrates that competitive contracting effectively lowered the costs of health care for those sectors of the health care system that used this strategy. Bidding by area gave far more equitable results than could have been obtained with a state-wide system with crude adjustments for each area. It is an alternative which can create strong incentives for innovation and cost-containment, and at the same time allows insurers to take into account local variation in supply and demand of care. As a potential alternative to a regulatory system, competitive bidding should be considered for regional experimentation in health insurer payment.

Actuarial Analysis↗
PubMed2002

Health insurer monopsony power: the all-or-none model.

The textbook model of monopsony that is typically employed in analyzing health insurer monopsony power does not adequately describe the supply decision of physicians confronting a dominant health insurer. Rather than restricting purchases in order to extract a lower price for provider services, monopsonistic insurers are able to obtain discounts from providers without experiencing a decrease in quantity when physicians are forced to operate along their "all-or-none" supply curve. The welfare effects of the all-or-none model of monopsony are compared to those implied by the traditional model.

Antitrust Laws↗
PubMed1998

Genetics and insurance in Britain: why more than just the Atlantic divides the English-speaking nations.

The British Government's official advisory committee on genetics has recommended a moratorium on the disclosure of genetic test results for life insurance until predictions based on such tests can be validated as actuarially important. In contrast, the trade association of the British insurance industry believes that genetic tests relating to eight conditions can yield information useful for life insurance. Although the Government has yet to respond, the debate is already moving on to genetic testing and the funding of health care for the elderly.

Advisory Committees↗
PubMed1978

Some effects of health insurance in Canada--from private enterprise toward public accountability.

Ten years after the introduction of national medical insurance in Canada, it is possible to view the effect of a comprehensive health-insurance program on the relations among physicians, society and government. With costs of health care paid from the public rather than the private purse, provincial efforts to control the cost of hospital and physician services are increasing, and various methods for cost containment are now visible. Since the budget for these expenses is publicly debated it competes for support against other publicly funded programs. The federal/provincial insurance system is evolving as an instrument of reform in the organization of health services and has led to the introduction of legislation that is changing the health-delivery system. A gradual shift in power between various health agencies, physicians, professional organizations and government is occurring.

Canada↗
PubMed1978

Consumer-choice health plan (first of two parts). Inflation and inequity in health care today: alternatives for cost control and an analysis of proposals for national health insurance.

The financing system for medical costs in this country suffers from severe inflation and inequity. The tax-supported system of fee for service for doctors, third-party intermediaries and cost reimbursement for hospitals produces inflation by rewarding cost-increasing behavior and failing to provide incentives for economy. The system is inequitable because the government pays more on behalf of those who choose more costly systems of care, because tax benefits subsidize the health insurance of the well-to-do, while not helping many low-income people, and because employment health insurance does not guarantee continuity of coverage and is regressive in its financing. Analysis of previous proposals for national health insurance shows none to be capable of solving most of these problems. Direct economic regulation by government will not improve the situation. Cost controls through incentives and regulated competition in the private sector are most likely to be effective.

Costs and Cost Analysis↗
PubMed1993

Insurance benefits coverage for persons with spinal cord injuries: determining differences across payors.

This investigation represents a preliminary step in determining differences in benefits coverage among three types of rehabilitation insurance payors (Catastrophic payors, which include Automobile No-Fault and Workers' Disability Compensation; Medicaid; and Third-party private payors). Subjects in this study were 122 spinal cord injury (SCI) outpatients who received their initial rehabilitation at the University of Michigan Medical Center and at the Rehabilitation Institute of Michigan. Insurance benefits received by them were examined across the following areas: accessible housing, transportation, personal attendant care services, professional outpatient services and adapted equipment. Results indicated differences across the three payors, with catastrophically-sponsored SCI outpatients receiving more benefits than SCI outpatients sponsored by public Medicaid or by private third-party insurance. Implications and recommendations for further studies are briefly discussed.

Adult↗
PubMed1981

Determining health insurance coverage of technology: problems and options.

By deciding which medical procedures are eligible for reimbursement, health insurance programs possess the potential to affect significantly technology use and health care spending. Traditionally, insurers have adopted a passive stance and made relatively few negative coverage determinations. However, resistance to rapidly rising costs has created a powerful inducement for third-party payors to become more prudent purchasers of health care services. Consequently, both Medicare and Blue Cross--Blue Shield are considering the implementation of changes that may ultimately result in more restrictive coverage decisions. This article examines the coverage process of Medicare and Blue Cross--Blue Shield and the policy changes that both programs are considering. In addition, it discusses the strengths and drawbacks of four coverage policy options: restricting insurance coverage of unproven procedures, introducing cost-effectiveness criteria, educating physicians and educating consumers.

Blue Cross Blue Shield Insurance Plans↗
PubMed1984

Hospice home care cost savings to third-party insurers.

A population-based, retrospective analysis of Medicare Part A and Blue Cross hospital insurance claims data was used to determine whether hospice home care cost savings to third-party insurers are substantial and result from the substitution of less expensive home care visits for more costly hospital inpatient days. The study was carried out by comparing the third-party payments of Cuyahoga County residents who died of cancer and were served by a hospice home care program (n = 152) with the insurance payments of cancer patients who never received hospice home care (n = 1,397). The data strongly supported the research hypothesis. The relative use of hospital days decreased more than 50% and the use of home care visits increased 10-fold when dying patients shifted from conventional care to hospice home care. This change in use represented a relative savings of about 40%, ranging from $1,089 per patient during the last 2 weeks of life to $2,676 per patient during the last 12 weeks of life. These results were not accounted for by group differences in age, type of cancer, or personal preference for home care.

Age Factors↗
PubMed1998

Effects of utilization management on patterns of hospital care among privately insured adult patients.

OBJECTIVES: This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan. METHODS: The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved). RESULTS: Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days. CONCLUSIONS: The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Adult↗
PubMed1978

National health insurance: comments on selected issues.

The primary objective of national health insurance is to make sure that good medical care is available to everyone at a price he or she can afford. Any plan when first adopted will have a role for both private and government insurance but, regardless of the mix, the combined system should meet the following goals: (i) to the extent possible the needs of low-income people should be met through plans that cover others; (ii) the part of the plan to be operated by government should be built on the administrative structure of Medicare, but with changes in reimbursement to encourage more efficient delivery of care; (iii) direct capital and manpower controls should be included; and (iv) rather than acting primarily as an insurer protecting people against the cost of medical care, the plan should be an aggressive buyer of health services, defining the product it is willing to buy and the price it is willing to pay.

Costs and Cost Analysis↗
PubMed1999

Genetics and the British insurance industry.

Genetics and genetic testing raise key issues for insurance and employment. Governmental and public concern galvanised the British insurance industry into developing a code of practice. The history of the development of the code, issues of genetic discrimination, access to medical information, consent and the dangers of withholding information and the impact on the equity of pooled risk are explored. Proactive steps by the Association of British Insurers suggest that moral reflection not legislation is the way forward.

Disclosure↗
PubMed2004

Is household smoking status associated with expenditure on food at restaurants, alcohol, gambling and insurance? Results from the 1998-99 Household Expenditure Survey, Australia.

AIM: To examine how household expenditure on food at restaurants, alcohol, gambling and insurance vary between smoking and non-smoking households. DESIGN: Cross sectional survey of households from private dwellings, conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design. SETTING: Australia, 1998-99. PARTICIPANTS: Nationally representative sample of households (n = 6892). MAIN OUTCOME MEASURES: Expenditure on meals at restaurants, alcohol, alcoholic beverages at licensed premises, gambling, and insurance. RESULTS: The odds of reporting expenditure on restaurant food and health insurance were 20% and 40% smaller for smoking than non-smoking households, respectively. The odds of reporting expenditure on alcohol (not including expenditure at licensed premises), drinking at licensed premises, and gambling were 100%, 50%, and 40% greater for smoking than for non-smoking households, respectively. CONCLUSIONS: The study suggests that smokers are more likely to engage in risky behaviour. Implementing smoking bans in licensed premises and gambling venues can provide an opportunity to reduce smoking prevalence. Quitting or cutting down smoking can provide opportunities for expenditure on other products or services, and enhance standards of living.

Alcohol Drinking↗