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PubMed1993

Health insurance and utilization of medical care for children with special health care needs.

Based on analyses of the 1988 National Center for Health Statistics, National Health Interview Survey, Child Health Supplement, this study examines the insurance coverage and utilization of physicians, hospitals, and prescribed medicine among the 9.6 million U.S. children with special health care needs, defined as children who had one or more selected chronic conditions that caused them to experience pain, discomfort, or being upset often or all of the time in the last year, or who were limited in their major childhood activities (playing or going to school) as a result of these or other impairments or health problems. The findings confirmed that substantial variation in access to routine medical care exists among these children. Though health status is an important predictor of which children use services in general, poor, minority children who lived with their mother or someone other than their parents, or those without insurance or an identifiable regular medical provider were most likely to experience financial barriers to access or were less apt to seek care than other children with comparable needs. Access to routine medical care remains particularly problematic for these subsets of children with special health care needs.

Adolescent↗
PubMed1992

A profile of black and Hispanic subgroups' access to dental care: findings from the National Health Interview Survey.

This study examined which black and Hispanic minority subgroups were least likely to obtain dental care and why, based on logistic regression analyses of the 1986 National Health Interview Survey. Blacks and Hispanics were less apt to have private dental insurance coverage, to be knowledgeable about the purpose of fluoride, to have been to a dentist in the past year, and, when they did go, were more apt to have gone in response to symptoms rather than for preventive reasons, compared to whites. Logistic regression analyses for adults 18 years of age and older and for children and adolescents 2 to 17 years of age showed that the following individuals had the lowest probability of having been to a dentist in the past year: males, members of larger families, adults who were unemployed or in blue-collar jobs, those who lived in the South or nonmetropolitan areas, people who perceived their health to be fair or poor, and those with no private dental insurance. Mexican-Americans were least likely to have been to a dentist regardless of their income or education. In general, the findings confirmed the importance of dental insurance, as well as suggesting a need for more school-based dental programs and public health clinic-based dental health education and outreach efforts for targeting minority children and adults.

Adolescent↗
PubMed1998

[AIDS and life insurance in Germany. 10 years successful risk management].

The introduction of AIDS specific measures by the German life assurance industry in 1988 was an important step towards prevention of adverse selection by the well known risk groups. In retrospect one can state that in the eighties there was a tendency of risk groups for inappropriately high insurance coverage. This could be curtailed with the introduction of a question as to a positive HIV test in each proposal form and a mandatory HIV test for every policy exceeding DM 250,000. These tendencies could very nicely be demonstrated by studies of own AIDS cases. The claims for death and disability benefits because of AIDS are as of now compared to the total claims of minor importance.

Acquired Immunodeficiency Syndrome↗
PubMed1991

The use of health services by older adults.

Using baseline data on the 5,151 respondents surveyed as part of the panel design of the Longitudinal Study on Aging (LSOA), this article estimates, cross-sectionally, the relationships hypothesized in the behavioral model of health services utilization. In addition to the traditional indicators of the predisposing, enabling, and need characteristics, the richness of the LSOA permits the inclusion of measures of multigenerational living arrangements, kin and nonkin social supports, health worries and the sense of health control, health insurance coverage, residential stability, and several multiple-item scales of functional limitations. Despite these innovations, the ability of the behavioral model to accurately predict the use of health services by older adults remains relatively unchanged. Important conceptual clarifications involving the hypothesized relationships, however, are identified and discussed.

Activities of Daily Living↗
PubMed1986

The effects of religious beliefs on the health care practices of the Amish.

The religious and cultural beliefs of the Amish result in many health care beliefs and practices which are significantly different from the dominant American culture. For example, the Amish are excluded from social security and health insurance coverage; they have different perceptions of health and illness; they do not practice birth control; they often lack the preventive practices of immunizations and prenatal care; and they may use a variety of traditional and nontraditional health care providers. Only by understanding the religiocultural belief system of this minority religious sect can nurse practitioners effectively meet the health care needs of their Amish patients.

Aged↗
PubMed1998

Demographic and socioeconomic predictors of dental care utilization.

The authors analyzed a comprehensive, nationally representative data set from the 1989 National Health Interview Survey to determine what factors are related to dental care utilization. The authors estimated the percentage of low-income and minority adults who reported visiting a dentist in the past year by race, income, employment status, dental insurance coverage status, sex, health status, education, marital status, age and major activity. Data analyses focused on 49,687 18- to 64-year-old dentate respondents, who were black, Hispanic or white. The authors found large differences in dental care utilization between blacks, Hispanics and whites, when controlling for education, income, age and other variables.

Adolescent↗
PubMed2005

Chronic hepatitis C infection in a rural Medicaid HMO.

CONTEXT: Chronic hepatitis C infection (CHCI) is an increasingly common problem, affecting about 2% of the US population. The cost and complexity of treatment and difficulties in communicating with the infected population are of concern to insurers and health planners. PURPOSE: To describe the clinical features of patients with CHCI in a rural Medicaid-covered population and to describe a method developed for treating CHCI in an underserved rural community. METHODS: We developed a disease management approach to patients with CHCI receiving insurance coverage through a Medicaid HMO in rural Oregon. A locally based multidisciplinary hepatitis committee was formed to develop a management protocol and a process for selecting patients for treatment. The committee met monthly to develop the treatment plan for individual patients. Day-to-day treatment was provided by a nurse under the supervision of the committee. FINDINGS: One hundred forty-three adults with CHCI were identified by their primary care physicians. About half the patients had a type 1 genotype. Treatment with pegylated interferon and ribavirin was completed on 21 persons, 11 (52%) of whom had a virologic cure. Problems with treatment toxicity were common. Patient satisfaction with the treatment by the nurse was high. CONCLUSIONS: CHCI is common in this rural, nonminority Medicaid-insured population. A locally based disease management model was developed that was well received by patients and was successful in delivering a high quality of care for people with CHCI in a rural area.

Adolescent↗
PubMed1990

Health care costs for employed hypertensives.

Health care insurance claims were used to track costs associated with hypertension for an employed population. Employees were classified as hypertensive (n = 373), high normal (n = 363), or normotensive (n = 2,411) on the basis of hypertension screening done at the worksite. Claims activity was monitored for the three groups during a three-year period, including periods before, during, and after the screening done at the worksite. The average amount claimed per employee was significantly higher for the hypertensives as compared with the normotensives or high normals, even after adjustment for age, race, sex, salary, marital status, and duration of insurance coverage. There was no significant difference in the average amount claimed per employee between high normals and normotensives. The health care costs for hypertensives are estimated to be about 80% more than those for normotensives. Hospital, physicians, and nursing care accounts for about 50 percentage points of this increment while the remaining 30 percentage points derive from drug costs.

Adult↗
PubMed1996

The importance of sense of community on people's perceptions of their health-care experiences.

OBJECTIVES: The authors study the relationship between people's sense of community and problems they experience with the health-care system, specifically problems related to cost, access, provider choice, and satisfaction. METHODS: Data from a 1993 Florida poll (n = 1202) was used to conduct a multinomial logit analysis to estimate people's sense of community as a function of 13 characteristics and perceptions of community. Logit analysis was used to estimate the relationship between people's sense of community and their health-care experiences, controlling for other demographic influences, including insurance coverage and self-reported health status. RESULTS: Lower sense of community was significantly associated with higher levels of choice, cost, and satisfaction problems in people's interactions with the health-care sector. CONCLUSIONS: Community quality needs to be considered in efforts to improve the functional capabilities of health-care institutions.

Adolescent↗
PubMed2004

China's public health-care system: facing the challenges.

The severe acute respiratory syndrome (SARS) crisis in China revealed not only the failures of the Chinese health-care system but also some fundamental structural deficiencies. A decentralized and fragmented health system, such as the one found in China, is not well-suited to making a rapid and coordinated response to public health emergencies. The commercial orientation of the health sector on the supply-side and lack of health insurance coverage on the demand-side further exacerbate the problems of the under-provision of public services, such as health surveillance and preventive care. For the past 25 years, the Chinese Government has kept economic development at the top of the policy agenda at the expense of public health, especially in terms of access to health care for the 800 million people living in rural areas. A significant increase in government investment in the public health infrastructure, though long overdue, is not sufficient to solve the problems of the health-care system. China needs to reorganize its public health system by strengthening both the vertical and horizontal connections between its various public health organizations. China's recent policy of establishing a matching-fund financed rural health insurance system presents an exciting opportunity to improve people's access to health care.

Capitalism↗
PubMed2006

Utilization and purchase of medical care services in Mexico by residents in the United States of America, 1998-1999.

OBJECTIVES: We assessed self-reported frequency of purchase of medications and medical care services in Mexico by southern New Mexico (United States, [U.S.]) residents in relation to their medical insurance coverage. METHODS: We analyzed data obtained in 1998 and 1999 from a health interview survey of residents in a six-county region of southern New Mexico, using prevalence and logistic regression methods for complex survey data. RESULTS: About 22% of southern New Mexico residents had purchased medications and 11% had sought medical care in Mexico at least once during the year preceding the survey. When we adjusted for the effects of other variables, persons able to pay for services out of pocket and those who were uninsured were more likely than persons who were fully covered to purchase medications or medical care in Mexico. CONCLUSIONS: Large numbers of people residing near the border in New Mexico traveled south to Mexico to purchase medications and medical care. Lack of medical insurance was associated with higher frequencies of these purchases. There seems to be a need to establish relationships between U.S. private and public care plans and Mexican medical care providers to identify appropriate mechanisms for U.S. residents to purchase medical care in Mexico.

Adolescent↗
PubMedDate not supplied

Rationing medical care.

Recent proposals to reform the health care financing system have sparked discussions concerning the need to ration health care. Relative to other western industrialized democracies, the US rations primary and preventive care more, tertiary care less, and makes greater use of price rationing and bureaucratic controls. Because insurance coverage is not universal and the extent of coverage varies across services, the poor and those patients needing long-term care are most heavily affected by price rationing. The current system also works to the advantage of procedure-oriented specialists and to the disadvantage of primary care physicians. Major reform of health care financing could change what is rationed, how it is rationed, and who is most affected. However, some rationing will remain necessary under any conceivable financing system.

Canada↗
PubMed2006

The effect of private insurance on the health of older, working age adults: evidence from the health and retirement study.

OBJECTIVE: Primarily, to determine if the presence of private insurance leads to improved health status, as measured by a survey-based health score. Secondarily, to explore sensitivity of estimates to adjustments for endogeneity. The study focuses on adults in late middle age who are nearing entry into Medicare. DATA SOURCES: The analysis file is drawn from the Health and Retirement Study, a national survey of relatively older adults in the labor force. The dependent variable, an index of 5 health outcome items, was obtained from the 1996 survey. Independent variables were obtained from the 1992 survey. State-level instrumental variables were obtained from the Area Resources File and the TAXSIM file. The final sample consists of 9,034 individuals of which 1,540 were uninsured. STUDY DESIGN: Estimation addresses endogeneity of the insurance participation decision in health score regressions. In addition to ordinary least squares (OLS), two models are tested: an instrumental variables (IV) model, and a model with endogenous treatment effects due to Heckman (1978). Insurance participation and health behaviors enter with a lag to allow their effects to dissipate over time. Separate regressions were run for groupings of chronic conditions. PRINCIPAL FINDINGS: The OLS model results in statistically significant albeit small effects of insurance on the computed health score, but the results may be downward biased. Adjusting for endogeneity using state-level instrumental variables yields up to a six-fold increase in the insurance effect. Results are consistent across IV and treatment effects models, and for major groupings of medical conditions. The insurance effect appears to be in the range of about 2-11 percent. There appear to be no significant differences in the insurance effect for subgroups with and without major chronic conditions. CONCLUSIONS: Extending insurance coverage to working age adults may result in improved health. By conjecture, policies aimed at expanding coverage to this population may lead to improved health at retirement and entry to Medicare, potentially leading to savings. However, further research is needed to determine whether similar results are found when alternative measures of overall health or health scores are used. Future research should also explore the use of alternative instrumental variables. Preliminary results provide no justification for targeting certain subgroups with susceptibility to certain chronic conditions rather than broad policy interventions.

Chronic Disease↗
PubMed2005

Regional and racial disparities in breast cancer-specific mortality.

Where and how one lives is associated with cancer survival. This study was designed to assess geographical region of residence, race/ethnicity, and clinical and socioeconomic factors as predictors of survival in a population based cohort of women with breast cancer followed for up to 12 years. In a cohort of 218,879 breast cancer patients >20 years of age at diagnosis, registered in the database of the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program between 1990 and 2001, we analyzed the association of breast cancer-specific survival with SEER region; age; stage; histology; hormone receptor status; race/ethnicity; and census data on educational attainment, income, employment, and insurance coverage. We compared Kaplan-Meier survival curves by region and race/ethnicity. We used Cox proportional hazards regression models to assess the association of mortality with region, race/ethnicity, and the other variables. Women who lived in Detroit had significantly higher mortality than those living in most other SEER regions. In most regions, black women had the poorest survival. The association of mortality with race did not differ significantly across regions, but it was significantly stronger among women 50-64 years of age than among women 65 and older. The SEER data document the association of breast cancer mortality with region, race, and socioeconomic status. Black race was a strong predictor of mortality in each region even after controlling for socioeconomic factors. The diminishing effect of race with age, which may only partially be explained by insurance in those over 65, suggests a need for research on the role of other factors, such as comorbid conditions or access to care, in breast cancer mortality.

Adult↗
PubMed1987

National policy and the medically uninsured.

Although the marketplace discipline imposed on the health care sector appears to be restraining increases in the cost of care, this haphazard and incremental "policy" is having deleterious effects on access to care by the uninsured. To help alleviate this problem within our current price-centered system, I suggest that three options be pursued: create state pools to fund indigent care; broaden insurance coverage availability through the workplace; and create medical individual retirement accounts to pay for long-term care, which would free up more funds for indigent care. We must mold our future health care system during this era of rapid change by developing a coherent policy, with input from both the private and the government sectors, to create an efficient and high-quality system that will provide needed care to all members of society.

Adolescent↗
PubMed1979

Health care costs: saving in the private sector.

Robeson offers a number of options to employers to help reduce the impact of increasing health care costs. He points out that large organizations which employ hundreds of people have considerable market power which can be exerted to contain costs. It is suggested that the risk management departments assume the responsibility for managing the effort to reduce the costs of medical care and of the health insurance programs of these organizations since that staff is experienced at evaluating premiums and negotiating with third-party payors. The article examines a number of short-run strategies for firms to pursue to contain health care costs: (1) use alternative delivery systems such as health maintenance organizations (HMOs) which have cost-cutting potential but require marketing efforts to persuade employees of their desirability; (2) contracts with third-party payors which require a second opinion (peer review), a practice which saved one labor union over $2 million from 1972 to 1976; (3) implementation of insurance coverage for less expensive outpatient care; and (4) the use of claims review. These strategies are compared in terms of four criteria: supply of demand for health services; management effort; cost; and time necessary for realized savings. Robeson concludes that development of a management plan for containing health care costs requires an extensive analysis of alternatives, organizational objectives, existing policies, and resources, and offers a table summarizing the cost-containment strategies that a firm should consider.

Ambulatory Care↗
PubMed1998

Beyond coverage and supply: measuring access to healthcare in today's market.

OBJECTIVE/PURPOSE: To stimulate discussion within the research and policy community about the value of and issues surrounding different ways to describe access to care in a health system reconfigured by the growth of managed care, competition, and other marketplace changes. PRINCIPLE FINDINGS: The concept of access has evolved over time to address shifting health policy concerns like the growing interest in looking beyond utilization as a measure of access to a better consideration, too, of the effectiveness of services used as judged by costs and outcomes. Yet current frameworks used to look at access are person-based and do not capture the complexity of the healthcare system and the complex structures involved in managed care organizations that combine delivery and financing and vary substantially within and across markets. In addition, many at times competing or conflicting policy goals on access exist. There also is an increasingly diverse and widening set of uses that include benchmarking against national goals, measuring performance of accountable entities, and providing consumer information. CONCLUSIONS AND RECOMMENDATIONS: Traditional access frameworks are invaluable in encouraging focus on historical measures of access, like insurance coverage and other barriers to system entry. But much greater attention needs to be paid to adapting current access frameworks so that they also better support the ability to understand how processes inherent in diverse health delivery and financing arrangements influence access to services within a system and what this means for how well individuals negotiate healthcare systems and the effects on care outcomes. The increasing demands on access measures and the growing diversity of users also point to a need for collaboration to better pool insights, share experiences, and honestly confront trade-offs or disagreements to progress in addressing these issues.

Delivery of Health Care↗
PubMed1988

Why not your pediatrician's office? A study of weekday pediatric emergency department use for minor illness care in a community hospital.

To determine the rationale for using a community hospital's emergency department for minor illness care on weekdays, we surveyed 150 parents of children 15 years of age or younger. Fifty (33.3%) participants had no identified source of routine pediatric care, and 31 (20.7%) had pediatric providers not locally available. For participants with local providers, major reasons for use of the emergency department included economic factors, parental knowledge, parent/provider communication, convenience, and insurance coverage. The results of this study demonstrate that the utilization pattern and sociodemographic profile of children seen in our emergency department on weekdays is more characteristic of an inner-city hospital than of a non-metropolitan setting. There are a number of feasible measures which could improve access to routine pediatric care for low socioeconomic families and reduce unnecessary emergency department utilization.

Adolescent↗