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PubMed2000

Does chronic illness affect the adequacy of health insurance coverage?

Although chronically ill individuals need protection against high medical expenses, they often have difficulty obtaining adequate insurance coverage due to medical underwriting practices used to classify and price risks and to define and limit coverage for individuals and groups. Using data from healthy and chronically ill individuals in Indiana, we found that chronic illness decreased the probability of having adequate coverage by about 10 percentage points among all individuals and by about 25 percentage points among single individuals. Preexisting condition exclusions were a major source of inadequate insurance, though not the only cause. Our results emphasize the impact of enforcing the Health Insurance Portability and Accountability Act (HIPAA) of 1997, which limits preexisting condition exclusions.

Adult↗
PubMed2004

A comprehensive snapshot of States' small group market reforms on insurer pricing & rating practices, 1999.

This paper presents a qualitative analysis of states' small group health insurance reforms that impact small group premiums, mostly enacted by the states during 1996-99, following the federal Health Insurance Portability and Accountability Act in 1996. It draws from an intensive review of statutes of 48 states and the District of Columbia as of 1999. It analyses regulations related to insurer pricing and rating practices concerning rating criteria and rating bands, pricing incentives, premium stability from year to year, minimum loss rations, reinsurance and carve-out coverage for the medically uninsurable. It also covers regulations targeting employer purchasing and coverage practices such as pooled purchasing and adverse selection. This is the second of a two-part series analyzing states' small group market reforms, the first being devoted to state reforms to promote access and improving the value of health plans offered in this market (Xirasagar et al. 2004). The variety in pricing and rating reforms illustrate the differences in the depth of reforms across states, and represent a far wider range of potential actuarial combinations than the sample of reforms documented in past literature.

Health Care Reform↗
PubMedDate not supplied

Growth in prescription drug spending among insured elders.

We examine growth in prescription drug use and spending in a well-insured elderly population in 1997 and 2000. We describe the high-cost segment of this population, identifying how it differs from the rest of the elderly regarding use and types of medications, and how stable this group is over time. Drug spending by the insured elderly rose more than 18 percent annually between 1997 and 2000. High-cost elders use more brand-name drugs, treat more conditions, and use more medications per condition. Once an insured elder becomes a high-cost user of prescription drugs, that person is likely to remain so. Our study suggests that a growing population of elderly is using many medications and may require considerable drug management.

Age Factors↗
PubMed2006

Dealing with dental insurance.

Dental insurance companies can have many different policies, with varying requirements depending on the company. This requires a tremendous amount of time on the part of dentists and their office teams to communicate with insurance companies, file all the proper data, acquire predetermination information when required and address a myriad of other factors. By managing this process carefully, practices can save time and labor expenses, especially if patients are well-educated regarding what their dental insurance covers and what it does not.

Dentist-Patient Relations↗
PubMed1980

Selection of health insurance by an employee group in Northern California.

Enrollment trends for a large employee group were analyzed to determine the extent to which consumers chose Blue Cross or Health Maintenance Organization (HMO) health insurance under various premium differentials. Data were collected from employment records of six University of California campuses for the period 1967 to 1978. Enrollment in the Kaiser Foundation Health Plan (an HMO) more than doubled during this period while enrollment in Blue Cross remained relatively stable. This increased preference for Kaiser coverage was associated with a concurrent relative rise in costs to employees of Blue Cross coverage. These data suggest that consumers are sensitive to insurance costs, and that given the opportunity HMOs can compete effectively with traditional health insurance.

Blue Cross Blue Shield Insurance Plans↗
PubMed2002

Stability and change in health insurance among older Mexican Americans: longitudinal evidence from the Hispanic established populations for epidemiologic study of the elderly.

OBJECTIVES: This study examined the association between health insurance coverage, medical care use, limitations in activities of daily living, and mortality among older Mexican-origin individuals. METHODS: We analyzed longitudinal data from the Hispanic Established Populations for Epidemiologic Study of the Elderly (H-EPESE). RESULTS: The uninsured tend to be younger, female, poor, and foreign born. They report fewer health care visits, are less likely to have a usual source of care, and more often receive care in Mexico. Conversely, those with private health insurance are economically better off and use more health care services. Over time, the data reveal substantial changes in type of insurance coverage. CONCLUSIONS: The data reveal serious vulnerabilities among older Mexican Americans that result from a lack of private Medigap supplemental coverage.

Activities of Daily Living↗
PubMed1993

The politics of reform: public health insurance in Canada.

The centerpiece of Canadian health policy is a system of public health insurance covering the cost of hospital and medical services for all Canadians. The author analyzes the historical development of this policy and critically assesses its structure and dynamics. He argues that health insurance was won by Canadian workers through protracted industrial and political struggle. At the same time, health insurance was accommodated to the existing structure of power and privilege within the health care delivery system, which precluded a significant shift in the distribution of health care consumption and perpetuated the "irrationality" of a system that treats health as a problem located in the sphere of personal consumption.

Canada↗
PubMedDate not supplied

Effects of "second generation" small group health insurance market reforms, 1993 to 1997.

In the mid-1990s, several state legislatures enacted a "second generation" of small group health insurance reforms that required guaranteed issue of all products and prohibited the use of health as a rating factor. We use data from two large employer surveys to compare the behavior of small business in nine states that adopted these reforms between 1993 and 1997 to the behavior of small business in 11 states and the District of Columbia, where neither of these small group health insurance market reforms existed prior to 1997 (N = 8,465 in 1993; N = 12,219 in 1997). Our analyses focus on several outcomes: health insurance offer and enrollment rates in any employer plan, and in an HMO plan; turnover in offer decisions; and premiums, variability in premiums, and the rate of change in premiums. Overall, we find no effect of small group reform on any of the outcomes; the sign of the effect is not consistent across reform states, the estimates rarely attain statistical significance, and they show no consistent pattern across the outcomes within each state. Therefore, predictions of the harm these regulations might cause to the market have not come to pass. On the other hand, proponents' hopes for a solution to low coverage rates among small businesses have not materialized either.

Fees and Charges↗
PubMed1996

Insurance reform in a voluntary system: implications for the sick, the well, and universal health care. American College of Physicians.

In the absence of universal coverage, carefully designed insurance reforms can make health insurance in the individual and small-group markets more affordable for those who need it most--the sick--and more secure for all subscribers. In this position paper, the American College of Physicians calls for specific strong reforms at both the state and federal levels. Substantial reform of the insurance marketplace is a necessary step toward achieving universal coverage. It should reflect the view that providing quality health care is in the best interests of the community and that health care financing should be a community responsibility.

Actuarial Analysis↗
PubMedDate not supplied

Stemming the risk of capitated contracts: what providers should consider when buying stop loss insurance.

Whether an organization decides to purchase stop loss insurance from an HMO or a stop loss specialist, the decision-makers should read and understand each proposal. This information is best obtained by working with a qualified insurance expert who understands stop loss insurance and managed care and health care contracting practices. The stop loss carrier's overall commitment to the organization purchasing its policy should be to provide the best possible service and protection against the financial consequences of catastrophic claims.

Capitation Fee↗
PubMed1996

Regulating health insurance: the challenges of managed networks.

The role of the regulator in health insurance is examined in the context of the change in nature of regulatory oversight necessary to monitor the activities of the regulated parties. Health insurance to this point has been largely regulated by insurance departments that have historically focused on monitoring the solvency and meeting the contractually required reimbursements for indemnity carriers. Now as the indemnity carrier has either migrated to managed care or faced a declining book of business, the historic role of regulation must change to match the new environment. This article examines the role of the health insurance/managed care regulator department under this new paradigm and identifies where and how the regulator can exert influence in such a system.

Bankruptcy↗
PubMedDate not supplied

Hospital self-insurance offers some advantages.

Practically all large employers are faced with the problem of providing economical employee insurance in its benefits program. Hospitals have some unique advantages over some other employers in terms of being able to provide self-insurance and eliminate most of the costs of sustaining an insurance carrier.

Health Benefit Plans, Employee↗
PubMedDate not supplied

Liability crisis: the insurer's point of view.

Insurers now find themselves caught in the negative results of business and investment decisions made during times of high interest rates. High premiums and low coverage have been the tactic for recovery, but it ill-behooves insurance buyers to now forget that they benefited from that period of low premiums and easy access to insurance.

Health Facilities↗
PubMed2001

[Mobbing--significance for private personal insurance].

The social conflict model called mobbing has hitherto almost remained undetected by private personal insurance systems. The mental and functional somatic disturbances caused by mobbing, however, have been well known for a long time and do not differ from those caused by other conflicts. Problems for the personal insurance develop from the fact that more often than not a (feigned) conflict solution will be sought by medical certifications of unfitness to work, referrals to hospitals and striving for acknowledgement of occupational disablement, none of which have a medical justification. A considerable portion of the national economic burden of mobbing will therefore--mostly unknowingly--be shouldered by private insurance companies. There are numerous medical diagnoses which may hide a mobbing conflict and are difficult to comprehend. This article represents instructions for better understanding and handling.

Costs and Cost Analysis↗
PubMed1986

AIDS and the limits of insurability.

Insurance is a technique to redistribute the economic consequences of loss from victims to the entire group. AIDS appears to lack the essential market and actuarial criteria of an insurable risk, without compromise to civil liberties or fiscal viability. Issues surrounding identification and classification of persons at risk of contracting the disease are most contentious. Accommodation, especially for health insurance, may be possible through mandated pools and other public and legal actions.

AIDS Serodiagnosis↗
PubMed2002

Finance issue brief: insurer liability: year end report-2002.

When a health plan denies payment for a procedure on grounds that it is not medically necessary or when it refuses a physician-ordered referral to a specialist, has it crossed the line from making an insurance judgment to practicing medicine? If the patient suffers harm as a result of the decision, is the plan liable for medical malpractice? Those were questions 35 states considered in 1999, and at least 32 states are grappling with this year as they seek to respond to physician and patient pressure to curb the power of the managed care industry. Traditionally, health insurers have been protected by state laws banning "the corporate practice of medicine," which means the patient's only recourse is to sue under a "vicarious liability" theory. Now, however, lawmakers are debating legislation to extend the scope of malpractice liability beyond individual practitioners to insurance carriers and plans themselves.

Employee Retirement Income Security Act↗
PubMed1993

Insurance and genetic testing: where are we now?

Basic research will spur development of genetic tests that are capable of presymptomatic prediction of disease, disability, and premature death in presently asymptomatic individuals. Concerns have been expressed about potential harms related to the use of genetic test results, especially loss of confidentiality, eugenics, and discrimination. Existing laws and administrative policies may not be sufficient to assure that genetic information is used fairly. To provide factual information and conceptual principles upon which sound social policy can be based, the Human Genome Initiative established an Ethical, Legal, and Social Issues Program. Among the first areas to be identified as a priority for study was insurance. This paper provides a review of life, health, and disability insurance systems, including basic principles, risk classification, and market and regulatory issues, and examines the potential impact of genetic information on the insurance industry.

Persons with Disabilities↗
PubMedDate not supplied

Public long-term care insurance in Japan.

A public long-term care (LTC) insurance program is likely to be introduced to Japan in the year 2000. A consensus on the need for more LTC resources in the rapidly aging society and dissatisfaction with the current system are some of the factors that have contributed to its introduction. Half the costs will be paid by premiums that will be levied on all those older than 40 years, and half will be covered by general taxation. The insurer will be the municipalities with a pooling mechanism at the national level to balance the differences in their demographic structure. The benefits will include institutional care, respite care, day care, home help, visiting nurses, and loan of devices. Eligibility status will be classified into 6 levels that will be determined by assessment of functional and cognitive status. However, there are few mechanisms to limit benefits and contain costs. Problems also exist in the design of the eligibility classification and in the assessment instrument. The proposed LTC insurance system highlights the need for defining what should be included in a "basic package" of LTC as an entitlement for every citizen, for an organizational mechanism and an assessment instrument to deliver services efficiently and equitably, and for physicians to work outside the traditional medical model. To what degree the Japanese public in general, and physicians in particular, is willing to deal with these issues is a challenge for the 21 st century.

Aged↗