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PubMed1998

Insurance coverage, physician recommendations, and access to emerging treatments: growth hormone therapy for childhood short stature.

CONTEXT: There is concern in both the medical community and the general public about mechanisms of medical decision making and the interplay of physician and insurer decisions in determining access to care. OBJECTIVE: To examine the medical process influencing access to growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with the treatment recommendations of US physicians. DESIGN AND PARTICIPANTS: Independent national representative surveys were mailed to insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children with Special Health Care Needs, and Medicaid programs, n=113), primary care physicians (n=1504), and pediatric endocrinologists (n=534) with response rates of 75%, 60%, and 81%, respectively. Each survey included identical case scenarios. Primary care physicians were asked decisions about referrals to pediatric endocrinologists. Endocrinologists were asked GH treatment recommendations. Insurers were asked coverage decisions for GH therapy. MAIN OUTCOME MEASURES: Insurer coverage decisions for GH in specific case scenarios were compared with the recommendations of primary care physicians and pediatric endocrinologists. RESULTS: Physician recommendations and insurance coverage decisions differed strikingly. For example, while 96% of pediatric endocrinologists recommended GH therapy for children with Turner syndrome, insurer policies covered GH therapy for only 52% of these children. Overall, referral and treatment decisions by physicians resulted in recommendations for GH therapy in 78% of children with GH deficiency, Turner syndrome, or renal failure; of those recommended for treatment, 28% were denied coverage by insurers. Similarly, GH therapy would be recommended by physicians for only 9% of children with idiopathic short stature, but insurers would not cover GH for the vast majority of these children. Furthermore, the data indicated considerable variation among insurers regarding coverage policies for GH (P<.01). CONCLUSIONS: Access to GH therapy differs depending on the type of insurance coverage. The deep discord between physician recommendations and insurance coverage decisions, exemplified by these findings, represents a major challenge to mechanisms of health care decision making, access, and costs.

Body Height↗
PubMed1990

[Utilization and medical cost of patients with different insurance coverage among group practice centers].

In order to explore the utilization and medical cost of patients with different insurance coverage in group practice centers, we collected patient data in three centers from September 1, 1987 to February 28, 1988. We classified the payments as self-payment,partial-reimbursement and total-reimbursement. There were 42,234 visits by 8,111 patients. The average frequency of visits within 6 months was 6.1 in total-reimbursement patients, 5.2 in partial-reimbursement patients and 2.6 in self-payment patients. We found that the frequency of visits increased with age in patients with total-reimbursement and partial-reimbursement. On the other hand, the frequency decreased after the age of 65 in patients with self-payment; whether it was related to the economic problems of the elderly needs further study. The highest medical cost per visit was NT$. 343 in total reimbursement patients, followed by NT$. 281 in partial-reimbursement patients. The lowest cost was NT$. 208 in self-payment patients. Yet, the highest ratio of total drug cost by total medical cost per visit was 73.7% in partial-reimbursement patients followed by 63.6% in total-reimbursement patients. The lowest ratio was 56.7% in self-payment patients. Although the partial-reimbursement system could not decrease the ratio of total drug cost by total medical cost per visit, it would be beneficial in group practice centers to decrease the patients' visits and the medical cost per visit. Therefore, this system should be executed in the future.

Adolescent↗
PubMedDate not supplied

Expanding individual health insurance coverage: are high-risk pools the answer?

Thirty states operate high-risk pools intended to offer coverage to persons denied coverage in the individual health insurance market. But in most states the high-risk pool mirrors the individual market's problems: Coverage is expensive, the waiting period for coverage of preexisting conditions is long, and benefits may be limited. A few states with high-risk pools have addressed these problems by adequately funding high enrollment and comprehensive benefits; some also require the market to accept more risk. But most discourage enrollment in the high-risk pool in myriad ways and fall to ensure access to the individual market for persons with health problems.

Health Policy↗
PubMed1997

The demand for health insurance coverage by low-income workers: can reduced premiums achieve full coverage?

OBJECTIVE: To assess the degree to which premium reductions will increase the participation in employer-sponsored health plans by low-income workers who are employed in small businesses. DATA SOURCES/STUDY SETTING: Sample of workers in small business (25 or fewer employees) in seven metropolitan areas. The data were gathered as part of the Small Business Benefits Survey, a telephone survey of small business conducted between October 1992 and February 1993. STUDY DESIGN: Probit regressions were used to estimate the demand for health insurance coverage by low-income workers. Predictions based on these findings were made to assess the extent to which premium reductions might increase coverage rates. DATA COLLECTION/EXTRACTION METHODS: Workers included in the sample were selected, at random, from a randomly generated set of firms drawn from Dun and Bradstreet's DMI (Dun's Market Inclusion). The response rate was 81 percent. FINDINGS: Participation in employer-sponsored plans is high when coverage is offered. However, even when coverage is offered to employees who have no other source of insurance, participation is not universal. Although premium reductions will increase participation in employer-sponsored plans, even large subsidies will not induce all workers to participate in employer-sponsored plans. For workers eligible to participate, subsidies as high as 75 percent of premiums are estimated to increase participation rates from 89.0 percent to 92.6 percent. For workers in firms that do not sponsor plans, similar subsidies are projected to achieve only modest increases in coverage above that which would be observed if the workers had access to plans at unsubsidized, group market rates. CONCLUSIONS: Policies that rely on voluntary purchase of coverage to reduce the number of uninsured will have only modest success.

Adult↗
PubMed1998

Effects of state reforms on health insurance coverage of adults.

States have tried a number of strategies to reduce the growing number of uninsured people. These include Medicaid expansions and various insurance reforms, such as low-cost plans, subsidized insurance products, risk pooling, open enrollment and continuity of coverage requirements, and community rating. Using data from 1989 to 1994, we examine the impact of such policies on health insurance coverage for adults. We find that few state policies have succeeded in increasing health insurance coverage. For those that work, impacts are very modest or are accompanied by adverse effects such as crowdout. Implementing effective state policies to reduce the number of uninsured remains a great challenge.

Adolescent↗
PubMed2004

Race, ethnicity, insurance coverage, and preoperative status of hip and knee surgical patients.

Our objective was to examine the association between race/ethnicity and insurance type and the preoperative status of patients undergoing joint arthroplasty surgery. Quality of life and WOMAC measures were collected preoperatively in a consecutive series of patients undergoing primary hip or knee arthroplasties (n = 573). Non-Hispanic whites had lower preoperative pain and WOMAC scores and higher Quality Well Being Index and SF-36 scores compared with other racial/ethnic subgroups. Patients with Medicare/private insurance had better preoperative scores relative to patients with Medicaid or no insurance. Racial/ethnic status was generally more strongly associated with preoperative status than was insurance type. Hispanics, blacks, and patients without Medicare or private health insurance reach arthroplasty surgery with lower preoperative functional and health status.

Arthroplasty, Replacement, Hip↗
PubMedDate not supplied

The role of health insurance coverage in reducing racial/ethnic disparities in health care.

Research showing racial/ethnic disparities in medical care obtained by people with comparable insurance has raised questions about the extent to which health insurance improves opportunities for care. To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.

Delivery of Health Care↗
PubMed2000

Health insurance coverage and the job market in California.

This Special Report examines why the uninsured rate is so much higher in California than it is in the rest of the United States; it focuses on labor market and demographic characteristics that may explain the differential in health insurance coverage. California has the third-highest rate of uninsured for the nonelderly population in the United States, accounting for 16.6 percent of the total U.S. uninsured population. In 1998, 24.4 percent of the nonelderly population in California (both workers and nonworkers under age 65) was uninsured, compared with 18.4 percent uninsured in the United States as a whole. Only Arizona (with 27.2 percent) and Texas (with 27.0 percent) had higher uninsured rates than California. Among California workers ages 18-64, nearly 24 percent (or 3.8 million workers) were uninsured in 1998. Eleven years earlier, in 1987, 19.3 percent (or 2.7 million workers) were uninsured. During the decade 1987-1997, the percentage of California workers with employment-based health insurance declined from 68.5 percent to 64.2 percent. But more recently, between 1997 and 1998, the percentage of workers with employment-based coverage increased slightly from 64.2 percent to 65.5 percent. Fifty-three percent of California workers employed in the agriculture sector were uninsured in 1998. Overall, agriculture accounts for 4 percent of the jobs in California; however, agricultural workers accounted for 8 percent of the uninsured. Demographics are a key factor affecting California's rate of uninsured. Twenty-seven percent of California workers are Hispanic, more than three times the proportion in the rest of the United States. Compared with the rest of the country, California has fewer workers who are white (54 percent vs. 76 percent) or black (6 percent vs. 12 percent), and more workers who are Asian (12 percent vs. 3 percent). More than 43 percent of Hispanic workers in California were uninsured in 1998, compared with 14 percent of white workers, 24 percent of black workers, and 21 percent of Asian workers. California workers--and Hispanic workers in particular--are more likely to be employed by small firms, which are significantly less likely to offer health benefits than large firms. Forty-four percent of the California work force was employed by firms with fewer than 100 employees, or was self-employed, compared with 40 percent of the work force in the rest of the United States. Sixteen percent of all workers in California did not graduate from high school. Among Hispanic workers, 44 percent did not graduate from high school; among white workers, 13 percent did not graduate. In comparison, 18 percent of Asian workers and 7 percent of black workers did not graduate from high school. In California, 60 percent of Hispanics earning less than $7 per hour were uninsured in 1998. In contrast, 26 percent of whites, 46 percent of blacks, and 41 percent of Asians earning less than $7 per hour were uninsured.

Adolescent↗