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Making fair decisions about financing care for persons with AIDS.

An estimated 40 percent of the nation's 55,000 persons with acquired immunodeficiency syndrome (AIDS) have received care under the Medicaid Program, which is administered by the Health Care Financing Administration (HCFA) and funded jointly by the Federal Government and the States. In fiscal year 1988, Medicaid will spend between $700 and $750 million for AIDS care and treatment. Medicaid spending on AIDS is likely to reach $2.4 billion by fiscal year 1992, an estimate that does not include costs of treatment with zidovudine (AZT). Four policy principles are proposed for meeting this new cost burden in a way that is fair, responsive, efficient, and in harmony with our current joint public-private system of health care financing. The four guidelines are to (a) treat AIDS as any other serious disease, without the creation of a disease-specific entitlement program; (b) bring AIDS treatment financing into the mainstream of the health care financing system, making it a shared responsibility and promoting initiatives such as high-risk insurance pools: (c) give States the flexibility to meet local needs, including Medicaid home care and community-based care services waivers; (d) encourage health care professionals to meet their obligation to care for AIDS patients.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Reform of financing for health coverage: what can reinsurance accomplish?

Reinsurance is one way that insurance companies pool risk, in this case, across insurance companies. Under conventional private practice, primary health insurers, including self-insured groups and HMOs, voluntarily contract with reinsurers to share some risk and some premiums. Because the primary carrier mainly wants to protect its solvency against unpredictable variation in claims experience, it normally reinsures only the "high end" of claims risk. This retrospective coverage of unusually high losses helps primary insurers take on more risk than they otherwise could. But it does not help secure affordable coverage for people with prospectively known high risks. Some plans for reforming private health insurance also invoke reinsurance-like mechanisms, especially in the markets for individual and small group coverage. There, reinsurance serves as part of a strategy for requiring that primary insurance be made available to all applicants, regardless of risk. Reinsurance or similar rules for allocating the burden of unusually high risks can help keep any one private insurer from having to bear a disproportionate share of high risks, and thus extend the reach of private insurance markets through regulation. But reinsurance alone does not reduce the underlying high cost of providing such primary coverage. Nor can reinsurance alone provide the resources to cover the uninsured, ensure that insurers will want to cover them, or make them voluntarily buy private coverage. Only some combination of new subsidies and mandates can do that.

Economic Competition↗
PubMed1992

Private insurance reform in the 1990s: can it solve the health care crisis?

A number of health insurance reform proposals have surfaced at the state governmental level in the United States. These include Medicaid expansion for the below-poverty or near-poverty uninsured, state subsidy to individuals and/or businesses for the purchases of health insurance, risk pools for the medically uninsurable, insurance industry-initiated reforms within the small group market, the promotion of "stripped down" insurance plans that reduce premium cost, and state mandating of employer-sponsored health insurance for the employed uninsured. All of these insurance reform proposals have serious limitations: (1) they fail to address the inequities of the underwriting principle by which older and sicker people pay more for health insurance than the young and healthy population; (2) they extend the illogical linkage of employment and health insurance; and (3) they do not slow the rate of health cost inflation nor do they contain a mechanism to finance broader health coverage through savings within the health sector. An alternative to insurance reform is the establishment of a social insurance program that brings the entire population into a single risk pool.

Adult↗
PubMed1988

Uncompensated care pools and care to the uninsured: lessons from the New York Prospective Hospital Reimbursement Methodology.

One policy response to both the growing number of uninsured and the increased volume of uncompensated care is the development of revenue pools to explicitly finance uncompensated care. Despite the growing popularity of this response, few analyses have examined their success in financing uncompensated care and improving access to the uninsured. This study examines one such program developed as part of New York State's all-payer rate-setting system. The results indicate that the revenue pools improved the financial condition of New York hospitals but were less effective in improving access to care by the uninsured. The latter result was traced to the method selected by New York to measure "need" and distribute payments to hospitals. If the goal of such programs is to earmark payments to the uninsured, methods other than the New York system should be employed.

Data Collection↗
PubMed1991

Universal access to health care. A comprehensive tax-based approach.

More than 30 million Americans lack health insurance, and millions more are "underinsured." Meanwhile, the cost of health care in the United States is escalating, and some of our care is of questionable value. This article presents a health care reform strategy that addresses these three fundamental problems in the US health care system. The strategy, designed to empower consumers to make cost-conscious health care choices, combines a universal tax credit that enables all Americans to purchase basic health coverage; insurance reforms including pooling and reinsurance mechanisms; requirements that all employers make insurance available to their employees and that all consumers purchase coverage; and efforts to measure and improve the quality and efficiency of health care services. This strategy would help us to achieve universal health insurance coverage, while creating the proper incentives for cost control. In addition, it can be largely internally financed through savings automatically triggered by its implementation.

Cost Control↗
PubMed1972

Ribonucleotide reductase activity of synchronized KB cells infected with herpes simplex virus.

The replication of herpes simplex virus (HSV) is unimpeded in KB cells which have been blocked in their capacity to synthesize deoxyribonucleic acid (DNA) by high levels of thymidine (TdR). Studies showed that the presence of excess TdR did not prevent host or viral DNA replication in HSV-infected cells. In fact, more cellular DNA was synthesized in infected TdR-blocked cells than in uninfected TdR-blocked cells. This implies that the event which relieved the TdR block was not specific for viral DNA synthesis but allowed some cellular DNA synthesis to occur. These results suggested that HSV has a means to insure a pool of deoxycytidylate derivatives for DNA replication in the presence of excess TdR. We postulated that a viral-induced ribonucleotide reductase was present in the cell after infection which was not inhibited by thymidine triphosphate (TTP). Accordingly, comparable studies of the ribonucleotide reductase found in infected and uninfected KB cells were made. We established conditions that would permit the study of viral-induced enzymes in logarithmically growing KB cells. A twofold stimulation in reductase activity was observed by 3 hr after HSV-infection. Reductase activity in extracts taken from infected cells was less sensitive to inhibition by exogenous (TTP) than the enzyme activity present in uninfected cells. In fact, the enzyme extracted from infected cells functioned at 60% capacity even in the presence of 2 mm TTP. These results support the idea that a viral-induced ribonucleotide reductase is present after HSV infection of KB cells and that this enzyme is relatively insensitive to inhibition by exogenous TTP.

Carbon Isotopes↗
PubMed1990

Risk contracting.

Explore the source record for details and available documents.

Accounting↗
PubMed1975

Liability and compensation independent of medical negligence: the new Swedish system.

On the 1st of January 1975 a new system of Treatment Injury Insurance was introduced in Sweden. (Until then the rules of tort law governed all liability insurances.) Almost all medical attendance within, and much of the attendance outside, hospitals is managed by County Councils (Landstingen). The new insurance is contracted by the managing County Council to a pool of Swedish Insurance Companies. The total amount of the premiums for this first year is calculated to be 16 milj Skr (4 milj $ = 1/2$ per inhabitant per year). By treatment injury shall be understood "injury or illness of a physical nature...as a direct consequence...of...treatment (excepting natural or probably consequences of an act justified from a medical point of view), or of incorrect result(s) of technical examination or clinical diagnostics, or of accidents in hospitals, doctors' offices or in connection with ambulance services".

Diagnostic Errors↗
PubMed1986

AIDS: the risks to insurers, the threat to equity.

The AIDS crisis poses a special challenge for American health care, which depends heavily on private insurance to pay medical bills. Can we provide adequate health care to all who need it and still meet the financial requirements of the private health insurance industry? More insurance carriers are turning to antibody testing in order to eliminate poor risks from non-group, direct-pay pools. Some cost-conscious employers have attempted to fire AIDS patients summarily or to exclude AIDS coverage from group insurance policies. Various remedies are available for spreading the financial risks of the epidemic, such as covering persons with AIDS under Medicare or in state-sponsored health insurance pools. Ethical questions about cost and access may also rekindle the debate about the need for national health insurance.

AIDS-Related Complex↗
PubMed1991

How do uncompensated care pools affect the level and type of care? Results from New York State.

Uncompensated care pools have been used by several states in their attempt to aid hospitals and increase the volume of care provided to patients without health insurance. We examined the uncompensated care pool used in New York State between 1983 and 1987. Our primary interest was to estimate the impact of the pools on the level and type of care provided to uninsured patients. Our results indicate that hospitals responded to the pools by increasing the volume of care provided to uninsured patients. Without the pools, over 30,000 fewer adjusted hospital admissions would have been provided to the uninsured in a typical year. Many of these newly purchased admissions were for "nondiscretionary" medical care, suggesting that beneficial care to the indigent was rationed prior to the introduction of the uncompensated care pools.

Charities↗
PubMed1984

Validity of multiple-choice examinations in surgery.

The difficulty of creating new, unambiguous, pertinent multiple-choice questions of a level appropriate to medical students implies that examinations must be compiled from a limited number of items. Furthermore, it is impossible to keep used questions inaccessible to all subsequent students. This study was undertaken to determine if these realities are compatible with examinations that are both valid and reliable. A pool of 480 multiple-choice questions was distributed to 232 students during the surgical clerkship. At the conclusion of each quarter, a 120-item multiple-choice examination that consisted of entirely new questions was administered (group I). These 960 questions were then made available to the next group of 218 students; each subsequent examination consisted of 50% new questions and 50% questions repeated verbatim from the publicized pool (group II). With the available pool now increased to 1200, the next examination consisted of 20% new and 80% repeat questions (group III). Reliability (internal consistency) was measured by the Kuder-Richardson-21 formula. Validity was measured by correlation between the multiple-choice examination and the average score of evaluations of each student by two oral examinations and five faculty members. Despite the expected increase in mean examination score, there is loss of neither reliability nor validity by inclusion of even 80% of items repeated from a large pool of multiple-choice questions that have been distributed to the students. Hence, instead of adding irrelevant, trivial, or inappropriate items or trying in vain to hide old examinations from new students, simple preparation of examinations from a large pool of questions is recommended. To insure fairness to all students, this pool should be made public knowledge.

Educational Measurement↗
PubMed1992

Insurer competition and protection from risk redefinition in the individual and small group health insurance market.

Analyses of problems in the health insurance market usually focus on the individual and small group market. Consumers in this market who experience an illness or diagnosis of illness in one time period are likely to have their future risk redefined by insurers. Despite the fact that risk-averse consumers should desire protection against redefinition of risk, policies featuring that protection currently are not common in the individual and small group market. Contracts offering that protection must either be offered by pools that can guarantee replenishment of good risks over time, or be multiperiod contracts. Risk replenishment is impossible for individuals and may be technically difficult for many small groups. Also, the terms of multiperiod contracts with a single insurer may be unattractive to individuals and small groups, given the current structure of the market. Multiperiod contracts with a pool, rather than an individual insurer, may make it possible for individuals and small groups to enjoy the same advantages as consumers who obtain employment-based health insurance through large firms.

Consumer Advocacy↗