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PubMed1987

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.

Choice Behavior↗
PubMed1988

The erosion of purchased health insurance.

In this paper, we trace the decline of purchased health insurance and examine the reasons for the rapid growth of self-insurance between 1981 and 1985. Then, using nationally representative data on benefits in larger private sector firms, we examine the changing content of self-insured plans and compare them with fully insured conventional plans from commercial insurers and Blue Cross and Blue Shield Plans. Between 1981 and 1985, the percentage of employees in mid- to large-sized firms covered by self-insurance grew from 21% to 42%. Self-insured plans cost more than purchased plans in 1981, and continued to cost more in 1985. Their higher premiums were not due to richer benefit packages. Indeed, they less often covered "fringe" services and required greater cost sharing via higher deductibles and coinsurance. Upon considering both the efficiency and the equity issues of self-insurance, we sound a cautionary note on this growing trend.

Blue Cross Blue Shield Insurance Plans↗
PubMed2003

Differences between physical and behavioral health benefits in the health plans of at-risk drinkers.

OBJECTIVE: The goal of this study was to describe the physical and behavioral health benefits of a representative community-based sample of at-risk drinkers potentially in need of behavioral health services. METHODS: A screening instrument for at-risk drinking was administered by telephone to a random community sample of more than 12,000 adults. A telephone interview was conducted with the health plans of 294 at-risk drinkers who were insured and who consented to the release of their insurance records to collect information about supply-side cost-containment strategies (for example, gatekeeping and restrictions on choice of provider), and demand-side cost-containment strategies (for example, deductibles, limits, coinsurance, and copayments). Information about health plan characteristics was successfully collected for 217 (72 percent) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. RESULTS: Both provider choice restrictions and gatekeeping were more likely to be used for behavioral health care than for physical health care. Greater cost-sharing for mental health than for physical health was most often achieved by using additional limits (83 percent) and higher coinsurance (66 percent) and less often achieved by using higher copayments (38 percent) and additional deductibles (13 percent). The greater cost-sharing for behavioral health amounted to a 30 percent ($42) difference in annual out-of-pocket costs for an average user of behavioral health services compared with full parity. CONCLUSIONS: The results provide information to advocacy groups and policy makers about how much equalization would have to occur in the insurance market before full parity could be achieved between physical health and behavioral health benefits for a population of individuals potentially in need of behavioral health services.

Adult↗
PubMed1990

Private health insurance of chronically ill children.

Accurate information regarding the adequacy of private health insurance coverage available to the families of chronically ill children is scarce. A national survey was conducted of firms offering health insurance to employees and their dependents. Data were collected concerning private health insurance coverage of services needed by chronically ill children, including basic medical care services, ancillary therapies, mental health services, and long-term care. Nearly all surveyed firms offered health insurance. Coverage of inpatient hospital care, outpatient physician services, medical supplies and equipment, x-ray studies, laboratory services, and prescription medications was widespread, but coverage of services such as physical therapy, speech therapy, occupational therapy, and nutrition services was much less prevalent. More than two thirds of the firms covered comprehensive home health services but often with limits and only in lieu of more expensive inpatient care. Long-term care, such as skilled nursing home care, was covered by only one third of firms. Overall, the survey results, combined with information concerning recent trends in private health insurance, reveal increasing coverage of lower cost alternatives to hospital or institutional care and improved maximum lifetime benefits and stop-loss coverage but also increased cost-sharing requirements. These results suggest that, although families with chronically ill children may have access to a widening range of services such as home health care or individual benefits management, they may be forced to bear an increasing proportion of the cost.

Child↗
PubMedDate not supplied

Self-insurance in times of growing and retreating managed care.

This paper examines trends in self-insurance and in the content of self-insured plans from 1993 to 2001. The percentage of employees enrolled in self-insured plans fell during these years. Much of the decrease was attributable to the decline of indemnity insurance and the rise of HMO and point-of-service plan enrollment. If the product mix had remained constant throughout these years, self-insured enrollment would have grown between 1993 and 1996 and then declined to its current 50 percent level. As a result of the Health Insurance Portability and Accountability Act (HIPAA), the use of preexisting condition clauses declined dramatically in self-insured plans. Self-insured and purchased plans cost similar amounts and provide similar benefits. Cost sharing is somewhat lower in self-insured PPO plans. During periods of rapid inflation, premiums increase more slowly for self-insured than for fully insured plans.

Cost Sharing↗
PubMed2001

Physician incentives and disclosure of payment methods to patients.

OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients' awareness of and interest in physician payment information or its potential impact on patients' evaluation of their care. DESIGN: Cross-sectional survey SETTING: Managed care and indemnity plans of a large, national health insurer. PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%). MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians' payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Non-managed fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians' payment METHOD: Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary. CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted.

Adult↗
PubMedDate not supplied

President Bush's comprehensive health reform program.

To deal with the shortcomings of the current U.S. health care system, President Bush has proposed a comprehensive reform package that would offer tax credits and deductions to low- and middle-income Americans to purchase private insurance, reform small market insurance to ensure availability and portability of insurance, allow creation of Health Insurance Networks to allow small businesses and nonprofit organizations to pool their purchasing power, reduce administrative costs, and control the growth of government health programs. Combined, the proposals would build on the strengths of the present private/public system and preserve consumer choice and free market discipline.

Cost Control↗
PubMed2002

Tracking health care costs: hospital spending spurs double-digit increase in 2001.

This Data Bulletin is based on data from the Milliman USA Health Cost Index ($0 deductible), which is designed to reflect claims increases faced by private insurers; the Kaiser Family Foundation/Health Research and Educational Trust survey of employer-based health plans for 1999- 2002; the KPMG survey of employer-based plans for 1991-98; and the U.S. Bureau of Labor Statistics Employment, Hours and Earnings series to track payroll costs and Hospital Producer Price Index to track hospital prices.

Cost Sharing↗
PubMed2001

Tracking health care costs: hospital care key cost driver in 2000.

This Data Bulletin is based on data from the Milliman USA Health Cost Index ($0 deductible), which is designed to reflect claims increases faced by private insurers; the Kaiser Family Foundation/Health Research and Educational Trust survey of employer-based health plans for 1999-2001; the KPMG survey of employer-based plans for 1991-98; the U.S. Bureau of Labor Statistics Employment, Hours and Earnings series to track payroll costs; and Center for Studying Health System Change 2000-01 site visits (see www.hschange.org).

Cost Sharing↗
PubMed2003

Tracking health care costs: trends slow in first half of 2003.

This Data Bulletin is based on data from the Milliman USA Health Cost Index (HCI) ($0 deductible), which is designed to forecast claims trends faced by private insurers and the U.S. Bureau of Labor Statistics' National Compensation Survey to track hourly compensation costs for nurses and Producer Price Index for general medical and surgical hospitals to track hospital prices. The HCI classifies spending on services performed in freestanding facilities in its hospital outpatient category, which is consistent with how insurers classify such services. Due to data limitations, the HCI includes spending for Medicaid and uninsured patients, which can cause HCI trends to differ from privately insured trends. The authors have adjusted the HCI estimates to remove the effect of distinct Medicaid hospital price trends. As with most economic data, the HCI is subject to periodic retroactive revisions.

Economics, Hospital↗
PubMed2004

Tracking health care costs: trends turn downward in 2003.

This Data Bulletin is based on data from the Milliman USA Health Cost Index ($0 deductible), which is designed to reflect claims trends faced by private insurers; the U.S. Bureau of Labor Statistics' (BLS) Producer Price Index for general medical and surgical hospitals and for physicians' offices to track hospital and physician prices; the BLS's Consumer Price Index for prescription drugs and medical supplies to track prescription drug prices; and the Towers Perrin 2004 Health Care Cost Survey and the Ninth Annual National Business Group on Health/Watson Wyatt Employer Survey Report 2004 for premium trends. It is adapted from "Tracking Health Care Costs: Trends Turn Downward in 2003" by Bradley C. Strunk and Paul B. Ginsburg, Health Affairs, Web-exclusive publication, June 9, 2004, www.healthaffairs.org

Forecasting↗
PubMed2006

Tracking health care costs: spending growth remains stable at high rate in 2005.

This Data Bulletin is based on data from the Milliman Health Cost Index 2005 Series ($0 deductible), which is designed to reflect claims trends faced by private insurers; the U.S. Bureau of Labor Statistics' (BLS) Producer Price Index for general medical and surgical for general medical and surgical hospitals and for physicians' offices to track hospital and physician prices; the BLS's Consumer Price Index for prescription drugs and medical supplies to track prescription drug prices; and the Kaiser Family Foundation/Health Research and Educational Trust 2006 Survey of Employer Health Benefits. It is adapted from "Tracking Health Care Costs: Continued Stability But At High Rates In 2005," by Paul B. Ginsburg, Bradley C. Strunk and Michelle I. Banker of HSC; and John P. Cookson of Milliman, Health Affairs, Web-exclusive publication, Oct. 3, 2006, www.healthaffairs.org.

Forecasting↗
PubMed1993

The effect of HMOs on premiums in employment-based health plans.

This study documents the effect of HMOs on premiums in employment-based health plans. We analyzed a survey of Minnesota employers conducted in 1986. Among 922 usable observations, 239 firms offered HMOs in addition to fee-for-service (FFS) health plans. We estimated an equation for the probability of offering an HMO, followed by equations for HMO enrollment share, and HMO and FFS premiums. The weighted average HMO and FFS premium in firms that offer HMOs was compared to the premium of FFS-only firms. We found that offering an HMO raises the average premium for family coverage health insurance by $25.14 per month and for single coverage by $3.68 per month. This effect was smaller for firms in the Twin Cities metropolitan area. HMOs may be viewed as a progressive and innovative health care benefit, but they are likely to increase firms' health insurance premiums.

Cost Sharing↗
PubMed1980

Utilization of publicly insured health services in Saskatchewan before, during and after copayment.

This study examines the effects both of introducing and of removing copayment charges under a universal public medical care and hospital insurance program. For a period between 1968 and 1971, the Province of Saskatchewan imposed user charges of approximately 33 per cent and 6 per cent on medical and hospital services, respectively. The effects of these charges are analyzed using pooled cross-section samples of families and using both multivariate methods and experimental/control groups designs. Diagnostic- and procedure-specific analysis is also performed on the hospital data using the individual as the unit of observation. The findings of the study indicate a copayment effect of 5.6 per cent for physicians' services. No evidence could be adduced that would support the conclusion of a copayment effect for hospital services.

Deductibles and Coinsurance↗
PubMed2005

The effect of health savings accounts on health insurance coverage.

The authors investigate the potential of Health Savings Accounts (HSAs) to expand health insurance coverage. They examine how many currently uninsured people might be encouraged to buy coverage through HSAs, and what the impacts of such actions might be on the group and nongroup health insurance markets. Their main conclusions: HSAs are not likely to be an important contributor to expanding coverage among uninsured people because most of them do not face high-enough marginal tax rates to benefit substantially from the tax deductibility of HSA contributions. Meanwhile, HSAs could potentially destabilize the small-group market. To the extent that they encourage well-compensated healthy workers to abandon job-based coverage--a result that is more likely if current HSA provisions are combined with proposed premium deductibility--HSAs could undermine the entire structure of job-based coverage among small firms.

Cost Savings↗
PubMedDate not supplied

How companies tackle health care costs: Part I.

From the experience of a cross-section of Fortune "500" companies and top nonindustrials, these authors develop a profile of the newer types of health plans and benefits designed to cut health care costs. After examining the various plans, their funding, and their results, however, the authors conclude that another form of health insurance, more like other kinds of insurance policies that cover only catastrophic events, is the most promising from all points of view. In a second article, Regina Herzlinger will examine corporate efforts to reshape the system of supplying health care.

Cost Control↗