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Gender, age, breed and distribution of morbidity and mortality in insured dogs in Sweden during 1995 and 1996.

More than 200,000 dogs insured by one Swedish company at the beginning of either 1995 or 1996 were included in a retrospective, cross-sectional study. They could be covered for veterinary care at any age, but were eligible for life insurance only up to 10 years of age. Accessions for veterinary care that exceeded the deductible cost were used to calculate the risk of morbidity. The morbidity and mortality data have been stratified by gender, age, breed, location and human population density. In each year, 13 per cent of the dogs experienced at least one veterinary care event and the mortality risk was 3.0 per cent. The risk of morbidity varied with age, gender, breed, and location. The risk of mortality increased principally with age. It was possible to derive population-based risks of morbidity and mortality from these insurance data.

Age Distribution↗

Proposal for national health insurance and health policy: social survey results.

Numerous proposals for national health insurance (NHI) are before the Congress. This study measures public preferences for three widely debated forms of NHI bases on national survey data from 1978. Analyses of the comprehensive, catastrophic and deductible forms of NHI are conducted separately using the multivariate probit technique. Findings suggest that, in general, public preference is greatest for the comprehensive plan and lowest for the catastrophic plan. Supporters of the comprehensive plan tend to be young, Democrats, members of lower socioeconomic groups, nonwhite, residents of the West, Northeast or urban areas, and without extended health insurance coverage. Support of NHI options is associated with political party preference as well as sociodemographic characteristics.

Deductibles and Coinsurance↗

Urban and rural differences in health insurance and access to care.

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies. Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P < 0.01). These differences were confirmed by multivariate analysis. Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.

Adult↗

Dental insurance and the oral health of preschool children.

Using data from the Rand Health Insurance Experiment, the effects of cost-sharing plans on the health of the primary teeth in 264 children aged 3 to 5 years were investigated. From six areas in the United States, families were assigned at random to different dental and medical insurance plans. The plans varied in the amount of required cost sharing. Families participated in the study for 3 (70%) or 5 (30%) years. Children covered by the plan (requiring no cost sharing) had significantly fewer decayed teeth and deft (decayed, extracted, and filled teeth) at the end of the study than did children covered by the cost-sharing plans. No differences existed among plans in the number of extracted and restored teeth. Children of middle- and low-income families benefited most from having access to free dental care.

Child Health Services↗

Comment on "Medicare benefits: a reassessment".

Americans have repeatedly demonstrated their preference for health insurance against out-of-pocket payments for large medical bills. The proposed reliance on "competitive markets" is not likely to meet with public or congressional favor, and risks substantial new costs while promising little fiscal relief. A more modest proposal is offered.

Aged↗

Adverse selection with a multiple choice among health insurance plans: a simulation analysis.

This study uses simulation methods to quantify the effects of adverse selection. The data used to develop the model provide information about whether families can accurately forecast their risk and whether this forecast affects the purchase of insurance coverage--key conditions for adverse selection to matter. The results suggest that adverse selection is sufficient to eliminate high-option benefit plans in multiple choice markets if insurers charge a single, experience-rated premium. Adverse selection is substantially reduced if premiums are varied according to demographic factors. Adverse selection is also restricted in supplementary insurance markets. In this market, supplementary policies are underpriced because a part of the additional benefits that purchasers can expect is a cost to the base plan and is not reflected in the supplementary premium. As a result, full supplementary coverage is attractive to both low and high risks.

Actuarial Analysis↗

Validity of self-reported prescription drug insurance coverage.

OBJECTIVES: This article assesses the validity of prescription drug insurance coverage as self-reported in the 1996/97 National Population Health Survey (NPHS). DATA SOURCE: The data are from the cross-sectional household component of Statistics Canada's 1996/97 NPHS. ANALYTICAL TECHNIQUES: Most seniors and all social assistance recipients are entitled to prescription drug benefits from their provincial governments. For NPHS respondents eligible for such benefits, the percentage reporting coverage in 1996/97 was calculated. Logit regression was used to assess the determinants of self-reported coverage. MAIN RESULTS: Only 51% of seniors and 46% of social assistance recipients who were eligible for provincial benefits reported drug insurance coverage in 1996/97. The probability of reporting coverage was generally higher in provinces with drug programs that did not impose deductibles.

Aged↗

Variations in health insurance coverage: benefits vs. premiums.

Renewed national interest in market forces to promote more efficient and cost-conscious behavior by patients and providers increasingly focuses on the structure of private health insurance benefits. Two features of procompetitive legislative proposals are considered: a ceiling on tax-free employer insurance premiums and offering greater choice of insurance plans. The interests of efficiency and equity invoke different kinds of risks and transfers; no single institutional approach is likely to yield the promised benefits.

Costs and Cost Analysis↗

The extent of ownership and the characteristics of Medicare supplemental policies.

Whether Medicare beneficiaries own private health insurance to supplement Medicare, and the characteristics of the policies they do own, are of interest both to public policy makers and to insurers. In this analysis of responses to a random survey of Medicare beneficiaries and of copies of the private insurance policies owned by these beneficiaries, the following variables were found to be important determinants of policy ownership: income, education, race, and self-perceived health status. It was also found that although most policies provide comprehensive coverage for Medicare copayments, few provide coverage for the many services and products needed by the elderly that are not covered by Medicare.

Aged↗

Risky business: when mom and pop buy health insurance for their employees.

The economics of small group insurance makes offering health benefits to employees a risky business. Surveys of employers from 1989 to 2003 reveal that more rapid premium increases are forcing small firms to impose higher cost-sharing. In 2003, premiums for small firms (3-199 workers) increased 15.5 percent, outpacing the 13.2 percent increase for large firms (200+ workers). From 2000 to 2003, deductibles among small firms increased 100 percent in PPO plans when employees use in-network providers and 131 percent when they use out-of-network providers; among large firms, deductibles in PPO plans increased 33 percent and 44 percent, respectively. And in 2003, 40.3 percent of employees in the smallest firms contributed 41 percent or more of the total family premium, compared with only 11.2 percent of employees in large firms. Clearly, fundamental change in the small employer market is necessary, including new options for helping small firms gain access to the advantages large firms have in purchasing health benefits.

Cost Sharing↗

Medicare financing reform: a new Medicare premium.

The original and continuing promise of Medicare can be preserved only through a complex package of fiscal reforms. Central to this should be a merger of Hospital Insurance and Supplementary Medical Insurance into a single Medicare trust fund, financed in part through income-related beneficiary premiums. Benefits could be expanded, while improving access and equity.

Cost Control↗

Payment restrictions for prescription drugs under Medicaid. Effects on therapy, cost, and equity.

In an attempt to contain costs, 27 Medicaid programs have implemented patient-level payment limits for medications, but the effects of these restrictions on quality of care, costs, and health status remain largely unknown. We measured the effect of one state's limit of three paid prescriptions per month and its replacement a year later by a $1 copayment. Using data on 48 months of claims in the study state (New Hampshire) and a comparison state (New Jersey), we employed time-series analysis to evaluate patient-level changes in the number of prescriptions filled for 16 drugs that varied in their clinical importance and cost. Among 10,734 continuously enrolled patients, the limit of three paid prescriptions per month caused a sudden, sustained drop of 30 percent in the number of prescriptions filled (from 1.10 to 0.77 prescriptions per patient per month); no change was observed in the comparison state. The 860 recipients of multiple drugs, who were predominantly female and elderly or disabled, were most severely affected; the number of prescriptions per month dropped from 5.2 to 2.8 (46 percent). The decrease was greatest for "ineffective drugs" (58 percent), but large drops were also observed for "essential" medications, such as insulin (28 percent), thiazides (28 percent), and furosemide (30 percent). Reductions in Medicaid prescriptions were minimally offset by increases in the size of the prescription or in out-of-pocket payments. When a $1 copayment replaced the three-prescription cap, prescriptions for most medications increased to just below precap levels. Medicaid's savings on drug costs resulting from both policies were comparable ($0.4 to $0.8 million annually), but the copayment policy had less effect on patients receiving multiple drugs. Because the clinical consequences of such policies cannot be assessed from prescription data alone, further study is needed to determine the effects of cost-containment strategies on health status and the use of other services among poor populations.

Cost Control↗

The relationship between older adults' knowledge of their drug coverage and medication cost problems.

OBJECTIVES: To determine whether chronically ill patients have gaps in knowledge about their prescription drug coverage and establish the relationship between gaps and medication cost problems. DESIGN: Nationwide, cross-sectional survey. SETTING: Nationwide survey conducted via the Internet. PARTICIPANTS: Three thousand one hundred nineteen adults aged 50 and older (1,400 of whom were aged > or = 65) who had prescription drug coverage and at least one chronic illness. MEASUREMENTS: Patients were asked about features of their drug benefits and whether they had experienced problems due to medication costs in the prior year. RESULTS: Twenty-five percent of respondents reported not knowing their usual prescription copayments, and 41% did not know whether there were caps on their drug coverage. Nonwhite race and lower income were independent risk factors for lack of knowledge about these aspects of pharmacy benefits. Lack of knowledge regarding the limits of coverage was associated with a greater likelihood of cutting back on medication use because of cost pressures, forgoing basic needs because of medication costs, borrowing money to pay for prescriptions, and worrying about medication costs (all P<.05). CONCLUSION: Many older adults with prescription drug coverage do not know important features of their pharmacy benefits. Racial minorities and those with low incomes may have the greatest difficulty understanding coverage and as a result may be at greatest risk for underusing their benefits. Education about Medicare reforms and other efforts to increase prescription coverage should accompany these policies.

Aged↗