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PubMed1990

Lessons from Canada's health program.

The Canadian health program is described and analyzed. Positive features include financing through progressive taxation; complete coverage of physician and hospital services; complete absence of deductibles, copayments, and extra charges by physicians and hospitals; lower administrative costs because private insurance companies are excluded from the program; and avoidance of the straitjacket of a single federal program by decentralization to the provinces. Negative features include ever-rising costs due to the almost complete dominance of fee-for-service payment to physicians; failure to monitor the quality of care; and neglect of serious support for preventive services and improved living standards--the two most important determinants of health status. Recommendations are made for a U.S. national health program that would incorporate the positive features of the Canadian program and avoid its deficiencies.

Canada↗
PubMed1988

Medicare Catastrophic Coverage Act of 1988.

The Medicare Catastrophic Coverage Act of 1988 is described, and implications for pharmacy are discussed. The Catastrophic Coverage Act, which will be phased in between 1989 and 1993, provides for the following benefits for Medicare beneficiaries: Under Part A, a single annual deductible and an unlimited number of days for inpatient care and covered services and improved benefits for hospice and skilled-nursing-care facilities; under Part B, a limit on out-of-pocket expenses, improved home-care benefits (including home i.v. therapy), and an outpatient prescription benefit. Long-term care was not addressed in this legislation; benefits for extended-care services were expanded, but they apply only to an acute illness. The new benefit for outpatient prescriptions provides for payment for both the drug product and professional services by the pharmacy. The benefits will be financed through a supplemental premium to be paid by all individuals who are eligible for Part A. The pharmacy profession should work with the Department of Health and Human Services in implementing the Act to ensure that this opportunity results in improved patient care through the wise application of pharmaceutical services.

Catastrophic Illness↗
PubMed1993

Sources of health insurance for the self employed: does differential taxation make a difference?

Health insurance obtained through employment has enabled many workers to take advantage of the favorable tax treatment of employer contributions to these benefits. However, the full deductibility of such employer payments as a business expense and their exemption from income taxation are not available to self-employed owners of unincorporated businesses. We identify the sources of health insurance for the self employed and examine how this disparity in tax treatment is associated with health insurance status. Analyses of data from the 1987 National Medical Expenditure Survey reveal that the differential taxation of the unincorporated self employed is associated with lower rates of employment-related coverage for themselves and their workers.

Chi-Square Distribution↗
PubMed1997

Optimal non-linear health insurance.

Most theoretical and empirical work on efficient health insurance has been based on models with linear insurance schedules (a constant co-insurance parameter). In this paper, dynamic optimization techniques are used to analyse the properties of optimal non-linear insurance schedules in a model similar to one originally considered by Spence and Zeckhauser (American Economic Review, 1971, 61, 380-387) and reminiscent of those that have been used in the literature on optimal income taxation. The results of a preliminary numerical example suggest that the welfare losses from the implicit subsidy to employer-financed health insurance under US tax law may be a good deal smaller than previously estimated using linear models.

Canada↗
PubMed1977

State laws mandating mental health insurance coverage.

Insurance companies and administrators of group insurance plans have accepted the premise that coverage for mental illness must be different from coverage for other health problems, and thus insurers continue to limit their liability through various exclusions and restrictions. For several years providers and consumers of services have worked for the enactment of state laws that mandate or regulate certain kinds of coverage for mental illness; as of January 1, 1977, a total of 22 states had such statutes. The author presents a state-by-state summary of the provisions. He also classifies many of the provisions into six categories and discusses the probable basis for their enactment.

Ambulatory Care↗
PubMed1989

Conventional health insurance: a decade later.

In this article, the 1987 conventional health plans are examined and 1987 group health insurance is compared with that of 1977. The source of information for 1987 is the national survey of 771 private and public employers conducted by the Health Insurance Association of America. Data for 1977 are from the National Medical Care Expenditures Survey. Findings show that conventional health plans' share of the group market declined from 95 to 73 percent during the decade; the majority of Americans covered by conventional group insurance are now enrolled in a plan that self-insures; prospective utilization review grew dramatically after 1984; and patient cost sharing increased, but not as significantly as conventional wisdom holds.

Data Collection↗
PubMed1991

The effect of owning private long-term care insurance policies on out-of-pocket costs.

This article examines the effect of owning long-term care insurance policies on the amount of out-of-pocket costs incurred by the elderly during their nursing home stays, and the importance of different policy features and restrictions. Data were drawn from the 1985 National Nursing Home Survey, and from copies of long-term care insurance policies collected from 11 leading companies during the spring and summer of 1988. The study results show a great deal of uncertainty concerning amounts the policies are likely to pay toward nursing home stays. This implies that the policies collected did not adequately fulfill one of the primary purposes of insurance: a reduction in risk and uncertainty. To examine whether rapid policy changes in recent years have made a difference, we assessed each of seven policy features and found that the two most important restrictions in long-term care insurance policies are prior hospitalization and level-of-care requirements. Recently, the National Association of Insurance Commissioners (NAIC) recommended that states prohibit the sale of policies containing these restrictions. Our findings confirm the wisdom of this recommendation. We did find, however, that two other policy restrictions--policy maximums and lack of inflation adjustment--are problematic. We recommend that the NAIC expand its model regulations to require that policy maximums be a minimum of four years, and that some form of inflation protection be incorporated into policy benefit structures.

Aged↗
PubMed1988

Insurance aspects of DRG outlier payments.

As part of the prospective payment system, the government pays 'outlier' payments for especially long or expensive cases. These payments can be viewed as insurance for the hospital against excessive losses. They mitigate problems of access and underprovision of care for the sickest patients, and provide additional payments to the hospitals that take care of them, thereby making payments to hospitals more equitable. This paper characterizes the outlier payment formulae that minimize risk for hospitals under any fixed constraints on the sum of outlier payments and minimum hospital coinsurance rate. We then simulate per-case payments for a policy that did not include any outlier payments, the current outlier policy, and several other policies that minimize risk subject to different coinsurance constraints. The current outlier policy achieves each of its goals to at least some extent, but more insurance could be provided without lessening attainment of the other goals. We also discuss some problems with the implementation of the current policy, such as its reliance on day outliers.

Actuarial Analysis↗