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PubMed2006

Zero lift programs in small rural hospitals in Washington state: reducing back injuries among health care workers.

In Washington State, health care workers have the highest rate of compensable back injuries. Washington Hospital Services, a self-insured workers' compensation program, implemented a zero lift program in 31 of its 38 hospitals. Zero lift was defined as replacing manual lifting, transferring, and re-positioning of patients with mechanical lifting or use of other patient assist devices. This program included two trusts, two pools of hospitals that self-insure workers' compensation. The pools are governed by elected boards of trustees from the pool memberships and regulated by the State Department of Labor and Industries. This pretest-posttest descriptive study compared patient-handling injury data prior to program implementation with those after program implementation. Patient-handling injury claims decreased by 43% in the participating hospitals from 2000 to 2004 (i.e., from 3.51 to 2.23). The time lost frequency rate decreased by 50% (i.e., from 1.91 to 1.03).

Accidents, Occupational↗
PubMed2003

Fecal corticosterone assessment in the epaulette shark, Hemiscyllium ocellatum.

The present study examined the feasibility of measuring the steroid hormone corticosterone in fecal extracts of epaulette sharks, Hemiscyllium ocellatum. Six immature, captive-raised epaulette sharks (four females and two males) were obtained from two different zoos and were maintained in a closed-system, 530-liter aquarium. After a one-month adaptation, fecal samples were collected daily from each animal for 33 days. Five-day sets of samples were pooled within animals to insure sufficient material for analysis. Fecal hormone extraction was achieved using repeated cycles of dichloromethane and aqueous washes. The levels of corticosterone were measured by reverse-phase high-performance liquid chromatography (HPLC). Corticosterone presence in HPLC eluent peaks from fecal extracts was determined by comparison of the elution pattern of corticosterone standard with the elution patterns of fecal extracts with and without the addition of tritiated corticosterone or exogenous, unlabeled corticosterone. Exclusive presence of corticosterone in HPLC eluent peaks presumed to be corticosterone was determined by nuclear magnetic resonance mass spectrometry. Corticosterone levels, calculated from a 10-point standard curve, ranged from 1.2 to 20.9 ng/g feces across all sharks, with 92.3% of values being < or =13.5 ng/g. Within individuals, the lowest average for corticosterone levels across 33 days was 2.6+/-0.4 ng/g feces, and the highest average was 8.4+/-2.2 ng/g feces. This study demonstrated that corticosterone was extractable from and reliably measurable in fecal extracts of epaulette sharks. This is the first evidence of this hormone in epaulette sharks and the first report of fecal corticosterone in elasmobranchs.

Animals↗
PubMed2005

[Area-wide dental prophylaxis methods and locating increased needs for prophylaxis in Braunschweig 2003/2004].

Based on the section sign 21 SGB V an extensive concept for measuring tooth-prophylaxis methods is used in Braunschweig. The program attains 20,000 children at the age of 3 to 15 years. It is mainly financed by the working pool of the health insurance. Small spatial gathered indicators are visualized in 30 defined parts of the town. City maps and excel-tables are presented in a SWOT-analysis by the example of the data of the primary schools.

Adolescent↗
PubMed1996

Failure of health care reform in the USA.

The failure of health reform in the USA reflects the individualism and lack of community responsibility of the American political culture, the power of interest groups, and the extraordinary process President Clinton followed in developing his highly elaborate plan. Despite considerable initial public support and a strong start, the reform effort was damaged by the cumbersome process, the complexity of the plan itself, and the unfamiliarity of key components such as alliances for pooled buying of health insurance. In addition, the alienation of important interest groups and the loss of presidential initiative in framing the public discussion as a result of international, domestic and personal issues contributed to the failure in developing public consensus. This paper considers an alternative strategy that would have built on the extension of the Medicare program as a way of exploring the possibilities and barriers to achieving health care reform. Such an approach would build on already familiar and popular pre-existing components. The massive losses in the most recent election and large budget cuts planned by the Republican majority makes it unlikely that gaps in insurance or comprehensiveness of coverage will be corrected in the foreseeable future.

Cultural Characteristics↗
PubMed1999

The medical malpractice risk associated with bariatric surgery.

BACKGROUND: Bariatric surgery has been classified as high risk by the medical malpractice industry, but it is unclear what data support this classification. When a small group of physicians is separated from their peers and asked to support their malpractice claims, their premiums will often rise unfairly in relation to the outcome of the claims. This report outlines the results of a survey sent to the members of the American Society for Bariatric Surgery (ASBS) asking for information on malpractice claims. METHODS: Surveys were mailed to the 285 ASBS members requesting which bariatric operations were performed, how many procedures were completed each year, details of any suits filed against the member including final outcome, and information on whether the members also performed gastric surgery for ulcer disease. RESULTS: Surveys were returned by 165 members (58%) from surgeons in 33 states and Washington, D.C. Malpractice claims had been made after 107 bariatric procedures and three ulcer procedures with the risk of a suit being filed for a bariatric procedure being approximately 1.6/1,000 cases. The average monetary award was $88,667. Of the suits that resulted in a jury trial, 14% agreed with the plaintiff. Over half the cases that had been resolved were either dropped or dismissed before trial. CONCLUSIONS: The incidence of suit being brought against ASBS members performing bariatric procedures is low. Once filed, most cases do not reach a jury trial. Settlements are usually under $100,000. These data suggest that this group of bariatric surgeons do not represent a disproportionately large risk pool for medical malpractice insurance companies.

Gastric Bypass↗
PubMed1994

Single payer: the California referendum.

The California Health Security Act is likely to appear on the November 1994 ballot. The bill would provide universal coverage to California residents and assign the state as the single payer for all medical care provided, financed with funding for programs already in place, employer payroll taxes, individual income taxes and taxes on tobacco products.

California↗
PubMed2002

Do welfare caseload declines make the Medicaid risk pool sicker?

Declining welfare caseloads may lead to a sicker population remaining in the Medicaid program, which could increase per enrollee costs and the level of adequate capitation rates. Using data from the 1997 National Survey of America's Families for adults and children, we examine differences in health status and utilization among welfare recipients and welfare leavers who did and did not retain Medicaid. We adjust utilization differences for insurance status and factors often used to adjust capitation rates. We conclude that declining welfare caseloads likely will result in a sicker and more expensive adult Medicaid risk pool.

Adult↗
PubMed2002

New model integrates DM and CM to boost care for high-risk patients.

It may seem like an obvious call to provide extensive DM and case management services to people who have been deemed "high-risk," but that is typically not the rule in the many "high-risk" pools that states have set up for people who have been denied commercial insurance elsewhere. However, in an unprecedented move, the non-profit insurer for the high-risk pool in Colorado is betting that an integrated system of DM and CM services will slash utilization while boosting health status. It's an innovative model that could well be replicated if all goes as planned.

Case Management↗
PubMed1998

Relationship between type of insurance and care during the early course of psychosis.

OBJECTIVE: Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission. METHOD: Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care. RESULTS: At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission. CONCLUSIONS: During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission.

Adult↗
PubMed1998

Where is the financial safety net for managed care physicians?

OBJECTIVE: Empiric research on mechanisms by which managed care physicians attempt to mitigate financial risk is lacking. We assumed the perspective of a managed care plan in investigating the relationship between risk sharing and the match between a physician's capitation payments and costs of care. DESIGN: The study design was a family of payment simulations using 2 years of managed care claims data. METHODS: Claims from a cohort of 82,525 managed care patients were used, with year 1 data determining a capitation rate for year 2 primary care services. The net provider payment in year 2 was examined under scenarios that might modify financial outcomes, including stop-loss insurance, age- and gender-adjustment of capitation, and risk pooling within independent practice associations. RESULTS: The size of a provider's patient panel was positively correlated with net per capita payment (r = 0.22; P < 0.0001 without risk modification strategies). The variance of the ratio of net to total revenue was utilized as a proxy for the degree of risk assumed in caring for a panel of capitated enrollees. Risk modification strategies reduced this variance measure, with risk pooling producing the largest effect, especially for providers of panels of fewer than 135 patients. In contrast, age- and gender-adjustment of capitation payments had little effect on reimbursement outcomes. CONCLUSIONS: Short of increasing the pool of capitated patients, risk modification strategies appear limited in their ability to produce more equitable reimbursement to providers with small patient panels. With many providers assuming substantial risk in pursuing managed care contracts, these dynamics may favor organizational forms of medical practice that facilitate large patient panels within a single plan.

Capitation Fee↗
PubMed2005

Restructuring primary health care markets in New Zealand: from welfare benefits to insurance markets.

BACKGROUND: New Zealand's Primary Health Care Strategy (NZPHCS) was introduced in 2002. Its features are substantial increases in government funding delivered as capitation payments, and newly-created service-purchasing agencies. The objectives are to reduce health disparities and to improve health outcomes. ANALYSIS: The NZPHCS changes New Zealand's publicly-funded primary health care payments from targeted welfare benefits to universal, risk-rated insurance premium subsidies. Patient contributions change from fee-for-service top-ups to insurance premium top-ups, and are collected by service providers who, depending upon their contracts with purchasers, may also be either insurance agents or risk-bearing insurance companies. The change invokes the tensions associated with allocating risk-bearing amongst providers, patients and insurance companies that accompany all insurance-based funding instruments. These include increases in existing incentives for over-consumption and new incentives for insurers to limit their exposure to variations in patient health states by engaging in active patient pool selection. The New Zealand scheme is complex, but closely resembles United States insurance-based, risk-rated managed care schemes. The key difference is that unlike classic managed care models, where provider remuneration is determined by the insurer, the historic right for general practitioners to autonomously set patient charges alters the fiscal incentives normally available to managed care organisations. Consequently, the insurance role is being devolved to individual service providers with very small patient pools, who must recoup the premium top-ups from insured individuals. Premium top-ups are being collected only from those individuals consuming care, in proportion to the number of times care is sought. Co-payments thus constitute perfectly risk-rated premium levies set by inefficiently small insurers, raising questions about the efficiency and equity of a 'universal' insurance system pooling total population demands and costs. The efficacy of using financial incentives to constrain costs and encourage innovation when providers retain the right to arbitrarily recoup costs directly from patients, is also questioned. RESULTS: Initial evidence suggests that total costs are higher than initially expected, and prices to some patients have risen substantially under the NZPHCS. Limited competition and NZPHCS governance requirements mean current institutional arrangements are unlikely to facilitate efficiency improvements. System design changes therefore appear indicated.

Journal Article↗
PubMed2003

Declining subscriptions to the Maliando Mutual Health Organisation in Guinea-Conakry (West Africa): what is going wrong?

Mutual Health Organisations (MHOs) are a type of community health insurance scheme that are being developed and promoted in sub-Saharan Africa. In 1998, an MHO was organised in a rural district of Guinea to improve access to quality health care. Households paid an annual insurance fee of about US$2 per individual. Contributions were voluntary. The benefit package included free access to all first line health care services (except for a small co-payment), free paediatric care, free emergency surgical care and free obstetric care at the district hospital. Also included were part of the cost of emergency transport to the hospital. In 1998, the MHO covered 8% of the target population, but, by 1999, the subscription rate had dropped to about 6%. In March 2000, focus groups were held with members and non-members of the scheme to find out why subscription rates were so low. The research indicated that a failure to understand the scheme does not explain these low rates. On the contrary, the great majority of research subjects, members and non-members alike, acquired a very accurate understanding of the concepts and principles underlying health insurance. They value the system's re-distributive effects, which goes beyond household, next of kin or village. The participants accurately point out the sharp differences that exist between traditional financial mechanisms and the principle of health insurance, as well as the advantages and disadvantages of both. The ease with which risk-pooling is accepted as a financial mechanism which addresses specific needs demonstrates that it is not, per se, necessary to build health insurance schemes on existing or traditional systems of mutual aid. The majority of the participants consider the individual premium of 2 US dollars to be fair. There is, however, a problem of affordability for many poor and/or large families who cannot raise enough money to pay the subscription for all household members in one go. However, the main reason for the lack of interest in the scheme, is the poor quality of care offered to members of the MHO at the health centre.

Attitude to Health↗
PubMed2003

A comparison of single- and multi-payer health insurance systems and options for reform.

A major choice confronting many countries is between single-payer and multi-payer health insurance systems. This paper compares single-payer models in the areas of revenue collection, risk pooling, purchasing, and social solidarity. Single-payer and multi-payer systems each have advantages which may meet countries' priorities for their health insurance system. Single-payer systems are usually financed more progressively, and rely on existing taxation systems; they effectively distribute risks throughout one large risk pool; and they offer governments a high degree of control over the total expenditure on health. Multi-payer systems sacrifice this control for a greater ability to meet the diverse preferences of beneficiaries. Several major reforms of single-payer insurance systems--expansion of the role of private insurance and transformation to a multi-payer system--are then described and illustrated using specific country examples. These reforms have been implemented with some success in several countries but face several important challenges.

Consumer Behavior↗
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↗
PubMed1997

U.S. public school enrollment-based health insurance initiatives and America's uninsured.

This article reviews current literature on school enrollment-based health insurance programs underway or pending in the United States. This model of affordable family health insurance delivery was first proposed in a 1988 New England Journal of Medicine Sounding Board article, but only a few states--Arkansas, Florida, New Hampshire, and Texas--have begun public sector-driven programs in the 1990s that use school enrollment as a pooling mechanism to purchase group insurance policies from the private sector. Public support of this model is strong, interest is currently growing, and other states, including North Carolina and Iowa, are exploring or have enacted legislation that supports establishment of school enrollment-based health insurance programs. After summarizing these public-sector initiatives, additional information is presented on uninsuredness in America; risk factors for uninsuredness among children; and national public and private initiatives in child health insurance using eligibility criteria other than or including school enrollment that were examined by the GAO in 1994/95.

Adolescent↗
PubMed1995

ERISA and health plans.

This Issue Brief is designed to provide a basic understanding of the relationship of the Employee Retirement Income Security Act of 1974 (ERISA) to health plans. It is based, in part, on an Employee Benefit Research Institute-Education and Research Fund (EBRI-ERF) educational briefing held in March 1995. This report includes a section by Peter Schmidt of Arnold & Porter, a section about multiemployer plans written by Judy Mazo of The Segal Company; and a section about ERISA and state health reform written by Kala Ladenheim of the Intergovernmental Health Policy Project. Starting in the late 1980s, three trends converged to make ERISA a critical factor in state health reforms: increasingly comprehensive state health policy experimentation; changes in the makeup of the insurance market (including the rise in self-insurance and the growth of managed care); and increasingly expansive interpretations of ERISA by federal courts. The changing interpretations of ERISA's relationship to three categories of state health initiatives--insurance mandates, medical high risk pools, and uncompensated care pools--illustrate how these forces are playing out today. ERISA does have a very broad preemptive effect. Federal statutes do not need to say anything about preemption in order to preempt state law. For example, if there is a direct conflict, it would be quite clear under the Supremacy Clause [of the U.S. Constitution] that ERISA, or any federal statue, would preempt a directly conflicting state statute. States can indirectly regulate health care plans that provide benefits through insurance contracts by establishing the terms of the contract. And they also raise money by imposing premium taxes. But they cannot do the same with respect to self-funded plans. That is one of the factors that has caused a great rise in the number of self-funded plans. State regulation [of employee benefits] can create three kinds of problems: cost of taxes, fees, or other charges; cost of dealing with substantive, possibly inconsistent, benefit standards; and cost of identifying, understanding, and complying with the regulations themselves.

Employer Health Costs↗