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PubMed1988

Effect of curtailed insurance benefits on use of mental health care. The Tenneco health plan.

This article presents the impact of a health insurance benefit redesign on utilization and costs for mental health care in a large corporation. The design change primarily limited coverage to 45 days of hospitalization and 20 outpatient visits. Group health insurance data before and after the benefit changes (effective January 1, 1984) were compared and analyzed. Per capita charges for mental health care between 1983 and 1985 decreased by 41%, from $89 to $53. Responses to the benefit modifications differed for inpatient and outpatient services. Inpatient costs and length of stay decreased dramatically, especially for dependents, while utilization rates remained about the same. Statistically significant increases occurred for outpatient care utilization and costs.

Adult↗
PubMedDate not supplied

Consumer understanding and satisfaction associated with a 3-tier prescription drug benefit.

OBJECTIVE: The purpose of this research was to investigate consumer understanding and satisfaction associated with a 3-tier prescription drug benefit among users of the prescription drug benefit. METHODS: This study involved a self-administered postal questionnaire and the use of prescription drug claims to evaluate utilization of prescription medications. Fifteen hundred subjects were randomly selected based on the following inclusion criteria. Each subject had to (1) be enrolled in a 3-tier copayment ($10 generic, $20 formulary brand, $35 nonformulary brand) prescription drug benefit; (2) be the primary beneficiary (cardholder); (3) be >18 years of age; (4) have received at least 1 prescription medication using his or her prescription drug insurance; and (5) have a mailing address on file. RESULTS: A total of 479 usable responses were returned (35% response rate). The mean (SD) understanding score was 2.22 (1.54) (range: 0 to 6). Fewer than 1% of respondents correctly answered all 6 items used to measure the level of understanding. The mean (SD) satisfaction score was 54.32 (19.69) (range: 0 to 100). Experience with purchasing a medication within a particular copayment tier was predictive of correctly answering the item related to that tier.s copayment amount. Multiple regression analysis revealed a relationship between the amount of use of the drug benefit and the degree of satisfaction with the drug benefit. There was no significant relationship between the level of understanding and the degree of satisfaction with prescription drug insurance. CONCLUSION: The average level of beneficiary understanding of the 3-tier copayment prescription drug benefit was very low, and the average degree of respondent satisfaction appeared to be near neutral. There was no significant relationship between the level of understanding and the degree of satisfaction with prescription drug benefits. The level of understanding was proportional to the amount of drug benefit use, but the degree of satisfaction was not related to the amount of drug benefit use.

Adolescent↗
PubMed1984

Dental insurance, a successful model facing new challenges.

Dental insurance has been the fastest growing fringe benefit during the 70s. Further, it has evolved into a cost-effective means for getting more people to seek dental treatment. Early worries of the purchaser and the profession about the uninsurability of dental care have largely been solved; to this day, though, no one has developed a model to successfully deliver individual coverage. In the 80s, dental insurance is facing some significant new challenges, mainly because purchasers of care perceive the need to trim all health care costs due to the rapid escalation of medical and hospital costs. Two avenues being pursued are "alternative delivery" and a "health tax" on fringe benefits. These two cost-containment efforts significantly threaten both the form and growth of dental insurance. It is important that the profession recognize the significance of these challenges and, recognizing the causes, become involved in finding solutions that do not diminish the quality of dental care.

Cost Control↗
PubMed2004

A flexible approach for estimating the effects of covariates on health expenditures.

Our estimation strategy uses sequences of conditional probability functions, similar to those used in discrete time hazard rate analyses, to construct a discrete approximation to the density function of an outcome of interest conditional on exogenous explanatory variables. Once the conditional density function has been constructed, we can examine expectations of arbitrary functions of the outcome of interest and evaluate how these expectations vary with observed exogenous covariates. We demonstrate the features and precision of the conditional density estimation method (and compare it to other commonly used methods) through Monte Carlo experiments and an application to health expenditures using the RAND Health Insurance Experiment data. Overall, we find that the approximate conditional density estimator provides accurate and precise estimates of derivatives of expected outcomes for a wide range of types of explanatory variables.

Adult↗
PubMed1985

Percentage of anaesthetic fee refunded to patients by schedule-using private medical insurers in New Zealand.

Refunds for anaesthetic services payable to patients by schedule-using private medical insurers or agencies have not been realistically adjusted for inflation or growth in incomes. Patients receive a lower actual refund than that usually implied by the insurers. If private anaesthetic fees had increased in line with award weekly wages, the average refund to patients would have been approximately 50% for most of the period 1968-1981.

Anesthesia↗
PubMed1995

Just health care system reform.

America spends almost one trillion dollars on health care, a larger percentage of its gross national product than other industrialized nations, and yet millions are without adequate health care insurance. The current system gives neither providers, patients, nor insurers incentives to seek cost-effective care; at the same time, individuals with the greatest health care needs are excluded from the system. The answer is not, as some suggest, an expanded federal bureaucracy, but society must address the plight of the underinsured. This papers offers 11 policies which build on the strengths of the private market to offer to all citizens the benefits of the world's best medical system. Universal catastrophic health insurance, along with the necessary changes in the legal and tax systems, would shift resources to patients who are currently under-utilizing the system and also toward necessary and cost-effective treatments.

Cost Control↗
PubMed2000

Optimal health insurance: the case of observable, severe illness.

We explore optimal cost-sharing provisions for insurance contracts when individuals have observable, severe diseases with a discrete number of medically appropriate treatment options. Variation in preferences for alternative treatments is unobserved by the insurer and non-contractible. Interest in such situations is increasingly common, exemplified by disease carve-out programs and shared decision-making (SDM) tools. We demonstrate that optimal insurance charges a copay to patients choosing the high-cost treatment and provides consumers of the low-cost treatment a cash payment. A simulation of the effect of such a policy, based on prostate cancer, indicates a substantial reduction in moral hazard.

Cost Sharing↗
PubMed1990

Costs of insuring preventive care.

Age-, sex-, and other risk factor-specific recommendations, published last year by the U.S. Preventive Services Task Force, for preventive clinical care have raised questions concerning the costs of providing health insurance for these kinds of services. Our study provides estimates of the costs to health insurance programs of covering the Task Force recommendations for the general population (not including high-risk populations). We estimate the average increase in the 1990 cost per month in a self-insured plan without cost-sharing to be $4.35 to $6.89 for an employee with family coverage and $1.21 to $2.41 for an employee with individual coverage. Preventive services would cost the Medicare program $3.99 to $5.10 per enrollee per month.

Adolescent↗
PubMed1986

Use of outpatient mental health services in HMO and fee-for-service plans: results from a randomized controlled trial.

Does a prepaid group practice (PGP) deliver less outpatient mental health care than the fee-for-service (FFS) sector when they serve comparable populations with comparable benefits? To examine this issue, we used data from the Rand Health Insurance Study, which randomized families into a prepaid group practice or FFS insurance plans. Participants in a FFS plan with no cost sharing (i.e., free care) are equally likely to visit a mental health specialist in a year, but incur 2.8 times the costs of prepaid participants (p less than .05). This difference is due to fewer visits per user, substitution of psychiatric social workers for psychiatrists and psychologists, and reliance on group rather than individual therapies in the prepaid plan. Because of the experimental design, these differences are due to institutional and incentive differences rather than adverse selection. We found no evidence of appreciable or significant adverse selection into or out of the prepaid group practice. A full evaluation of the desirability of prepaid or fee-for-service care requires data on health outcomes, which are not presented here.

Adult↗
PubMed1987

Purpose and function in government-funded health coverage.

Government-funded health insurance programs that claim to provide comprehensive funding of their clients' demands have commonly adopted a purposive (deductive) approach to the problem of health care funding. This involves determining the extent of covered benefits by seeking an "adequate" definition of health or health care. Payment is then limited to only those procedures medically required or indicated. In this paper we argue that the purposive approach is inadequate, and that attempted adherence to it results in a curious dislocation of service, serious inequities, and an unhealthy contemplation of the definition of health. These problems are the result of structural deficiencies in the approach, and so will not be rectified by tinkering with the definitions adopted. As an alternative, we present an outline of a functional (inductive) approach, which seeks to identify which of the expectations of its clients the government health insurance system may realistically satisfy.

Attitude to Health↗
PubMed1986

A review of studies of the impact of insurance on the demand and utilization of specialty mental health services.

Insurers and employers perceive the demand for mental health care to be highly responsive to the terms of insurance. Better coverage, it is believed, would increase demand, increasing expenditures through use of services that may be discretionary in nature. This article attempts to shed light on this issue by summarizing and evaluating the results of more than 40 published and unpublished studies. The major criterion for inclusion was the availability of information on the size of the population covered, so that rates of utilization could be calculated. More recent studies are emphasized. If research at the population level using aggregate utilization as a dependent variable is the "first generation of research," studies of individual use over a period of a year constitutes the "second generation." The emerging research on episodes of treatment represents a new "third generation" of studies. If some progress can be made on issues of ways in which patients form expectations about their treatment and its cost, this new generation of research promises to model demand response more precisely to coverage terms that change within a year, such as deductibles or limits.

Ambulatory Care↗