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PubMed1981

Private health insurance plans in 1978 and 1979: a review of coverage, enrollment, and financial experience.

The private health insurance industry collected $55.9 billion in premiums in 1979 and returned $50.2 billion in benefits to its subscribers. Premiums rose 12.4 percent, slightly faster than in 1978 when premiums rose 11.4 percent, to $49.7 billion. Benefits rose 11.4 percent in 1979, down from the 12.6 rate in 1978. After operating expenses were deducted, the industry showed underwriting losses of $1.4 billion in 1979 and $1.5 billion in 1978. About 78 percent of the population was insured for hospital care, 76 percent for x-ray and laboratory examinations, and about 76 percent for surgical services in 1979. Smaller percentages had coverage for other types of care. An estimated 64 percent of the aged bought private hospital insurance, and about 43 percent bought surgical insurance, mostly to supplement Medicare benefits. An estimated 12 percent of persons under age 65 had no protection against the cost of hospital care either through private insurance or a public program such as Medicare or Medicaid.

Insurance↗
PubMed1988

Utilization review of psychiatric care: building a program that works.

Since the early 1970s the federal government, private insurers, and employers have searched for ways to control health care costs. In 1972, Congress, dissatisfied with hospitals' utilization review efforts under the Medicare program created Professional Standards Review Organizations (PSROs). Ten years later when the Medicare reimbursement system underwent radical changes, the utilization review system remained more or less intact but had its name changed to Professional Review Organizations (PROs). The insurance industry has developed and employed, with varying levels of success, several cost-saving tactics, including deductibles and copayments for specialized care, limitation of benefits by diagnosis or facility type, exclusion of specific disorders, inclusion of dollar limits, pre-payment claims review for specific types of service, and post-payment review with retroactive denial of claims. Case management is the latest development in the ever-widening search to put a lid on health care costs. These attempts to measure the effectiveness of care vis a vis the dollar spent for it have been especially difficult for psychiatry, a less measurable science than other fields of medicine. Because psychiatry straddles the disciplines of sociology, psychology, and medicine, it is not easily understood. Inadequate documentation of care, a paucity of outcome studies, and confidentiality issues all combine to make utilization review particularly difficult in psychiatry. This paper will describe a collaboration between Blue Cross and Blue Shield of Maryland and four private psychiatric hospitals in the state that resulted in a workable, effective utilization review program acceptable to providers, payers, and patients.

Adolescent↗
PubMed2005

Judgment processes in older adults' drug benefit evaluations.

BACKGROUND: The Medicare Prescription Drug, Improvement and Modernization Act of 2003 will provide drug coverage to older adults through a variety of mechanisms, including stand-alone prescription drug benefits. Variation in cost-sharing and utilization controls is permitted, leading potentially to a wide variety of prescription benefit plans. However, little is known regarding the manner in which beneficiaries will integrate information to form plan evaluations. OBJECTIVES: The objectives of this study were to assess and compare the use of compensatory and configural judgment models in older adults' evaluations of drug benefit plans. METHODS: Three focus groups were conducted with a total of 19 seniors to elicit relevant drug plan attributes. A separate group of 32 seniors then judged the suitability of 48 drug benefit profiles based on these attributes. Within-subjects regression analysis was used to reveal each participant's judgment policy. RESULTS: Focus groups suggested that copayment, premium, deductible, formulary use, and mail-service use were relevant plan attributes. Regression analyses showed that while most participants used compensatory judgment models in evaluation formation, 12 (37.5%) subjects used conjunctive judgment models. CONCLUSIONS: Configural judgment processes are used frequently by older adults when evaluating drug benefit plans. Future research using more fine-grained techniques (eg, process tracing) might help further elucidate judgment processes in this context.

Aged↗
PubMed1989

Substitution between prescribed and over-the-counter medications.

Using data from the Health Insurance Experiment (HIE), this article examines use of over-the-counter drugs (OTC) in a general, nonelderly population. Families from six areas of the country were assigned to health insurance plans that varied in the amount of medical care cost sharing. Thus, the out-of-pocket prices of OTC relative to prescription drugs were experimentally varied. The sites were chosen to represent markets with differing access to physician services. Multivariate methods were used to relate OTC use (collected from bi-weekly health diaries) to cost sharing and demographic variables. The empirical results do not support the expectation that people assigned less generous insurance for prescription drugs substitute OTC for prescriptions. People with complete insurance coverage purchased more of both types of drugs, suggesting OTC are an adjunct to formal medical care, rather than a substitute for it. Better educated and more knowledgeable consumers used more OTC drugs and spent more of their drug budget on OTC products. That there was greater OTC drug use in HIE sites with poorer access to formal medical care suggests there was some substitution between formal care and self-care with OTC drugs. Overall, however, better financial access to formal care promotes rather than substitutes for OTC use.

Adolescent↗
PubMed1990

Medicare program; changes to maintenance of effort requirements (section 421 of the Medicare Catastrophic Coverage Act)--HCFA. Notice.

This notice announces the effect on employers of the repeal of section 421 (Maintenance of Effort Provision) of the Medicare Catastrophic Coverage Act of 1988 (MCCA). The enactment of Public Law 101-234 (Medicare Catastrophic Coverage Repeal Act of 1989) on December 13, 1989 repealed many of the provisions of MCCA and restored the Medicare benefit levels to those available prior to January 1, 1989. Consequently, employers are relieved of their Maintenance of Effort responsibilities effective January 1, 1990.

Catastrophic Illness↗
PubMed1991

Employer-sponsored prescription drug benefits.

In summary, between 1979 and 1989, prescription drug costs increased by 151 percent, the rate of growth second only to the costs of hospital room and board. While expenditures on prescription drugs in the United States account for only 3 percent of all medical expenses, there is great interest in prescription drug coverage.

Data Collection↗