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PubMed2002

Effectiveness of community health financing in meeting the cost of illness.

How to finance and provide health care for the more than 1.3 billion rural poor and informal sector workers in low- and middle-income countries is one of the greatest challenges facing the international development community. This article presents the main findings from an extensive survey of the literature of community financing arrangements, and selected experiences from the Asia and Africa regions. Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Micro-level household data analysis indicates that community financing improves access by rural and informal sector workers to needed heath care and provides them with some financial protection against the cost of illness. Macro-level cross-country analysis gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators. The background research done for this article points to five key policies available to governments to improve the effectiveness and sustainability of existing community financing schemes. This includes: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) insurance to protect against expenditure fluctuations and re-insurance to enlarge the effective size of small risk pools; (c) effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks.

Community Health Services↗
PubMed2003

[Summing up of functioning of the system of compulsory medical insurance in the Russian Federation and prospects for its formation in Ukraine].

Submitted in the paper are data obtained as a result of analyzing and pooling information now available about positive and negative sequels of introduction in the Russian Federation of a compulsory medical insurance. Emphasis is placed on the relevance of, and need for, taking account of practical experience gained by the Russian Federation in deciding on the question about time and expediency of the start of a similar reform in Ukraine and on the importance of use of innovational approaches and technology at the stage of its planning.

Costs and Cost Analysis↗
PubMed1987

New directions in life care: an industry in transition.

Current approaches to financing long-term care are inadequate; they are even less likely to meet future needs of increasing numbers of disabled and chronically ill elderly persons. While insurers, providers, and policy makers are developing models of risk-pooling that cover long-term care, the industry that first put these concepts into practice is moving in other directions. Despite the success of many continuing-care retirement communities in offering full and affordable long-term care coverage, a new trend emphasizes amenities over comprehensiveness. Sponsorship and consumer demand are contrasted with insurability of risks as key issues for the industry and for policy makers.

Aged↗
PubMed2006

Workplace absenteeism and aspects of access to health care for individuals with migraine headache.

OBJECTIVES: (1) To examine the relationship between access to care and the number of missed workdays, and (2) to determine how this relationship is confounded by the presence of having health insurance and health care use among migraineurs. DESIGN/METHODS: This retrospective, pooled, cross-sectional study used 1996 to 1999 Medical Expenditure Panel Survey data. Employed migraineurs who were between 18 and 65 years of age were included. Individuals reporting a neoplastic or an acute pain condition were excluded. An access to care index was developed using Rasch Partial Credit Analysis. A 2-part model was used to estimate the annual number of missed workdays. RESULTS: Of the 703 migraineurs, 538 (77%) reported missing work time. Of those who missed work, the mean (SE) annual number of missed workdays was 4.4 (.39). A higher level of access to care (P= .025) and presence of depression (P= .033) were significantly associated with missing a greater number of workdays. We created a proxy for migraine severity based on migraine-related prophylactic medication use and hospitalization(s). Severe migraines were significantly (OR = 2.01, SE = .51, P= .006) associated with an increased likelihood to miss workdays. When health insurance was included in the model, a higher level of access to care was significantly associated with the increased likelihood to miss workdays (OR = 1.04, SE = .021, P= .05). From the original model, the odds ratio (1.035 to 1.040) and the SE (.020 to .021) increased slightly. When health care use was included in the model and health insurance was removed, (1) emergency department visits were significantly (P= .006) associated with missing a greater number of workdays, and (2) access to care was significantly associated with missing a greater number of workdays (P= .028). When having health insurance and health care use were simultaneously included in the model, a higher level of access to care was significantly associated with greater likelihood to miss work (OR = 1.040, SE = .0212, P= .05) and missing a greater number of workdays (P= .005). However, a change of 1 standard deviation in the score would be associated with a 12% change in the odds to miss work and only 8 percentage points change in the number of missed workdays. CONCLUSIONS: Contrary to expectations, a higher level of access to care is significantly associated with an increased likelihood to miss work and with missing a greater number of workdays. Depression, migraine severity, and health care use are important explanatory variables. Having health insurance may be a confounder between access to care and workplace absenteeism.

Absenteeism↗
PubMed2001

Estimating Determinants of Multiple Treatment Episodes for Substance Abusers.

BACKGROUND: Health services researchers have increasingly used hazard functions to examine illness or treatment episode lengths and related treatment utilization and treatment costs. There has been little systematic hazard analysis, however, of mental health/substance abuse (MH/SA) treatment episodes. AIMS OF THE STUDY: This article uses proportional hazard functions to characterize multiple treatment episodes for a sample of insured clients with at least one alcohol or drug treatment diagnosis over a three-year period. It addresses the lengths and timing of treatment episodes, and the relationships of episode lengths to the types and locations of earlier episodes. It also identifies a problem that occurs when a portion of the sample observations is ǣpossibly censored. Failure to account for sample censoring will generate biased hazard function estimates, but treating all potentially censored observations as censored will overcompensate for the censoring bias. METHODS: Using insurance claims data, the analysis defines health care treatment episodes as all events that follow the initial event irrespective of diagnosis, so long as the events are not separated by more than 30 days. The distribution of observations ranges from 1 day to 3 years, and individuals have up to 10 episodes. Due to the data collection process, observations may be right censored if the episode is either ongoing at the time that data collection starts, or when the data collection effort ends. The Andersen-Gill (AG) and Wei-Lin-Weissfeld (WLW) estimation methods are used to address relationships among individuals multiple episodes. These methods are then augmented by a probit censoring model that estimates censoring probability and adjusts estimated behavioral coefficients and related treatment utilization and treatment costs. There has been little systematic hazard analysis, however, of mental health/substance abuse (MH/SA) treatment episodes. RESULTS: Five sets of variables explain episode duration: (i) individual; (ii) insurance; (iii) employer; (iv) binary, indicating episode diagnosis, location, and sequence; and (v) linkage, relating current diagnoses to previous diagnoses in a sequence. Sociodemographic variables such as age or gender have impacts at both the individual and at the firm level. Coinsurance rates and deductibles also have impacts at the individual and the firm levels. Binary variables indicate that surgical/outpatient episodes were the shortest, and psychiatric/outpatient episodes were the longest. Linkage variables reveal significant impacts of prior alcoholism, drug, and psychiatric episodes on the lengths of subsequent episodes. DISCUSSION: Health care treatment episodes are linked to each other both by diagnosis and by treatment location. Both the AG and the WLW models have merit for treating multiple episodes. The AG model permits more flexibility in estimating hazards, and allows researchers to model impacts of prior diagnoses on future episodes. The WLW model provides a convenient way to examine impacts of sociodemographic variables across episodes. It also provides efficient pooled estimates of coefficients and their standard errors. LIMITATIONS: The insurance claims data set covers 1989 through 1991, predating current managed care plans. It cannot identify untreated substance abusers, nor can it identify those with out-of-plan use. It provides treatment information only if services are covered by the insurance plan and are defined with a substance abuse diagnosis code. Like medical records, insurance claims will not specify substance abuse treatment received within the context of other health care (and thus identified by a non-substance abuse diagnosis code) or community services. IMPLICATIONS FOR POLICY AND RESEARCH: This article characterizes multiple health treatment episodes for a sample of insured clients with at least one alcohol or drug treatment diagnosis within a three-year period. We identify both individual and employer effects on episode length. We find that episode lengths vary by the diagnosis type, and that the lengths (and by inference cost and utilization) may depend on the treatments that occurred in previous episodes. We also recognize that health care or illness episodes may be ongoing at times of health care events prior to the ends of data collection periods, leading to uncertain episode lengths. Corresponding estimates of costs or utilization are also uncertain. We provide a method that adjusts the episode lengths according to the probability of censoring.

Journal Article↗
PubMed2005

Effective financing of maternal health services: a review of the literature.

Health care can be funded in a number of ways ranging from direct user charges (out of pocket) payments to indirect methods that pool across time (prepayment) and across different risk and wealth groups (insurance and general taxation). All these methods can be used to finance maternal health services. When assessing the impact of financing mechanisms it is important to be aware of the different ways they effect service delivery patterns and utilisation. Specifically most systems have both equity and efficiency aspects that combine to impact on health service utilisation and health status. In general indirect methods that help families to pool the costs of maternal health services are preferable to direct methods of payment. It is also clear, however, that user charges may sometimes help to mitigate deficiencies in systems of pooled funding. Available literature suggests that financing mechanisms for maternal health services could be improved by systems that increase transparency, help to mitigate demand-side costs of services and provide funding for that promote transparent charging for services. While the limited experience of demand-side mechanisms for improving access to maternal health services more evaluation is required.

Maternal Health Services↗
PubMed2001

Defined contribution health benefits.

This Issue Brief discusses the emerging issue of "defined contribution" (DC) health benefits. The term "defined contribution" is used to describe a wide variety of approaches to the provision of health benefits, all of which have in common a shift in the responsibility for payment and selection of health care services from employers to employees. DC health benefits often are mentioned in the context of enabling employers to control their outlay for health benefits by avoiding increases in health care costs. DC health benefits may also shift responsibility for choosing a health plan and the associated risks of choosing a plan from employers to employees. There are three primary reasons why some employers currently are considering some sort of DC approach. First, they are once again looking for ways to keep their health care cost increases in line with overall inflation. Second, some employers are concerned that the public "backlash" against managed care will result in new legislation, regulations, and litigation that will further increase their health care costs if they do not distance themselves from health care decisions. Third, employers have modified not only most employee benefit plans, but labor market practices in general, by giving workers more choice, control, and flexibility. DC-type health benefits have existed as cafeteria plans since the 1980s. A cafeteria plan gives each employee the opportunity to determine the allocation of his or her total compensation (within employer-defined limits) among various employee benefits (primarily retirement or health). Most types of DC health benefits currently being discussed could be provided within the existing employment-based health insurance system, with or without the use of cafeteria plans. They could also allow employees to purchase health insurance directly from insurers, or they could drive new technologies and new forms of risk pooling through which health care services are provided and financed. DC health benefits differ from DC retirement plans. Under a DC health plan, employees may face different premiums based on their personal health risk and perhaps other factors such as age and geographic location. Their ability to afford health insurance may depend on how premiums are regulated by the state and how much money their employer provides. In contrast, under a DC retirement plan, employers' contributions are based on the same percentage of income for all employees, but employees are not subject to paying different prices for the same investment.

Adolescent↗
PubMed1978

Multivariate estimation of reference ranges.

This paper describes a new method for estimating reference ranges of 21 frequently performed laboratory tests utilizing routine test results of selected hospital patients. Computer programs perform the selection of patient records and the statistical analysis. The patient selection criteria of (1) short hospital stay and (2) short laboratory record provide a data base rich in normal results. The statistical program excludes records with excessive variation, and in repeated data-exclusion passes through the data base progressively narrows the range of acceptability. The decision to exclude a record is based on the "pooled variation." The average value of the "pooled variation" increases as the range is narrowed. This approach insures that the process stops after a few passes, and the most consistent data remain included in the calculation of reference ranges. Statistical properties of the data sets, as well as comparison with normal ranges for healthy subjects and review of 560 clinical charts, support the idea that serviceable reference ranges are obtained. The method is suitable for monitoring the reference ranges of the laboratory at frequent intervals.

Blood Chemical Analysis↗
PubMed2005

Rural-urban differences in employment-related health insurance.

CONTEXT: Rural residents are disproportionately represented among the uninsured in the United States. PURPOSE: We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. RESEARCH DESIGN AND ANALYSIS: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996--1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance. FINDINGS: The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference. CONCLUSIONS: Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.

Adult↗
PubMed2000

Impact of HMO market structure on physician-hospital strategic alliances.

OBJECTIVE: To assess the impact of HMO market structure on the formation of physician-hospital strategic alliances from 1993 through 1995. The two trends, managed care and physician-hospital integration have been prominent in reshaping insurance and provider markets over the past decade. STUDY DESIGN: Pooled cross-sectional data from the InterStudy HMO Census and the Annual Survey conducted by the American Hospital Association (AHA) between 1993 and the end of 1995 to examine the effects of HMO penetration and HMO numbers in a market on the formation of hospital-sponsored alliances with physicians. Because prior research has found nonlinear effects of HMOs on a variety of dependent variables, we operationalized HMO market structure two ways: using a Taylor series expansion and cross-classifying quartile distributions of HMO penetration and numbers into 16 dummy indicators. Alliance formation was operationalized using the presence of any alliance model (IPA, PHO, MSO, and foundation) and the sum of the four models present in the hospital. Because managed care and physician-hospital integration are endogenous (e.g., some hospitals also sponsor HMOs), we used an instrumental variables approach to model the determinants of HMO penetration and HMO numbers. These instruments were then used with other predictors of alliance formation: physician supply characteristics, the extent of hospital competition, hospital-level descriptors, population size and demographic characteristics, and indicators for each year. All equations were estimated at the MSA level using mixed linear models and first-difference models. PRINCIPAL FINDINGS: Contrary to conventional wisdom, alliance formation is shaped by the number of HMOs in the market rather than by HMO penetration. This confirms a growing perception that hospital-sponsored alliances with physicians are contracting vehicles for managed care: the greater the number of HMOs to contract with, the greater the development of alliances. The models also show that alliance formation is low in markets where a small number of HMOs have deeply penetrated the market. First-difference models further show that alliance formation is linked to HMO consolidation (drop in the number of HMOs in a market) and hospital downsizing. Alliance formation is not linked to changes in hospital costs, profitability, or market competition with other hospitals. CONCLUSIONS: Hospitals appear to form alliances with physicians for several reasons. Alliances serve to contract with the growing number of HMOs, to pose a countervailing bargaining force of providers in the face of HMO consolidation, and to accompany hospital downsizing and restructuring efforts. IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Physician-hospital integration is often mentioned as a provider response to increasing cost-containment pressures due to rising managed care penetration. Our findings do not support this view. Alliances appear to serve the hospital's interest in bargaining with managed care plans on a more even basis.

Delivery of Health Care, Integrated↗
PubMed1994

[A preliminary study of the determinants of hospital length of stay among the aged].

The current study reviewed the medical records of those inpatients who were 55 years old at admission and were admitted to Kaohsiung Medical College Hospital between 1983 and 1992. The purpose was to investigate the influences of patient characteristics and disease factor on the length of hospital stay. The long-term goals of these results are to provide a better understanding of the medical needs of aged people, especially the need of hospital beds, and to aid in an effective planning of medical resources for them to maintain their health. 57,009 records were collected. The average length of stay was 14.28 days with a standard deviation of 21.06. Gender, age, condition at discharge, number of diseases diagnosed, year admitted, and whether insured showed significant difference when they were tested by univariate statistical procedures. Multiple regression (MR) analysis was used to test the relative importance of these variables. It showed that whether or not cataracts were diagnosed had the most influence on the length of stay for the pooled samples. Condition at discharge, numbers of admissions, number of diseases diagnosed, and insurance had moderate predictive power. MR on the ten leading diseases separately showed that numbers of admissions, conditions at discharge, and insurance status were the three most important predictors at most models. Number of diseases diagnosed and admission year were also in several of the 10 models. However, gender did not enter any model.

Aged↗
PubMed1992

Government, private health insurance, and the goal of universal health care coverage.

The Health Insurance Association of America advocates joint efforts by federal and state governments and the private sector to achieve the goal of universal access to health care. It recommends several changes in the small employer market to provide greater predictability and protection to those insured, including establishment of private, not-for-profit reinsurance organizations authorized by the states. State risk pools for uninsurable individuals who are not part of an employer group are also proposed. The federal government role would include expanding Medicaid eligibility and exempting all insured plans from state mandated benefits. HIAA's proposal also stresses the continued growth and use of managed care programs.

Cost Control↗
PubMed2000

Medicaid managed care reimbursement for HIV and its implications for access to care.

The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care.

Capitation Fee↗
PubMed1991

Empire and the business of health insurance.

I examine the development of privately provided insurance since World War II, giving special attention to Empire Blue Cross, and argue that the competition between employers and unions for the loyalty of workers after the passage of the Taft-Hartley Act helped diffuse private health insurance benefits already favored by federal policies. For-profit insurers did not challenge the privileged status of Blue Cross plans because they recognized the political benefits that the plans offered and because they did not wish to offend the plans' sponsors. A relatively easy and profitable business, health insurance has been greatly disturbed by the system inflation accompanying the introduction of Medicare and Medicaid programs. Now self-insurance and various managed-care schemes are major threats. The future may bring consolidation and the strengthening of pools, just the opposite of today's system fragmentation.

Blue Cross Blue Shield Insurance Plans↗