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PubMed1990

Biased selection under the senior health plan prior use capitation formula.

A widely acknowledged shortcoming of the current AAPCC capitation formula for Medicare HMOs is its inability to adjust capitation levels for differences in health status among enrolled groups. Prior use models have been proposed as one alternative to the current AAPCC risk classes. From 1984 through 1987, Senior Health Plan (SHP) participated in a HCFA-sponsored demonstration project in which capitation payments were determined by a prior use formula incorporating information on inpatient hospital days and Part B deductibles. This paper contains findings about selection bias in SHP enrollment from analyses of preenrollment reimbursements and postenrollment mortality rates of SHP enrollees compared with Medicare FFS beneficiaries and enrollees of other Medicare HMOs in the Minneapolis-St. Paul area.

Capitation Fee↗
PubMed1987

Cost sharing and the changing pattern of employer-sponsored health benefits.

The perception that employers have been redesigning group health benefits to encourage more cost-effective use is distorted by limited study methods. New estimates of initiatives undertaken by larger private-sector employers--based on nationally representative data from the U.S. Bureau of Labor Statistics--reveal a more uncertain picture of cost containment. Cost sharing for initial hospital stays was broadened between 1981 and 1985, but coverage in most other areas--categories of care, lifetime benefit limits, etc.--was actually increased. Real health care expenditures will continue to grow absent more significant employee cost sharing.

Community Participation↗
PubMed1988

The demand for episodes of mental health services.

Observational studies of demand for mental health services showed much greater use by those with more generous insurance, but this difference may have been due to adverse selection, rather than in response to price. This paper avoids the adverse selection problem by using data from a randomized trial, the RAND Health Insurance Experiment (HIE). Participating families were randomly assigned to insurance plans that either provided free care or were a mixture of first dollar coinsurance and free care after a cap on out-of-pocket spending was reached. We estimate that separate effects of coinsurance and the cap on the demand for episodes of outpatient mental health services. We find that outpatient mental health use is more responsive to price than is outpatient medical use, but not as responsive as most observational studies have indicated. Those with no insurance coverage would spend about one-quarter as much on mental health care as they would with free care. Coinsurance reduces the number of episodes of treatment, but has only a small effect on the duration and intensity of use within episodes. Users appear to anticipate exceeding the cap, and spend at more than the free rate after they do so.

Data Collection↗
PubMed1987

Dental care demand among children with dental insurance.

As the number of families with dental insurance and expenditures for dental care has increased over the past two decades, so has interest in determining cost-sharing effects on dental demand among insureds. Using a representative sample of Pennsylvania Blue Shield children insureds during 1980, we estimate cost-sharing effects on dental demand for basic (diagnostic, preventive, restorative, endodontic, and extraction services) and orthodontic care. Results indicate that cost-sharing has little influence on the probability of using any dental services and basic expenditures. However, the probability of using orthodontic services decreases 2.1 percent when the proportion of orthodontic expenditures paid by the parent increases 10 percent. By reducing the cost of care, cost-sharing reduces social class differences in dental demand common in unisured populations, likely producing public oral health benefits.

Child↗
PubMed1988

The demand for episodes of treatment in the Health Insurance Experiment.

This paper analyzes claims data from the RAND Insurance Experiment, which were grouped into episodes of treatment. The insurance plans in the experiment have coinsurance and a cap on out-of-pocket spending. Using new statistical techniques to adjust for the increased sickliness of those who exceed the cap, the effects of coinsurance on cost per episode and number of episodes are estimated. Cost sharing reduced the number of episodes but had little effect on cost per episode. People in the experiment responded myopically as their current insurance status changed through the year. The price elasticity of spending was about -0.2 throughout the range of coinsurance studied. When data permit it, the study of episodes complements analyses of annual medical spending by revealing more about how decisions to spend are made within the year.

Ambulatory Care↗
PubMed2003

Horizontal inequity in health care utilization in Japan.

International comparisons of horizontal inequity in health has recently become one of the most pertinent issues in health economics. However, no previous studies have been undertaken on Japan. This omission is rectified in this paper. Moreover, we consider the dynamics of horizontal inequity in health over six years from 1992 to 1998. These dynamics have never been considered in this field. In a rigorous international comparison, though we cannot find any horizontal inequity in health in 1998, we find pro-rich inequity before 1995. The reason for this may be the reform of the health insurance system in 1997.

Adolescent↗
PubMedDate not supplied

Employer perspectives on the preferred provider organization concept.

The goal of preferred provider organizations (PPOs) is to identify cost effective physicians, hospitals and other providers and form them into healthcare delivery systems. Widespread interest in PPOs stems from the belief that they can contain costs while offering consumers a choice of physicians and hospitals. But there is little information available about the demand by employers to offer PPOs as a health plan option. This study gathered information on employers' attitudes toward PPOs through a survey of companies in the Minneapolis metropolitan area. Most of the surveyed firms were found to be self-insured and offered a choice of healthcare plans, including HMOs. Contrary to some previous studies, healthcare costs are a major concern by all of the firms. PPOs are viewed as one part of an overall strategy to reduce those costs while maintaining quality of care and convenient access to providers. Although somewhat skeptical about potential savings and concerned over the administrative costs of offering a new health plan, most of the firms indicated support for the PPO concept. The greatest market opportunity for PPOs is to offer the plan as an alternative within the company's existing indemnity plan, wherein employees who use the preferred providers are exempt from at least a portion of the coinsurance and deductible requirements.

Cost Control↗
PubMed2006

Coordinated care in a 'consumer-driven' health system.

High-deductible health plans--with and without spending accounts--are gaining ground. Will these evolving benefit designs complement or undermine the coordination of care for patients with chronic illnesses? Based on an October 2005 roundtable sponsored by the California HealthCare Foundation and Health Affairs, this paper discusses the implications of a changing health insurance market for the chronically ill, capitation payment for medical groups, and consumers navigating the system.

Capitation Fee↗
PubMed1992

Medicare: looking for pareto optimal changes.

Medicare enrollees are at risk for potentially unlimited out-of-pocket costs for acute care, defined here as prescription drug costs and copayments on covered services. As a result, many enrollees supplement Medicare with Medigap insurance, which increases their premium costs and their use of Medicare-covered services. The objective of this study was to limit enrollees' risk for acute care costs without increasing federal spending. The study found that savings from prohibiting Medigap would be sufficient to provide a copayment cap under Medicare. If Medicare's copayment requirements were also restructured, the savings would finance a prescription drug benefit as well. Most enrollees could expect lower expenses for premiums and out-of-pocket costs combined, but expenses would be significantly higher for 5% of enrollees, all current Medigap policyholders.

Acute Disease↗
PubMed1990

Financing long-term care. An insurance-based approach.

A joint public-private insurance program is the best approach to resolving the problem of financing long-term care. In this report, we describe one possible approach in detail. A modest expansion of the current (ie, after repeal of the Medicare Catastrophic Coverage Law of 1988) Medicare benefit for persons needing relatively short-term nursing home and home care services would be a first step. For those with extended long-term service needs, a non-means tested, publicly funded program with joint federal-state financing and administration would provide coverage after a substantial elimination period and with an income-related copayment. Private long-term care insurance purchased through employers before retirement or in the periretirement period, through use of income or equity accumulated in life insurance, pension funds, or home ownership, would be used to fund the exclusionary period or copayments of the public program by those who wish to have greater protection for income or assets. The role of Medicaid would be limited to paying for the deductible, copayments, and initial long-stay expenses of those with low incomes and limited assets.

Cost Allocation↗
PubMed2004

Did the distribution of health insurance in China continue to grow less equitable in the nineties? Results from a longitudinal survey.

This paper examines changes in the distribution of health insurance across socioeconomic groups in China over the 1989-1997 period. The analysis is based on the China Health and Nutrition Survey (CHNS), a unique micro-level longitudinal survey of households in eight Chinese provinces. Findings indicate that while aggregate insurance coverage rates in the sample changed little over this period, certain previously noted differences in coverage rates across socioeconomic groups narrowed significantly. These findings bring into question the presumption that continued market-oriented reform would lead to increased differences in coverage across those groups. The results, in fact, suggest exactly the opposite, that as the market oriented changes have occurred important disparities in health insurance coverage have been reduced. If these reductions are occurring there are important implications for policy. The groups normally targeted for equity reasons seem to be making progress over time but continued improvements are needed for these groups to reach the levels of coverage enjoyed by more fortunate subgroups.

Adolescent↗