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PubMed2003

Rural-urban differences in health care benefits of a community-based sample of at-risk drinkers.

CONTEXT: Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas. PURPOSE: This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas. METHODS: A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies. FINDINGS: Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees. CONCLUSIONS: Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.

Actuarial Analysis↗
PubMed1998

Medicare program; recognition of NAIC model standards for regulation of Medicare supplemental insurance--HCFA. Notice.

This notice describes changes made by the Balanced Budget Act of 1997 to section 1882 of the Social Security Act, which governs Medicare supplemental insurance. It also recognizes that the Model Regulation adopted by the National Association of Insurance Commissioners (NAIC) on April 29, 1998, as corrected and clarified by HCFA, is considered to be the applicable NAIC Model Regulation for purposes of section 1882 of the Social Security Act. The changes made by HCFA (1) correct a drafting error in section 12.B(2) of the Model that is inconsistent with Federal law, and (2) add a clarification that copayments for hospital outpatient department services under Part B of Medicare must be covered under the "core benefits" of a Medicare supplemental insurance policy in the same manner as coinsurance for those services. Finally, this notice prints as an addendum the full text of the NAIC Model Regulation, as corrected and clarified by HCFA.

Aged↗
PubMed1985

Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trial.

Health care expenditures of 1,136 children whose families participated in a randomized trial, The Rand Health Insurance Experiment, are reported. Children whose families were assigned to receive 100% reimbursement for health costs spent one third more per capita than children whose families paid 95% of medical expenses up to a family maximum. Outpatient use decreased as cost-sharing rose for a variety of use measures: the probability of seeing a doctor, annual expenditures, number of visits per year, and numbers of outpatient treatment episodes. Hospital expenditures did not vary significantly among children insured with varying levels of cost-sharing. Episodes of treatment for preventive care were as responsive to cost-sharing as episodes for acute or chronic illness. The results give no reason not to insure preventive care as liberally as care for acute illness.

Adolescent↗
PubMed1996

Underwriting: a key to healthy capitation agreements.

In some markets, healthcare providers in integrated delivery systems have been assuming full-risk capitated contracts. Some of these contracts have been profitable, but others have produced inconsistent financial results. These results may reflect inadequate underwriting practices. For providers and HMO insurers to establish financially successful capitation agreements, they must develop and audit an underwriting process to evaluate the health risk of the population entering the managed care system.

Capitation Fee↗
PubMed1993

Proposals to modify the taxation of Social Security benefits: options and distributional effects.

This article presents simulation estimates of the income-distributional effects in 1994 of several proposals to modify the taxation of Social Security benefits under the Federal personal income tax. Under the benefit-taxation provisions that have been in effect since 1984, up to 50 percent of benefits are included in taxable income for taxpayers with incomes above certain thresholds. In 1994 about 20 percent of beneficiary families will pay a larger income tax as a result of these provisions. Because of the benefit taxation thresholds, the affected families are concentrated in the upper half of the income distribution: about 70 percent of these families have incomes that put them in the top 30 percent of families by income. If the current taxation thresholds were kept and the percentage of benefits includable in taxable income were raised above 50 percent, the tax effect would remain concentrated on the upper income families. If, on the other hand, the percentage includable were kept at 50 percent while the taxation thresholds were lowered or eliminated, more beneficiary families with incomes in the middle deciles would become affected. The lowest income beneficiary families, however, would remain unaffected, because their benefits would be protected from income taxation by exemptions and the standard deduction. The simulations indicate that only a very few families in the bottom 20 percent of families by income would be affected even if the benefit taxation thresholds were eliminated entirely.

Insurance Benefits↗
PubMed1990

Privacy Act of 1974; matching program--HCFA. Notice of a matching program--the Internal Revenue Service (IRS), the Social Security Administration (SSA), and HCFA--disclosure of IRS taxpayer identity and filing status information to be matched with SSA earned income information for Medicare beneficiaries and their spouses.

As required by Section 6202 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989), Public Law 101-239, the Department of Health and Human Services is providing public notice that the IRS and the SSA will disclose certain information regarding the taxpayer identification and filing status and the earned income of Medicare beneficiaries and their spouses for HCFA's use in identifying Medicare secondary payer (MSP) situations. This will enable HCFA to seek recovery of identified mistaken payments that were the liability of another primary insurer or other type of payer. The matching report set forth below is in compliance with the Computer Matching and Privacy Protection Act of 1988 (Pub. L. No. 100-503).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

Health care economic factors and the effects of benefits plan design changes.

Medical benefits costs now exceed 13% of payroll, up from 5% in the early 1980s. Full reimbursement for more expensive hospital-based care, a technology and specialist supply explosion funded by Medicare and Medicaid, and cost shifting from these programs to private insurance have fueled this rapid growth. Benefits plans, which had provided essentially free care, have been changed slowly and incrementally to increase cost sharing and, thus, cost sensitivity on the part of employees. Many insurance plans also limit coverage by requiring that treatment be "nonexperimental" and "medically necessary." Long-term inquiry demonstrates that total expenditures, hospitalization rates, ambulatory visit rates, dental visits, and prescription drug use were significantly higher for free care than for plans with substantial copayments. A study sponsored by a business coalition in Houston showed that increased deductibles shifted care to the inpatient setting, raising total costs. Higher contribution rates reduced both inpatient and outpatient costs. Caps on payment for certain services, such as mental health care, reduced costs significantly with apparently minimal adverse effects on health.

Deductibles and Coinsurance↗
PubMed1998

Using pharmacoeconomic analysis to make drug insurance coverage decisions.

Our objective was to institute a cost-effectiveness-based reimbursement eligibility and coverage scheme for drugs in the Canadian province of British Columbia. All applications from drug manufacturers requesting Pharmacare (British Columbia government-funded drug insurance plan) coverage were evaluated by the Pharmacoeconomic Initiative (PI) of British Columbia. PI recommendations are according to a majority decision reached by a multidisciplinary volunteer expert committee and are based on a critical evaluation of pharmacoeconomic studies submitted by manufacturers seeking reimbursement eligibility. Coverage for drugs is universal and completely free for the financially indigent. Others are charged a small copayment and/or a deductible. PI assessments are evidence-based. Published guidelines from the Canadian Coordinating Office of Health Technology Assessment (CCOHTA) and/or Ontario Ministry of Health guidelines for the economic evaluation of pharmaceuticals are recommended for preparing submissions to the PI. Between January 1996 and December 1996, the PI made recommendations on 21 submissions; 4 of these were cost-effectiveness or cost-utility analyses; 3 were cost-minimisation analyses; 6 were cost comparisons or cost-consequence analyses; and 8 were provincial formulary budget impact studies. Of the 21 PI recommendations, 18 were accepted by Pharmacare and decisions are pending for 2 others, thus providing a concordance rate of 95% (18/19; kappa = 0.89). A total of 7 of the 21 products were recommended for formulary inclusion by the PI; 4 were as per drug company requests (i.e. full-benefit status) and 3 were recommended under restricted use. Only 5 of 21 submissions, of which 4 had favourable reviews, complied with either the CCOHTA or the Ontario Ministry of Health guidelines. Most studies were conducted, not from a societal perspective, but from the perspective of the provincial healthcare system. Most of the analysis were short term and therefore discounting was not applied. Sensitivity analysis was not performed in more than half (52%) of the submissions, and 48% of applications used inappropriate comparators. Ontario is the only other Canadian province with a similar process, with cost-effectiveness criteria for reimbursement eligibility. However, analysis in that province during the same approximate time period demonstrated a low concordance between Ontario Drug Benefit and PI decisions (kappa = 0.07). Currently, the mandated or suggested use of technology assessments of pharmaceuticals with cost effectiveness as the primary end-point is a reality in several countries worldwide. Our results, based on actual experience from implementing such a programme, suggest that while industry is slow to adapt to the new reporting requirements it may also be sceptical about the importance of cost effectiveness and guideline compliance in decision-making.

British Columbia↗
PubMed2000

[Breast cancer screening and medical consumption].

BACKGROUND: The use of general health services by women targeted by breast cancer screening campaigns, and its variations, are poorly known. A survey has been undertaken during one of these campaigns in a britton department. This study aimed at pointing out possible differences in use of general health services: search for an overuse by women whose screening resulted positive/negative, in relation to women whose screening resulted full negative; search for an overuse by women having participated, in relation to women within the age range of the screening campaign and not having wished to participate. METHODS: Three groups of women, aged 50 to 69 years, free of breast cancer, were compared. A random sample was drawn in each group, weighing for age in group D0. Inclusion of cases was undertaken between January 1995 (beginning of the screening campaign) and June 1996. Use of health services was recorded during the six months following the first screening test, using the health insurance services data. Expenses related to inpatient care were not recorded. RESULTS: The structure of age of the three groups was comparable. The proportion of women having requested no reimbursement was identical between the groups D+ and D-. For the D+ group, the average cost was 4,246 Francs per woman. It dropped to 3,871 Francs after deduction of expenses related to additional medical examinations following the finding of a positive screening test. It was 5% higher than the average cost in the D- group (3,698 Francs). The cost varied a great deal within each group and the differences observed between the groups were not statistically significant The proportion of women of the D0 group not having requested any reimbursement was significantly lower than those of the groups D- and D+, overall, and for the majority of the categories of expenditure. CONCLUSION: The result of the screening does not induce significant variation of use of general health services, apart from the expenses induced by the invalidation of the positive result. The group of women not having participated in screening includes a stronger proportion of both low and higher health services users.

Age Distribution↗
PubMed1996

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); five separate changes--DoD. Final rule.

This final rule addresses five separate changes to comply with provisions affecting CHAMPUS. These changes will update this part to include as a benefit, a screen to check for the level of lead in the blood of an infant; to eliminate the implied statement that ambulance services are covered only to, from, and between hospitals; to include other forms of prescribed contraceptives by eliminating the reference that limits prescribed contraceptives only to those taken orally; to identify three additional Gulf Conflict groups eligible for the delay in the increased deductible; and to establish lower limits on the fiscal year catastrophic cap from $10,000 to $7,500 for all eligibles except dependents of active duty personnel, whose limit remains at $1,000.

Government Agencies↗
PubMed1995

The effect of an Rx-to-OTC switch on medication prescribing patterns and utilization of physician services: the case of vaginal antifungal products.

OBJECTIVE: We examined the impact of over-the-counter (OTC) availability of vaginal antifungal products, beginning in January 1991, on medication prescribing patterns and utilization of physician services. DATA SOURCES AND STUDY SETTING: Data on utilization of health care services and prescription medications by female members (ages 11 and older) of the Fallon Community Health Plan (FCHP), a group model health maintenance organization and a component of the Fallon Health Care System of central Massachusetts. The census for such individuals increased from 49,551 in January 1990 to 67,365 in December 1992. DESIGN: Time-series analyses were employed to assess changes in prescribing patterns of vaginal antifungal products and physician visits for vaginitis from January 1, 1990 through December 31, 1992. Monthly numbers of prescriptions for vaginal antifungal products and physician visits per 100 members were measured. Monetary savings relating to the prescription-to-OTC switch were also estimated. DATA COLLECTION METHODS: The computerized management information system of FCHP contains records on utilization of all health care services and prescriptions filled, collected as part of routine fiscal activities. We identified all vaginally administered products on the FCHP formulary used for the treatment of vaginal candidiasis and determined the number of prescriptions filled for these agents during each month of the study period. We also identified the number of physician office visits characterized by the ICD-9-CM code 616.10 ("vaginitis and vulvovaginitis, unspecified") occurring during each month of the study period. PRINCIPAL FINDINGS: For the one-year period after OTC availability of vaginal antifungal products (January 1991 through December 1991), we estimated that the number of prescriptions dispensed for these products was reduced by 6.42 per 100 female FCHP members ages 11 and older. Physician visits for vaginitis were reduced by 0.66 per 100 members. Estimated savings to the Fallon Health Care System for the one-year period following OTC availability were $42,528 in medication costs and $12,768 to $25,729 for costs associated with physician visits, depending on use of laboratory testing in patient evaluations. CONCLUSIONS: The findings of this study suggest that the prescription-to-OTC switch of vaginal antifungal treatments reduced health care costs to the insurer in the managed care setting. These favorable effects on costs for the insurer need to be weighed against shifts in medication costs to consumers and potential adverse consequences to the patient relating to errors in self-diagnosis.

Adolescent↗
PubMed2005

Patients' perceptions of cultural factors affecting the quality of their medical encounters.

OBJECTIVE: The aim of this study was to identify key domains of cultural competence from the perspective of ethnically and linguistically diverse patients. DESIGN: The study involved one-time focus groups in community settings with 61 African-Americans, 45 Latinos and 55 non-Latino Whites. Participants' mean age was 48 years, 45% were women, and 47% had less than a high school education. Participants in 19 groups were asked the meaning of 'culture' and what cultural factors influenced the quality of their medical encounters. Each text unit (TU or identifiable continuous verbal utterance) of focus group transcripts was content analysed to identify key dimensions using inductive and deductive methods. The proportion of TUs was calculated for each dimension by ethnic group. RESULTS: Definitions of culture common to all three ethnic groups included value systems (25% of TUs), customs (17%), self-identified ethnicity (15%), nationality (11%) and stereotypes (4%). Factors influencing the quality of medical encounters common to all ethnic groups included sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), social class-based discrimination (9%), ethnic concordance of physician and patient (8%), and age-based discrimination (4%). Physicians' acceptance of the role of spirtuality (2%) and of family (2%), and ethnicity-based discrimination (11%) were cultural factors specific to non-Whites. Language issues (21%) and immigration status (5%) were Latino-specific factors. CONCLUSIONS: Providing quality health care to ethnically diverse patients requires cultural flexibility to elicit and respond to cultural factors in medical encounters. Interventions to reduce disparities in health and health care in the USA need to address cultural factors that affect the quality of medical encounters.

Adolescent↗
PubMed1987

Continuous recording of drug prescribing in Sweden 1974-1983. Methods and examples of utilization of data.

Drug prescribing in Sweden under the National Insurance Act has been continuously recorded since 1974. A random sample of 1 in 288 is drawn from the about 24 million prescriptions issued yearly and the following data are recorded: dispensing pharmacy, type of prescription, year and month of dispensing, year of birth and sex of the patient, trade name, quantity, dosage, and price of the drug. The numbers of prescriptions of drugs free of charge increased by 32% between 1974 and 1983, while that of price deducted drugs decreased by 7%. The national cost of drugs rose sharply during the period. The per capita cost of drugs to persons aged greater than or equal to 75 years was more than eight-fold higher than for persons aged less than or equal to 14 years. A two-fold difference in the number of prescription items was found between women and men, and there were nine- to ten-fold differences between age-groups. Total prescribing varied modestly over time, as did the prescribing to most patient groups and for most groups of drugs. Exceptions to this were prescribing to children, particularly of antiallergic drugs for which a 50% increase was observed between 1974 and 1975, mainly due to increased prescribing of phenylpropanolamine. The recording of prescriptions as described is useful for early identification of new patterns of drug use and for mapping drug utilization and drug dosages in different age groups. The system is particularly powerful as a complement to other methods for recording drug use in Sweden, e.g. wholesale sales statistics and individual prescription monitoring in the county of Jämtland.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

A comparison of cost-sharing versus free care in children: effects on the demand for office-based medical care.

Using data from the community based RAND Health Insurance Experiment, the effect of cost-sharing versus free care on the use of office-based medical care in children was examined. Children from families on cost-sharing plans had a 22 percent lower probability (P less than 0.005) of having an episode of care during the study year. Both the number of episodes of care and total charges for outpatient professional services were 30 percent lower (P less than 0.005) with cost-sharing. cost-sharing reduced average charges for medical services by 30 percent (P less than 0.01) and pathology charges by 45 percent (P less than 0.005). cost-sharing reduced medical services received by 26 percent (P less than 0.05) and pathology services received by 43 percent (P less than 0.05) but did not have a significant effect on either the price for medical services or pathology services. It was concluded that there is a large difference between cost-sharing insurance plans and free care in the demand for office-based medical care in children. Cost-sharing results in children receiving fewer services, not lower priced services.

Child↗
PubMed2004

Moving beyond the typologies of managed care: the example of health plan predictors of screening mammography.

OBJECTIVES: To develop a framework of factors to characterize health plans, to identify how plan characteristics were measured in a national survey, and to apply our findings to an analysis of the predictors of screening mammography. DATA SOURCE: The primary data were from the 1996 Medical Expenditure Panel Survey. STUDY DESIGN: Women ages 40+, with private insurance, and no history of breast cancer were included in the study (N = 2,909). We used multivariate logistic regression to estimate mammography utilization in the past two years relative to health plan and demographic factors. Health plan measures included whether there is a defined provider network, whether coverage is restricted to a network, use of gatekeepers, level of cost containment, copayment and deductible amounts, coinsurance rate, and breadth of benefit coverage. PRINCIPAL FINDINGS: We found no significant difference in reported mammography utilization using a dichotomous comparison of individuals enrolled in managed care versus indemnity plans. However, women in health plans with a defined provider network were more likely to report having received a mammogram in the past two years than those without networks (adjusted OR= 1.21, 95 percent CI = 1.07-1.36), and women in gatekeeper plans were more likely to report receiving mammography than those without gatekeepers (adjusted OR = 1.18, 95 percent CI = 1.03-1.36). Restricted out-of-network coverage, use of cost containment, enrollee cost sharing, and breadth of benefit coverage did not appear to affect mammography use. CONCLUSIONS: It is important to examine the effect of individual health plan components on the utilization of health care, rather than use the traditional broader categorizations of managed versus nonmanaged care or simple health plan typologies.

Adult↗
PubMedDate not supplied

The cost of tax-exempt health benefits in 2004.

The tax expenditure for health benefits is the amount of revenues that the federal government forgoes by exempting health benefits and spending from the federal income and Social Security taxes, including (1) employer health benefit contributions for workers and retirees, (2) health benefit deductions for the self-employed, (3) health spending under flexible spending plans, and (4) the tax deduction for health expenses. We estimate that this expenditure will be dollars 188.5 billion in 2004. Families with incomes of dollars 100,000 or more (14 percent of the population) account for 26.7 percent of all health benefit tax expenditures.

Insurance, Health↗
PubMedDate not supplied

Expanded Medicare law shifts the financial load.

The new Medicare law broadens coverage for hospital inpatients, skilled nursing facilities, hospices, and home healthcare, and it adds respite care and outpatient prescriptions to the list of covered services. For the first time, beneficiaries, rather than employers and employees, will pay the full cost of the benefits, with all beneficiaries paying a monthly flat premium and approximately 40 percent paying an income-based supplemental premium. The new law does not expand long-term care coverage significantly. The new financing arrangements reflect a growing sentiment that higher-income elderly and disabled persons should pay part of the cost of their Medicare benefits. It also alleviates the financial hard-ship that an older couple must endure for one spouse to quality for Medicaid nursing home benefits while the other spouse remains in the community. The higher limits on income and resources that a community spouse may retain could adversely affect the development of long-term care insurance, however. Many people who meet the higher-standards may be unwilling to purchase such insurance. The new law may displease some beneficiaries, perhaps causing them to question whether Medicare is becoming a welfare program. Its financing mechanism almost certainly will cause beneficiaries to scrutinize more closely future proposals to improve Medicare benefits.

Aged↗