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PubMed1980

Factors affecting differences in Medicare reimbursements for physicians' services.

Under Medicare's Part B program, wide variations are found in average reimbursements for physicians' services by demographic and geographic characteristics of the beneficiaries. Average reimbursements per beneficiary enrolled in the program depend upon the percentage of enrolled persons who exceed the deductible and receive reimbursements, the average allowed charge per service, and the number of services used. This study analyzes differences in average reimbursements per beneficiary for physicians' services in 1975 and discusses allowed charges and use factors that affect average reimbursements. Differences in the level of allowed charges and their impact on meeting the annual deductible are also discussed. The study indicates that average reimbursements per beneficiary are likely to continue to vary significantly year after year under the present Part B cost-sharing and reimbursement mechanisms.

Analysis of Variance↗

PubMed1986

Changes in distribution of Medicare expenditures among aged enrollees, 1969-82.

In this article, we examined the concentration of Medicare expenditures among the aged for 1969, 1975, and 1982 to determine if expenditures have become more concentrated among a few heavy users of service over time. Despite an increase in reimbursements for the aged from $6.0 billion in 1969 to $41.8 billion in 1982, the distribution of those expenses remained remarkably stable, with a slight lessening in the concentration of reimbursements in 1982. Patterns were similar for both Part A (hospital insurance) and Part B (supplementary medical insurance) services. The concentration of expenditures was much greater among survivors than among people who died in both 1975 and 1982, with little change in the distribution of expenditures within either group.

Aged↗

PubMed1988

Law No. 88-16, 5 January 1988.

Among other things, this Law extends the scope of social protection granted to mothers In France. It seeks to ensure that women who stay at home to bring up their families are not penalized in any way and to encourage such women to have a third child. The following are among measures of the Law: 1) entitlement to receive benefits in kind from the sickness insurance scheme in the event of divorce or the death of the spouse was previously restricted to a limited period (one year, extended until the date of the third birthday of the last child); it is now granted without limit of time and without charge, in the event of either contingency, to single parents aged 45 or over who have, or have had, three or more dependent children; 2) the possibility for any parent with dependent children residing in France and not engaging in any occupational activity to join the voluntary old-age pension scheme has now been extended to cover invalidity; the contributions payable (which may be deducted from family allowances) will be calculated on the basis of the minimum guaranteed wage (SMIC); 3) reversionary pensions of widows between ages 55 and 65 who have dependent children are to be increased by a uniform amount, set at 400 francs per month and adjustable; and 4) periods of maternity leave will be taken into account in the determination of seniority rights within an enterprise, particularly in the context of notice of dismissal (half of all periods of parental educational leave were already taken into account).

Aid to Families with Dependent Children↗

PubMed1987

The effect of cost sharing on the use of antibiotics in ambulatory care: results from a population-based randomized controlled trial.

Little is known about how generosity of insurance and population characteristics affect quantity or appropriateness of antibiotic use. Using insurance claims for antibiotics from 5765 non-elderly people who lived in six sites in the United States and were randomly assigned to insurance plans varying by level of cost-sharing, we describe how antibiotic use varies by insurance plan, diagnosis and health status, geographic area, and demographic characteristics. People with free medical care used 85% more antibiotics than those required to pay some portion of their medical bills (controlling for all other variables). Antibiotic use was significantly more common among women, the very young, patients with poorer health, and persons with higher income. Use of antibiotics for viral, viral-bacterial, and bacterial conditions did not differ between free and cost-sharing insurance plans, given antibiotics were the treatment of choice. Cost sharing reduced inappropriate and appropriate antibiotic use to a similar degree.

Adult↗

PubMed1997

Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction.

BACKGROUND: The requirement of copayments for emergency care is thought to control costs by reducing "inappropriate" visits to the emergency department. However, requiring copayments may lead to adverse outcomes if patients delay seeking care for emergency conditions. To determine whether such requirements are associated with delays in seeking care, we examined the length of time from the onset of symptoms to arrival at the hospital among patients with myocardial infarction who did or did not have required insurance copayments. METHODS: All patients were enrolled in a single health maintenance organization (HMO) and presented with myocardial infarction at 1 of 19 hospitals in King County, Washington, from 1989 through 1994. There were 602 patients whose health insurance required a copayment for emergency department care (range, $25 to $100) and 729 patients with no copayment requirement. Data on the time to presentation were obtained from a review of ambulance and hospital records. RESULTS: The median length of time from the onset of symptoms to arrival at the hospital, as adjusted for age, sex, and race, was 135 minutes for the copayment group and 137 minutes for the group with no copayment (95 percent confidence interval for the difference, -19 to +16 minutes). There was no significant association between the presence or absence of a copayment requirement and the time to arrival at the hospital after adjustment for calendar year, income, educational level, cardiac history, or clinical symptoms. Since some patients may be unaware of their copayment requirement, we performed a subgroup analysis of data on patients who had a previous visit to the emergency department with the same copayment status - that is, of patients who were likely to know about their copayment. This analysis also showed no significant association between the requirement for a copayment and delays in seeking treatment. CONCLUSIONS: For privately insured patients in this HMO, the requirement of modest, fixed copayments for emergency services did not lead to delays in seeking treatment for myocardial infarction.

Adult↗

PubMed1980

Physicians' charges under Medicare: assignment rates and beneficiary liability.

Under Medicare's Part B program, the physician decides whether to accept assignment of claims. When assignment is accepted, the physician agrees to accept as full payment Medicare's allowed charge. Physicians' acceptance of assignment is of considerable importance in relieving the beneficiaries of the burden of the costs of medical care services. This factor and the beneficiaries' liabilities for premiums, the annual deductible, and coinsurance are analyzed in considerable detail in this report. Data from physicians' claims for services in 1975 show that 45.8 percent of the services and 47.2 percent of the charges were assigned for the aged. There were wide variations in the rate of acceptance of assignment by physician specialty, and by age, race, and residence of beneficiaries. Total beneficiary liability from the deductible, coinsurance, and from unassigned claims amounted to 37.7 percent of total physicians' charges due. When the premium which the beneficiary pays for Part B is included, beneficiary liability rises to 69.2 percent of total physicians' charges due.

Aged↗

PubMedDate not supplied

Hospital's six-point program clears up financial picture.

To deal with the many changes affecting patient accounts today and reduce the backlog in accounts due, Mercy Hospital, Hamilton and Fairfield, OH, adopted a six-point program with the following goals: Creation of an admitting and outpatient registration quality assurance program; Creation of a patient financial representative position; Commitment to electronic claims processing; Redistribution of work load in the billing office; Improved relations with community employers; Internalization of collection efforts. Since the program was implemented, the hospital has reduced accounts receivable from $15,935,000 to $10,809,000 and days outstanding from 115 to 70.7 gross. It has improved community and patient relations and intensified collection efforts, all with a staff reduction from 26 full-time employees to 24.5. The hospital's further plans include acquiring new software to electronically process commercial accounts; improving cash collections for deductibles and copayments at the time of discharge'; reducing collection expense through an automated collection software package, inexpensive collection letter series, and credit cards; and providing on-the-spot bank loans at discharge.

Accounting↗

PubMed1995

[Patient satisfaction as a criterion of quality assurance in inpatient psychosomatic rehabilitation].

The investigation of patient satisfaction with treatment by means of simple standardised self-rating instruments is a focal point of monitoring and improvement of treatment quality in the programme of quality assurance of rehabilitation within the statutory social insurance system. In the field of psychosomatic rehabilitation this criterion contains a number of problems due to the individual traits of patients, the treatment institutions, and the rehabilitation process. A structural discrepancy between the patients' attitudes and the requirements of the rehabilitation measure causes a systematic potential of dissatisfaction of the patients throughout the whole rehabilitation procedure. The specific quality of psychosomatic rehabilitation requires differentiation in the assessment and interpretation of patient satisfaction as a criterion of quality assurance as well as in the deduction of subsequent measures for improvement. Doubts are also raised as to the usefulness of a simple and global reference to patient satisfaction as a criterion of quality assurance even beyond the field of psychosomatic rehabilitation.

Humans↗

PubMedDate not supplied

How low can you go? The impact of reduced benefits and increased cost sharing.

Amid escalating health care costs and a managed care backlash, employers are considering traditional cost control methods from the pre-managed care era. We use an actuarial model to estimate the premium-reducing effects of two such methods: increasing employee cost sharing and reducing benefits. Starting from a baseline plan with rich benefits and low cost sharing, estimated premium savings as a result of eliminating five specific benefits were about 22 percent. The same level of savings was also achieved by increasing cost sharing from a 15 dollars copayment with no deductible to 20 percent coinsurance and a 250 dollars deductible. Further increases in cost sharing produced estimated savings of up to 50 percent. We discuss possible market- and individual-level effects of the proliferation of plans with high cost sharing and low benefits.

Actuarial Analysis↗

PubMed2001

Service system finance: implications for children with depression and manic depression.

An estimated 6.2% of children in the United States satisfy the criteria for a depression diagnosis, but approximately half of this group do not receive necessary treatment. Thus it is important to consider potential barriers to use through service system finance. This article reviews three major types of changes affecting access: parity legislation, managed care, and public contracting. How these developments will affect children with depression and manic depression (DMD) is unclear. To better understand the potential effects on children with DMD, this review uses new data from the Medical Expenditure Panel Survey to describe the service use patterns of this population. These children have higher levels of expenditures, higher rates of inpatient use, and higher rates of Medicaid payment than do other children with mental health diagnoses; they also are overrepresented among the costliest cases of mental illness in children. Children with DMD pay a relatively low out-of-pocket share, suggesting that parity efforts focusing only on copayments and deductibles will have little effect on the absolute out-of-pocket burden for these children. Because children with DMD are overrepresented among high utilizers of health services, health care rationing arrangements or techniques, such as utilization review and capitation, may place this population at particular risk.

Bipolar Disorder↗

PubMed1990

[The impact of partial cost sharing on the attitude of insured persons with hypertension].

The study evaluated the impact of the October 1984 introduction of 10% cost sharing on insured persons belonging to the Employees' Health Insurance Scheme. There was a total of 199 subjects with hypertension, all of whom were insured by a health insurance society under the scheme from January 1982 to March 1986. The consultation rate for hypertension, as revealed by the medical receipts, was studied with time sequential analysis to evaluate the impact. Moreover, the differences of the impact pertinent to sex, age, medical facility, first year of visit and complications were analyzed. The results are as follows. 1. The study disclosed an increase in the rate of consultation during the six-month period before the introduction and a substantial decrease in the rate during the following six months. The impact proved to be temporary because the rate of consultation returned to the originally estimated level. 2. The impact on insured persons whose first year of visit was more recent was larger than that of those whose first year of visit was before 1980. The impact on patients with complications was larger than that on those without complications. 3. The effect of the first year of visit was independent of that of complications.

Adult↗

PubMed2003

Return to work and claim duration for workers with long-term mental disabilities: impacts of mental health coverage, fringe benefits, and disability management.

This paper examines the relationship of mental health benefits provided by 116 employers, to return to work and duration of disability claims for 407 of their employees who were on long-term disability (LTD) leave for mental disorders. Mental health benefits data were coded from summary plan description booklets provided by employers. Information on other fringe benefits and employers' disability management practices were obtained from a survey of the employers. Relationships between mental health benefit features, other fringe benefit and disability management factors, and our outcomes were estimated via logistic regression and survival analysis. Results indicated that three mental health benefit plan features were negatively related to the return-to-work probability:(1) a high deductible (> $600), (2) longer preexisting condition exclusion periods, and (3) having a carve-out. This suggests that cost saved by access restrictions may be partially offset by higher turnover costs for employees with disabilities due to mental disorders. Carve-outs were also predictive of shorter claims duration.

Female↗

PubMed1981

Medicare program; determination of payment amount for services furnished by independent rural health clinics: Health Care Financing Administration. Final rule with a request for additional comments.

This final rule amends the regulations concerning payment for services furnished by independent rural health clinics under the Medicare program. Specifically, we are amending the regulations at 42 CFR 405,2425(b) to clarify how interim Medicare reimbursement to the clinic is calculated when services are furnished to a beneficiary who has not met the Medicare Part B deductible requirements. The amendment is needed to correct an inaccurate statement in the current regulations of the rules governing payment in these situations. We are also amending the regulations at 42 CFR 405,2427(b) to clarify our procedures to be used by the Medicare carriers in calculating the total reimbursement amount due the clinic at the time of final cost settlement.

Ambulatory Care Facilities↗

PubMed1990

Shared-risk arrangement between employers and insurers.

Development of and initial experience with a shared-risk arrangement between an employer, Allied-Signal, Incorporated, and a health insurer, CIGNA Corporation, are discussed. Rapidly rising health-plan costs and projections for even greater increases in the next three years, coupled with other related considerations, spurred Allied-Signal to undertake a major re-evaluation of its employee health plan in 1987. After extensive discussions and consultation, Allied-Signal negotiated a shared-risk contract with CIGNA, a dual-option insurer, under which premium price increases are capped for a period of three years. CIGNA is at risk for any costs that exceed premium revenue; if costs are less than premium revenue, CIGNA will retain the surplus. Price and geographic accessibility to Allied-Signal beneficiaries were the two key factors in the choice of CIGNA Corporation. The company selected a point-of-service delivery model, which grants employees greater freedom of choice in the use of health-care providers; those who use network providers pay a fixed copayment while those who use nonnetwork providers pay a fixed copayment providers pay an annual deductible plus 20% of medical expenses incurred above the deductible. During the first year of the program, 75% of beneficiaries used network providers from 95% to 100% of the time. The actual costs for the first 18 months were less than projected and much less than increases experienced by fee-for-service plans during that same period. The shared-risk contract between Allied-Signal and CIGNA Corporation has been successful thus far.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗

PubMed1994

Health care and the principle of fair equality of opportunity: a report from The Netherlands.

In The Netherlands, the public funding of a number of health care services is controversial. What can we learn from this about the moral concerns that underlie these judgements? And, if there is anything to learn, can we use this improved understanding to scrutinise the adequacy of particular decisions concerning the public funding of health care services? In the present paper, I will analyse three cases: corrective surgery, In Vitro Fertilisation and liver transplantation. I will summarise the arguments that have been used to support or to challenge the public funding of these services. I will then assess the merits of Daniels' fair equality of opportunity account of justice in health care. Can this account improve our understanding of the moral concerns underlying our judgements about the public funding of these services? Can it serve to scrutinise the adequacy of particular decisions that are made concerning the public funding of health care services? My answer to both questions will be a qualified yes. Daniels' account can provide guidance, but not because we can deductively infer from it what is right and what is wrong. Instead, I will argue for a more casuistic use of the concept of fair equality of opportunity.

Attitude↗

PubMed2004

Search for the most complete multivitamin.

The group descriptor "multivitamin" doesn't guarantee that all vitamins are included in the product or that they are present in proportion to nutritional requirements. In fact the great majority of multivitamin preparations do not contain all the 13 established vitamins. We have reviewed the stated composition of all vitamin products registered with the Australian Therapeutic Goods Administration. All containing fewer than five vitamins were excluded and so were those containing non-culinary herbs or amino acids, or intended only for export, or designed for children and pregnancy or in the form of powder and injections. 163 multivitamins were left for scoring. One point was awarded for each vitamin but a point was deducted if the amount was below or clearly above the Recommended Dietary Intake (RDI). We found two multivitamin preparations containing 13 vitamins at levels close to the RDIs: Centrum Complete (our score 11) and Centrum Select 50+ (score 10); five multivitamins containing 12 vitamins: the best Avon Women's Complete (score 12) and Pluravit (score 10). Others contain fewer vitamins (or scored less than 10). Centrum and Pluravit are available at major outlets and their cost is moderate. We recommend that these most complete multivitamins should be clearly listed in MIMS and dispensed in public hospitals when " Rx multivitamins" is prescribed. People who take a multivitamin supplement to insure that they obtain their vitamin requirements would be best to ask for a multivitamin that contains all (or nearly all) the 13 true vitamins.

Australia↗

PubMed2002

Medical Savings Accounts in publicly funded health care systems: enthusiasm versus evidence.

Medical Savings Accounts (MSAs) have been suggested as a possible solution to Canada's health care funding woes. This approach is intended to reduce demand for health services by making individuals financially responsible for their pattern of consumption. MSAs may have appeal in the private insurance industry. A review of the scant literature on the experience in the public systems of Singapore and China, where such plans have been implemented, and on a simulation using United States Medicare data, suggests that the approach alone has not controlled costs and may increase inequalities in publicly funded systems. The conclusion is that current knowledge of MSAs is too limited to recommend their incorporation into the Canadian health care system.

Canada↗

PubMedDate not supplied

Do drug benefits help Medicare beneficiaries afford prescribed drugs?

We surveyed a random sample of 1,500 elderly people with chronic diseases who were enrolled in eight Medicare+Choice plans with a zero-premium, dollars 200-dollars 300 annual drug benefit and no deductible. An estimated 32 percent did not fill a prescription or reduced a prescribed dosage because of out-of-pocket costs. Lower drug benefits, higher out-of-pocket costs, lower income, and poorer health were associated with underuse of medications. Drug benefits with high out-of-pocket costs might not be effective for beneficiaries who use medications for chronic diseases, especially those with low incomes.

Aged↗