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At least 145 records · Page 8Linked to original sources

PubMed1997

Single payers and multiple lists: must everyone get the same coverage in a universal health plan?

In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both more efficient and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits.

Abortion, Induced↗

PubMedDate not supplied

Reporting clinical trial results to inform providers, payers, and consumers.

Results of randomized clinical trials are the preferred "evidence" for establishing the benefits and safety of medical treatments. We present evidence suggesting that the conventional approach to reporting clinical trials has fundamental flaws that can result in overlooking identifiable subgroups harmed by a treatment while underestimating benefits to others. A risk-stratified approach can dramatically reduce the chances of such errors. Since professional and economic incentives reward advocating treatments for as broad a patient population as possible, we suggest that payers and regulatory bodies might need to act to motivate prompt, routine adoption of risk-stratified assessments of medical treatments' safety and benefits.

Clinical Protocols↗

PubMedDate not supplied

Hospital payment systems: will payers like the future better than the past?

Unsustainable health care cost growth has forced payers to reexamine goals for hospital payment systems. Employers want simplicity and transparency, with comparative performance data available in the public domain. Insurers favor simplicity but prefer to keep the analysis of comparative performance data and pricing private. Thirty-five pay-for-performance experiments have been devised in the private sector, to reward hospitals for higher quality and move toward more effective payment systems. Definitive results are not yet known, and caveats remain, but early signs are promising. We develop three scenarios for future hospital payment systems and identify policy actions to improve outcomes.

Economics, Hospital↗

PubMedDate not supplied

Managing biotechnology in a network-model health plan: a U.S. private payer perspective.

Emerging biotechnology poses challenges to payers, including access, coverage, reimbursement, patient selection, and affordability. Premera Blue Cross, a private regional health plan, developed an integrated cross-functional approach to managing biologics, built around a robust formulary process that is fast, flexible, fair, and transparent to stakeholders. Results are monitored by cost and use reporting from merged pharmacy and medical claims. Utilization management and case management strategies will integrate with specialty pharmacy programs to improve outcomes and cost-effectiveness. Creative approaches to provider reimbursement can align providers' incentives with those of the plan. Redesign of member benefits can also encourage appropriate use of biotechnology.

Biological Products↗

PubMed2006

Health status: what does it mean for payers and patients?

Disturbances to health can be divided broadly into limitations of basic activities of daily living (washing, dressing, etc.) that are common to all patients and other limitations that depend on individual circumstances. A distinction should be drawn between health status and health-related quality of life. Health status questionnaires are standardized for "typical patients," and this should be borne in mind when interpreting such scores from studies that give an average result using population-based measurements. Such studies give a good indication to payers of the average effects of a treatment, but provide no indication other than probability of benefit to individuals. This applies even more with health improvements that manifest uniquely in each patient. Two widely used disease-specific questionnaires in chronic obstructive pulmonary disease-the Chronic Respiratory Questionnaire and the St. George's Respiratory Questionnaire-are health status, rather than quality of life, instruments. Health status scores from questionnaires provide measures of the effects of disease, not measures of the disease itself. The relationship between high health status score and increased risk of dying is due to the fact that both reflect underlying disease activity. In therapeutic studies, health status improves because the underlying disease activity has been moderated by therapy. Improved health does not improve mortality or morbidity per se. It is also important to appreciate that the impact of any measured change in health may also be determined by the patient's baseline state.

Disease Management↗

PubMed1991

Changes to Medicare Secondary Payer (MSP) provisions--HCFA. Notice.

This notice describes how subsections 6202(b), (c), and (e) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) affect the Medicare Program These subsections: Create uniform rules for computing Medicare secondary payments for all MSP situations; Exempt from the MSP provisions services performed for a religious order by members of the order who take a vow of poverty; Prohibit group health plans (GHPs) from "taking into account" that an individual is entitled to Medicare when Medicare is the secondary payer; Prohibit GHPs from differentiating, in the services they provide, between individuals with end-stage renal disease (ESRD) and other individuals covered by the plan; Require that GHPs of employers of 20 or more employees provide the same benefits under the same conditions to employees age 65 or older and employees' spouses age 65 or older as they provide to employees and spouses under age 65; Impose a 25 percent excise tax on contributions that employers and employee organizations make to nonconforming GHPs, i.e., plans that do not comply with the MSP provisions; Extend to all MSP situations the Federal Government's right to take legal action to collect double damages if a primary plan fails to comply with the Medicare secondary payment requirements of the law; Make the provisions for special enrollment periods for the disabled parallel to those in effect for the working aged. The statutory changes made by subsections 6202(b), (c), and (e) can be put into effect without first issuing regulations because it is clear on the face of the statute what the Congress intended.(ABSTRACT TRUNCATED AT 250 WORDS)

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

PubMed1991

Medicare program; Medicare secondary payer data match--HCFA. Notice.

This notice provides employers with information about the Medicare Secondary Payer (MSP) Data Match Program that involves HCFA, the Internal Revenue Service, and the Social Security Administration. The Data Match was provided for by Section 6202 of the Omnibus Budget Reconciliation Act of 1989. Under this provision, employers who receive data match questionnaires from HCFA for those employees who are Medicare beneficiaries or the spouse of a Medicare beneficiary must report certain health plan coverage information. The information will be used to determine whether Medicare payments for these beneficiaries should be or should have been primary or secondary to any payment that should be or should have been made by an employer group health plan (GHP).

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

PubMed1992

Should private payers adopt RBRVS fee schedules?

Independent Blue Cross and Blue Shield plans are adopting RBRVS-based fee schedules for reimbursing physicians. Some argue that private payers should follow suit.

Blue Cross Blue Shield Insurance Plans↗

PubMed1993

Managed competition. An analysis of consumer concerns. Single-Payer Coalition for Health Security.

This analysis of managed competition was written by the Single-Payer Coalition for Health Security, a broad-based coalition of groups representing for the most part consumers of health care, including American Public Health Association; Church Women United; Citizen Action; Consumers Union; National Association of Social Workers; National Council of Senior Citizens; Neighbor to Neighbor; NETWORK: A National Catholic Social Justice Lobby; Oil, Chemical & Atomic Workers International Union; Older Women's League; Physicians for a National Health Program; Public Citizen; United Cerebral Palsy Associations; and United Church of Christ. What follows is a substantial excerpt from their working paper, issued in January 1993.

Competitive Medical Plans↗

PubMed1993

Practice parameters benefit all. Patient management strategies improve outcomes for patients, lower costs for payers.

Practice parameters, patient management strategies designed to help physicians make clinical decisions, can eliminate thousands of unwarranted medical procedures each year, resulting in greater satisfaction for patients and lower costs for payers. But physicians have yet to adopt many recently issued parameters. The enthusiasm with which they embrace newer guidelines depends on their views concerning the expertise of the sponsoring organization and the participants in the group that developed the parameter. Practice parameter development is costly. Before creating a practice parameter, it is a good idea to find out if a parameter already exists that can be modified for local use, or if one is being developed elsewhere. Some think inertia is a major obstacle to carrying out practice parameter guidelines. Others believe healthcare professionals' opposition is a more substantial roadblock. Some physicians believe practice parameters threaten their autonomy and the art of their practice. Pressure from patients to use certain procedures can also be an obstacle. Practice parameters work best if developed by authoritative physician specialty organizations. Implementation needs to be backed up with continuing education and feedback.

Attitude of Health Personnel↗

PubMedDate not supplied

Single payer health care--the 100 percent solution.

Unlike President Clinton's plan, we don't have to guess whether single payer health care will work--we know it does. It's also less disruptive, less costly, and is easy to understand and administer.

Cost-Benefit Analysis↗

PubMed1994

Single payer: the California referendum.

The California Health Security Act is likely to appear on the November 1994 ballot. The bill would provide universal coverage to California residents and assign the state as the single payer for all medical care provided, financed with funding for programs already in place, employer payroll taxes, individual income taxes and taxes on tobacco products.

California↗

PubMed1994

Should insurers pay the same fees under an all-payer system?

Medicare's use of diagnosis-related groups (DRGs) and the resource-based relative value scale (RBRVS) has led to interest in developing a national all-payer system in which insurers use the same payment methods and payment rates. Using data for 81 high-volume DRGs from 457 California hospitals, we conclude that a single set of rates for hospital care would not be appropriate. On average, Medicare patients were 11.7 percent more expensive than commercially insured patients, but less expensive in many DRGs. Further research is needed to determine if Medicare patients require more physician resources compared with non-Medicare patients, particularly for surgical procedures.

California↗

PubMed1991

Better MSP (Medicare secondary payer) process may boost payments.

Because the Federal government estimates large overpayments by Medicare, changes in the Medicare Secondary Payer (MSP) program may play a significant role in future Medicare budget cuts. A major contributor to MSP problems is providers' failure to adequately collect coverage information from Medicare beneficiaries. Along with data sharing between Federal agencies to help identify responsibility for Medicare claims, providers likely will face more pressure to properly collect Medicare beneficiary information. Because of MSP program payment structure, improving billing offices' procedures for collecting Medicare beneficiary information ultimately may increase providers' overall payments.

Admitting Department, Hospital↗

PubMed1995

Assessing the role of the Blues plans' all-payer clearinghouses.

A growing number of the nation's 67 Blue Cross and Blue Shield plans, many of which are dominant health insurers in their markets, are attempting to expand their electronic health care transactions business. At least a dozen plans have created claims clearinghouses designed to handle claims and other electronic transactions destined for any payer.

Blue Cross Blue Shield Insurance Plans↗

PubMed1995

Medicare program; Medicare secondary payer for individuals entitled to Medicare and also covered under group health plans; correction--HCFA. Final rule with comment period; correcting amendments.

This document makes corrections to the final rule with comment period entitled "medicare program; medicare secondary payer for individuals entitled to medicare and also covered under group health plans" that was published in the Federal Register on Thursday, August 31, 1995 (60 FR 45344).

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

PubMed1994

The Medicare secondary payer program: Part I.

In order to apprise managed care organizations of their potential exposure under the Medicare Secondary Payer laws, this two-part article examines many of the lessons learned from litigation related to the program.

Aged↗

PubMed1994

Medicare program; Medicare Secondary Payer (MSP) amendments--HCFA. General notice.

This notice--1. Describes the changes made to the MSP for the disabled provision by sections 13561(b) and 13561(e) of the Omnibus Budget Reconciliation Act of 1993, Public Law 103-66, hereafter referred to as OBRA '93; and 2. Provides guidance for employers and employer health plans so that they can provide to Medicare contractors and beneficiaries the information necessary to implement these changes. Section 13561(b) changes the sunset date of the MSP for the disabled provision from October 1, 1995 to October 1, 1998. Section 13561(e) modifies the MSP for the disabled provision to conform to the MSP for the working aged provision, so that for both groups, the MSP provision applies (and the group health plan is primary payer) only when coverage under the plan is based on "current employment status with an employer."

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