Health Insurers

BACKGROUND: In an effort to control drug spending, health plans are increasingly shifting specialty drugs from their medical benefit to the pharmacy benefit. One consequence of this trend is that some health plans have both a medical and a pharmacy coverage policy for the same drug. OBJECTIVE: To examine how frequently health plans issue medical and pharmacy benefit policies for the same specialty drug and to evaluate the concordance between plans' medical and pharmacy policies when plans issue both policy types. METHODS: We identified specialty drug coverage policies from the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which includes policies issued by 17 of the largest US commercial health plans. Policies were current as of August 2020. We determined plans that issued both medical and pharmacy policies. Next, we identified drugs with "medical-pharmacy policy pairs," ie, drugs for which a plan issued both a medical and a pharmacy policy. For these pairs, we compared the plan's policies while accounting for the following coverage criteria: patient subgroups (patients must meet certain clinical criteria), prescriber requirements (a specialist must prescribe the drug), and step therapy protocols (patients must first fail alternative treatments). We considered medical-pharmacy policy pairs to be discordant if coverage criteria differed, eg, the medical policy included a prescriber requirement but the pharmacy policy did not. RESULTS: Eight plans issued separate medical and pharmacy benefit coverage policies for the same specialty drug and indication. Among these 8 plans, we identified 1,619 medical-pharmacy policy pairs. Eighty-six percent of pairs were concordant (1,386/1,619), and 14% were discordant (233/1,619). Discordance was most often due to differences in plans' application of step therapy protocols (184/233), followed by prescriber requirements (52/233) and patient subgroups (25/233). Forty pairs were discordant in multiple ways. Of discordant pairs, medical policies were more restrictive 41% (96/233) of the time; pharmacy policies were more restrictive 54% (125/233) of the time; 5% of the time (12/233), the medical policy was more restrictive in some ways, but the pharmacy policy was more restrictive in others. Overall, plans imposed coverage restrictions in their medical and pharmacy policies with similar frequencies. CONCLUSIONS: Commercial health plans' medical and pharmacy coverage policies for the same specialty drugs tended to be concordant, although we found coverage criteria to be discordant 14% of the time. Medical and pharmacy policies that are inconsistent in their coverage criteria and restrictions complicate, and potentially hinder, patients' access to specialty drugs. DISCLOSURES: Drs Kauf, O'Sullivan, and Strand were employees of Alkermes, Inc., when the study was conducted and may own stock in the company. Mx Levine, Mr Panzer, and Dr Chambers have no conflicts of interest to disclose. This research study was supported by Alkermes, Inc.

Psychosocial and Socioeconomic Issues Facing the Living Kidney Donor

We are pleased to publish this special issue on health insurance, which coincides with a wave of health care reform in the United States. The debate over health care reform is much broader than the insurance coverage of health services, although health insurance is an important financing tool that affects many market participants. In fact, health insurance introduces, among other things, distortions in resource allocation by increasing access to health, by modifying the demand for and the supply of health care services, by changing individuals' incentives for health prevention, by affecting worker absenteeism and productivity, by increasing the financial obligations of firms, and by smoothing consumption over time. Scott Harrington proposes a comprehensive overview of the U.S. health care reform (as of early December 2009) with a focus on health insurance. His article presents the three main motivations for the reform: (1) high and rising annual growth of per capita expenditures in health expenditures not necessarily leading to a higher average quality of health for the population, (2) lack of access to insurance coverage of about 48 million residents, and (3) Medicare deficit and Medicaid cost growth. The author outlines the health care reform bills in the U.S. House and Senate, including the key provisions for expanding and regulating health insurance, and projections of the proposals' costs, funding, and impact on the number of people with insurance. The article also discusses other issues related to the reform: (1) the potential effects of mandated health insurance in conjunction with proposed premium subsidies and health insurance underwriting and rating restrictions, (2) the proposed creation of a public health insurance plan, and (3) provisions that would modify permissible grounds for health policy rescission and that would repeal the limited antitrust exemption for health and medical liability insurance. It concludes by contrasting the reform bills with market-oriented proposals and an outlook on future developments. The remainder of the special issue comprises analyses of health insurance issues that will continue to hold whatever the chosen reform. One important research question is the effect of asymmetric information on the functioning of insurance markets and particularly on health insurance. Alma Cohen and Peter Siegelman review the empirical literature on adverse selection in insurance markets. They focus on empirical tests of the basic prediction of adverse selection, namely, that policyholders that purchase more insurance coverage tend to be riskier. They observe that when such a correlation exists, it varies across insurance markets and pools of insurance policies. They discuss various reasons why a coverage--risk correlation may not be found in some markets. The presence of a positive coverage-risk correlation can also be explained by moral hazard, and the authors discuss methods for distinguishing moral hazard from adverse selection. Finally, they analyze how learning by policyholders and insurers can affect conclusions about the presence of asymmetric information in insurance markets. The next three articles deal with health care spending but do not analyze asymmetric information in detail, although this problem may be present in their data. Anthony T. Lo Sasso, Lorens A. Helmchen, and Robert Kaestner use a unique data set from an insurer to analyze the effects of consumer-directed health plans on health care spending. They conclude that the marginal dollar contributed by the employer to the spending account is entirely spent on outpatient and pharmacy services. In contrast, out-of-pocket spending is not responsive to the amount the employer contributes to the spending account. The magnitudes of the effects suggest important health care spending consequences of higher employer contributions to spending accounts. Their findings could be explained in part by moral hazard. Employers may offer employees a choice of health plans either to promote competition among plans or to better cater to employees' preferences for different types of products. …

Context: Throughout Europe, the financial risks of health and long-term care are covered to varying degrees through models of national (health) insurance. Such insurance draws upon the principle of solidarity. Much is unknown on the solidarity-effects of reforms in national insurance schemes. Objective: To present an empirical analysis of the effects of recent reforms in national health insurance on solidarity in one country. Methods: We conducted a comparative analysis of the 2006 health care insurance reform and the 2015 long-term care insurance reform in the Netherlands. A multidimensional analytical framework of solidarity was developed to study the solidarity-effects of both reforms. Findings: Reforms of health care and long-term care insurance in the Netherlands had some solidarity effects, but they should not be overstated. We found evidence for increased and decreased solidarity. Health care insurance seems more ‘immune’ to reductions in solidarity than long-term care insurance. Limitations: The present case study involves reforms in the Netherlands. The solidarity framework is specifically designed for the study of solidarity-effects of reforms on national health and long-term care insurance. Effects on informal arrangements for care are beyond the scope of this study. More detailed and quantitative research is required to investigate how the reforms played out for specific groups, for instance the frail elderly, people with a disability and people with rare conditions. Similarly, long-term effects require further investigation. Implications: Given the limited scope of our analysis, more comparative research (including on an international scale) is required to develop systematic insight into the solidarity-effects of reforms in national health and long-term care insurance.

Low-income households in rural areas of Ethiopia are facing catastrophic out-of-pocket health care expenditure due to lack of proper financing mechanism complemented with unexpected health related shock. However, to smooth their health care consumer spending, they need to have a cost-effective health insurance. This study analyzes' Households Willingness to Pay (WTP) for health insurance and the potential market for this cost effective health insurance products. The data used in this study was collected from rural households in East Shewa zone, Adama Woreda, which constitutes about 500 household heads respondents. The Contingent Valuation Method (CVM) with double bounded dichotomous choice (DBDC) elicitation method was used to estimate respondents WTP for proposed health insurance technology. The result of the study shows that households' average WTP (considering their ability to pay) is higher than their cost of public health care and self-treatment per year at a national level on average. Variables such as farm income, frequent visit to the health center, age, education, and insurance cost (premium) are significant determinants of households' willingness to pay. For the hypothetical health insurance scenario, households do have enough willingness to pay to cover cost for public health care consumption expenditure if the payment mode is planned, conducive and once per year. The study implies valuable information for policy makers and concerned stakeholders such as the Ministry of health and different private insurance provider in health care financing.

This paper provides an overview of the U.S. health care reform debate and legislation, with a focus on health insurance. Following a synopsis of the main problems that confront U.S. health care and insurance, it outlines the health care reform bills in the U.S. House and Senate, including the key provisions for expanding and regulating health insurance, and projections of the proposals’ costs, funding, and impact on the number of people with insurance. The article then discusses (1) the potential effects of the mandate that individuals have health insurance in conjunction with proposed premium subsidies and health insurance underwriting and rating restrictions, (2) the proposed creation of a public health insurance plan and/or non-profit cooperatives, and (3) provisions that would modify permissible grounds for health policy rescission and repeal the limited antitrust exemption for health and medical liability insurance. It concludes by contrasting the reform bills with market-oriented proposals and with brief perspective on future developments.

ACA in 2014: What patients need to know

This paper documents the changing picture of health insurance coverage for pregnant women in the four-year period following Medicaid expansion and assesses the extent to which the crowding-out phenomenon may have influenced the observed trends. The report documents the distribution of insurance coverage for pregnant women in the post-expansion period and describes demographic characteristics of women covered under Medicaid. It examines the rate at which Medicaid-eligible women enroll in the program and addresses the crowding-out issue by comparing the trend in employer-sponsored coverage among poor and near-poor pregnant women with those among nonpregnant women and men of similar ages and incomes.

The present study reports the first comprehensive study on the coordination of benefits program in healthcare insurance in Indonesia. Every individual Indonesian citizen who works is required to have health insurance as a fulfillment of the obligation to be physically and comprehensively healthy. Ownership of health insurance can be through government programs which are mandatory government policies for every employee or health insurance managed by the services of a commercial insurance company. So that every Indonesian employee or citizen generally has 2 health insurance memberships, one is commercial insurance and the other is mandatory insurance from the government, BPJS health insurance. The use of health insurance from commercial insurance is the first choice, while BPJS health insurance is used as a backup if the coverage limit on commercial insurance has expired. With limited coverage limits provided by private insurance based on premium payments for each class registered by the company, the government facilitates a program to use the benefits of the two health insurances simultaneously, known as the Coordination of Benefits between BPJS Health and commercial insurance. This study uses a qualitative method to analyze how far this program has progressed, as well as the development of an additional health insurance benefit program in Indonesia. The end goal of this research it can be concluded that highlighting the benefits of this program that can be maximized by health insurance participants, what obstacles are faced by participants, as well as health services when using the coordination of benefits program and its development in the future.

Hospitals are health service institutions that have a central role in providing medical services to the community. The quality of service provided by hospitals greatly determines the level of patient satisfaction. Patient satisfaction is not only influenced by the results of treatment, but also by various other aspects such as the friendliness of medical personnel, speed of service, comfort of facilities, a sense of empathy by medical personnel, the use of health insurance and ease of administration. The purpose of this study is to find out how much health insurance and empathy affect outpatient satisfaction in hospitals. This study is a meta-analysis research with article search conducted based on the feasibility criteria of the PICO model, including: P = Outpatient; I= Health and empathy insurance; C= No health insurance and no empathy; O= Patient satisfaction. Articles were collected from Google Scholar, PubMed and Science Direct. Keywords use "Health insurance" AND "empathy" AND "patient satisfaction" AND "outpatient" AND "Cross-sectional" AND "Multivariate" OR "Adjusted Odds Ratio". The study used 7 selected cross-sectional studies for meta-analysis, with 4,517 respondents indicating that patients with health insurance were 2.27 times more likely to feel satisfied than patients without health insurance. (aOR= 2.27; CI 95%= 1.24 to 4.14; p< 0.02), and patients who had a sense of empathy were 3.41 times more likely to feel satisfaction than patients who did not have a sense of empathy (aOR= 3.41; CI 95%= 2.33 to 4.98; p< 0.52). The conclusion is that health insurance and Empathy can improve outpatient satisfaction in Hospitals. The keywords used were Health Insurance, Empathy, Patient Satisfaction, Outpatients, and Hospitals.

This article provides an overview of the U.S. health care reform debate and legislation, with a focus on health insurance. Following a synopsis of the main problems that confront U.S. health care and insurance, it outlines the health care reform bills in the U.S. House and Senate as of early December 2009, including the key provisions for expanding and regulating health in surance, and projections of the proposals' costs, funding, and impact on the number of people with insurance. The article then discusses (1) the potential effects of the mandate that individuals have health insurance in conjunction with proposed premium subsidies and health insurance underwriting and rating restrictions, (2) the proposed creation of a public health insurance plan and /or nonprofit cooperatives, and (3) provisions that would modify permissible grounds for health policy rescission and repeal the limited an titrust exemption for health and medical liability insurance. It concludes by contrasting the reform bills with market-oriented proposals and with brief perspective on future developments.

IntroductionHealth insurance has been found to increase healthcare utilisation and reduce catastrophic health expenditures in a number of countries; however, coverage is often unequally distributed among populations. The sociodemographic patterns of health insurance in Namibia are not fully understood. We aimed to assess the prevalence of health insurance, the relation between health insurance and health service utilisation and to explore the sociodemographic factors associated with health insurance in Namibia. Such findings may help to inform health policy to improve financial access to healthcare in the country.MethodsUsing data on 14,443 individuals, aged 15 to 64 years, from the 2013 Namibia Demographic and Health Survey, the association between health insurance and health service utilisation was investigated using multivariable mixed effects Poisson regression analyses, adjusted for sociodemographic covariates and regional, enumeration area and household clustering. Multivariable mixed effects Poisson regression analyses were also conducted to explore the association between key sociodemographic factors and health insurance, adjusted for covariates and clustering. Effect modification by sex, education level and wealth quintile was also explored.ResultsJust 17.5% of this population were insured (men: 20.2%; women: 16.2%). In fully-adjusted analyses, education was significantly positively associated with health insurance, independent of other sociodemographic factors (higher education RR: 3.98; 95% CI: 3.11–5.10; p < 0.001). Female sex (RR: 0.83; 95% CI: 0.74–0.94; p = 0.003) and wealth (highest wealth quintile RR: 13.47; 95% CI: 9.06–20.04; p < 0.001) were also independently associated with insurance. There was a complex interaction between sex, education and wealth in the context of health insurance. With increasing education level, women were more likely to be insured (p for interaction < 0.001), and education had a greater impact on the likelihood of health insurance in lower wealth quintiles.ConclusionsIn this population, health insurance was associated with health service utilisation but insurance coverage was low, and was independently associated with sex, education and wealth. Education may play a key role in health insurance coverage, especially for women and the less wealthy. These findings may help to inform the targeting of strategies to improve financial protection from healthcare-associated costs in Namibia.

Employer-sponsored health plans typically provide less coverage for mental health and substance abuse treatment than for medical or surgical treatment. The merits and costs of mandating parity, or equivalent coverage, for insurance benefits for mental health and substance abuse treatment have been a recent topic of significant public debate. This article presents cost estimates for a variety of comprehensive parity mandates, including parity for different diagnoses, benefit provisions, and types of health insurance delivery systems.

‘The workman is worthy of his hire’* What is an anaesthetist worth in 2010?

Funding Acknowledgements Type of funding sources: None. Background Although the prevalence of atrial fibrillation (AF) is increasing worldwide, little is known about the exact risk factors of AF; and the disease"s association with socioeconomic status (SES) is under debate. Purpose This study aimed to examine the association between SES and the risk of AF in Korean patients with diabetes mellitus. Methods We studied 2,429,610 diabetic patients (mean age 56.9 years, female 40%) who underwent health check-ups from 2009 to 2012, using the National Health Insurance Service (NHIS) database of Korea. Subjects were categorized into 6 groups according to the number of times (0 through 5) entitled for medical aid (MA) recipient, within the past 5 years from the date of check-up. (Fig. 1) Division of Medical Care Assistance in the Ministry of Health and Welfare selects the medical aid beneficiaries. The recipients should not have a reliable caregiver, nor their income be more than 40% of the standard median income. Among the study population, 64,818 were classified as MA group: 10,697 in MA 1, 11,005 in MA 2, 12,431 in MA 3, 10,689 in MA 4, 19,996 in MA 5, respectively. The remaining 2,364,792 were never entitled to MA recipients within 5 years and were assigned to the non-MA group. The incidence rate and hazard ratio of AF were then calculated for each group. Results Risk factors for cardiovascular disease were measured at baseline. More current smokers were in MA 5 group (28.7% in MA 5, 26.7% in non-MA, 26.2% in MA 1, 23.8% in MA 2, 23% in MA 3, 23.2% in MA 4, respectively, p &amp;lt; 0.001), while more heavy drinkers were in the non-MA group than among the MA groups (20.7% vs. 6.2–7.9%, p &amp;lt; 0.001). Hypertension and dyslipidemia were generally higher in MA groups than in the non-MA group (hypertension, 60.8–65.8% in MA groups vs. 54.8% in non-MA group; dyslipidemia, 44.1–54.9% in MA groups vs. 39.6% in non-MA group, all, p &amp;lt; 0.001), and the non-MAs tended to do more physical activities (20.7% vs. 15.4–15.8%, p &amp;lt; 0.001). Obese people with BMI≥30 were more in MA groups, especially in the MA 5, than in the non-MA group (7.5% in non-MA, 9.3%–9.7% in MA 1–4, and 12.2% in MA 5, all, p &amp;lt; 0.001). 80,257 were newly identified as AF in the retrospective 5 years. All the MA groups showed a higher risk of AF than the non-MA group: hazard ratio (95% confidence interval [CI]) for each group, 1.44 (1.32–1.58) in MA 1, 1.58 (1.45–1.73) in MA 2, 1.52 (1.39–1.65) in MA 3, 1.53 (1.40–1.68) in MA 4, and 1.35 (1.24–1.45) in MA 5. Adjusting with multi-variables, the MA 5 showed 54% increased risk of AF compared to the non-MA group (HR, 1.54, [95% CI, 1.42–1.67]). (Fig. 2) Conclusion The risk of AF increased more than 50% in patients who needed medical aid 5 years in a row, and the risk also rose greatly in patients with only a short experience of socioeconomic hardship. Based on the findings, we need more attention to individuals with recent socioeconomic deprivation to provide timely management for AF and its complications. Abstract Figure. Fig. 1