Commercial Insurance Carriers Research Articles

Characteristics of occupational burns in Oregon, 2001–2006

Occupational burns are known to be a serious public health concern. This article describes work-related burns in Oregon between 2001 and 2006. Oregon Workers' Compensation (WC) burn claims were analyzed; data from a commercial insurance carrier (CIC) was used to characterize non-disabling burn claims. To ensure that our primary data source (WC) captures as many burn cases as possible, we compared hospitalized cases to a regional burn center (RBC) and Oregon hospital discharge index (HDI) data. The WC burn injury rate ranged from a high of 1.8 per 10,000 workers in 2001 to a low of 1.4 per 10,000 in 2004. We identified 2,165 accepted burn claims in CIC data, of which 85% were non-disabling. We matched data from a regional burn center to a subset of hospitalized claims from WC data and found an additional 44 cases of occupational hospitalized burns representing a 3% increase in total cases captured. Occupational burns continue to be a problem for working Oregonians, and the use of additional data sources outside of WC augments our surveillance system.

Medical Malpractice in Gastroenterology

Gastroenterologists commonly perceive themselves to be at increased legal risk because they perform invasive procedures. However, there is little published information about gastroenterology (GI) malpractice claims. The goal of this study was to evaluate available malpractice claim data within GI. This study was a database analysis of GI claims submitted by insurance companies to the Physician Insurers Association of America Data Sharing Project from January 1, 1985, to December 31, 2005. Another analysis from 2005 compared GI claims with other subspecialties. Sixty-six percent of physicians involved in claims had previous claims experience. The most common reasons for claims were errors in diagnosis (28%) and improper performance of a procedure (25%). Seventy-two percent of reported closed claims were settled out of court. Of 12,367 total claims in 2005, only 233 (1.8%) were within GI. GI ranked below other procedurally based subspecialties in numbers of claims per physician. GI does not rank highly among subspecialties in malpractice claims and only a minority of claims are procedure-related. Physicians with claims experience are likely to have further claims against them and should consider evaluating their practices.

Immunization update: pertussis, meningoccocus, and human papillomavirus.

New vaccines are being recommended for adolescents at a brisk pace. Immunization is an effective preventive measure, and by bringing adolescents in for a medical intervention, the new vaccines promise not only to protect adolescents from the specific diseases they address, but also to enhance other health care services, including screening for other health risk behaviors. This article discusses the newest vaccination recommendations for adolescents pertaining to the meningococcal and tetanus, diphtheria, and acellular pertussis vaccines and reviews the human papillomavirus vaccines developed for use in the United States. With the advent of these new vaccines, the potential exists to improve adolescent health significantly through prevention, adding new incentive to increase adolescent immunization rates for all indicated vaccines.

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Pediatricians Should Use RBRVS-based Fee Schedules

Why Pediatricians Should Use RBRVS-based Fee Schedules

Metamorphosis of Dentistry: Update on Alternative Delivery Systems

In 1985, Americans spent $27.8 billion for dental care. Patients paid $18 billion out-of-pocket, while private health insurance paid about $9.2 billion. Public programs paid approximately $600 million primarily through Medicaid. Commercial insurance carriers have increased their market share to more than 80 million subscribers, or more than 70 per cent of the total market. Dental service corporations and Blue Cross/Blue Shield plans cover more than 30 million subscribers, while independent plans have policies with more than 6 million customers. Dentistry today is a big business, and Big Business wants to make it their business. What makes health care vastly different from the manufacture and sale of microwaves, furniture and clothing, or the production and serving of fast foods is that the provider is in a unique relationship with the consumer/patient and will always have a large measure of control for this reason. Receiving dental care is not the same as purchasing a new pair of tennis shoes, but good business practices from other business arenas can make it possible for greater numbers of people to have greater access to it. Over the past 25 years a metamorphosis of dentistry has been generated by a rather constant interplay between the various involved parties to obtain a position of least financial risk. Insurance carriers and/or administrative intermediaries want the risk placed on the dentist, employers want the administrators to take it, and dentists want employers, administrators, or patients to assume it. The future will see the gradual evolvement of equitable plans dividing the risk among the four principle parties. Plans are being put in place today that already reflect this. A viable alternative delivery system means: Dental care providers who have the knowledge and incentive to perform quality care; administrators willing to share some of the risk; and employers and consumers who are sophisticated and realistic in their demands in today’s marketplace. All these factions are currently interacting to create the new dental picture we see today—and will see in the future.

Dealing with grief and bereavement in the emergency department.

J udden and unexpected deaths following traumatic injuries or suicide attempts are commonplace in the emergency department. The stress and anxiety that family members face in light of impending loss can sometimes leave them stunned and overwhelmed with the need for both medical and psychologic support. The recognition that this need must be addressed has sometimes been met with the support of a psychologist, social worker, or psychiatric nurse or, in some contexts, with the support of trained personnel who aid family members and allow them to regain homeostasis. Recognition of this need raises a question: Is it incumbent on the emergency department to provide support services, including grief and bereavement counseling, to family members who are overcome with anxiety and grief? Are there enough staff members to address this need, or is providing such a service a luxury to be offered only when time permits? Furthermore, does the staff member who hopes to assist grieving relatives require more than good communication skills and concern? Does grief and bereavement counseling require a specially trained professional? In addition, the question of who is the appropriate person to provide such care arises. This issue is not an ethereal one, and although it may be only peripheral to emergency care, it has become an increasingly pervasive topic in other sectors of health care. In fact, it has been widely discussed by such groups as the Health Care Finance Administration (which administers Medicare and Medicaid), the Joint Commission for the Accreditation of Hospitals, and commercial insurance carriers. These discussions and potential reimbursement for such services will likely have an influence on the provision of ED services for grieving families. The impetus for this concern has arisen with the renewed activity of hospices. In July 1982, bills were introduced in the House and Senate, and at the same time major federal agencies, Blue Cross and Blue Shield, and others became actively involved in this process, In scores of states, hospice services are now provided, and major unions have recently included hospice services as part of their insurance package. All

Update on Federally Qualified Health Maintenance Organizations in Providing Dental Care Services

The combined survey results indicate that 27 of the 99 federally qualified HMOs, as of Sept 30, 1979, offered comprehensive dental services to plan members as a supplemental benefit, usually available on an optional basis for an additional premium. The number of HMOs (and, hence, eventual dental involvement) is likely to increase for several reasons: renewed commitment by the Administration to increased financial, promotional, and technical support for the HMO program; aggressive advertising campaigns spearheaded by the federal government to raise public awareness, understanding, and acceptance of the HMO concept; increased efforts to enroll federal employees, as well as Medicare and Medicaid recipients; additional support from business and labor concerned with the escalating costs of health care; and further involvement by Blue Cross/Blue Shield plans and commercial insurance carriers.

The Case against State Regulation of Uninsured Employee Welfare Plans

The controversial question whether uninsured employee welfare plans should be regulated as insurance was analyzed in an article by Harold van B. Cleveland published in 1960.1 Reexamination of this question seems in order in view of developments which have weakened the industry position favoring such regulation. Employee welfare plans sometimes do provide death benefits, accident and sickness benefits, hospital-medical-surgical and related benefits to employees and dependents on an uninsured basis, commonly called self-insurance. Benefits are paid directly from general funds of the employer, or from a trust or other separately maintained fund, without a commercial insurance carrier. Substantial savings may be realized by eliminating commissions and state premium taxes and recapturing income on reserves otherwise held by the insurance carrier. A fundamental point to be kept in mind is that application of existing insurance laws to uninsured welfare plans would not simply regulate them in the sense of imposing safeguards-it would effectively

Medical Care for the People of Massachusetts: The Contribution of Blue Shield

THERE are now fifty-seven medical-care plans sponsored by medical societies and operating in thirty-three states. They cover approximately 4,500,000 persons. Fifty-five of these plans are nonprofit; the other two utilize the services of commercial insurance carriers. In the fifteen states that do not have plans in operation, nonprofit plans are being organized in seven, commercial plans are being organized in three, and preliminary discussions are under way in four. This leaves but one state in which nothing tangible is being accomplished.Much of the credit for this remarkable picture must go to the Council on Medical Service of the American . . .