Comprehensive Health Insurance Research Articles

The Development and Evaluation of an Integrated Electronic Prescribing and Drug Management System for Primary Care

ObjectiveTo develop and evaluate the acceptability and use of an integrated electronic prescribing and drug management system (MOXXI) for primary care physicians. DesignA 20-month follow-up study of MOXXI (Medical Office of the XXIst Century) implementation in 28 primary care physicians and 13,515 consenting patients. MeasurementMOXXI was developed to enhance patient safety by integrating patient demographics, retrieving active drugs from pharmacy systems, generating an automated problem list, and providing electronic prescription, stop order, automated prescribing problem alerts, and compliance monitoring functions. Evaluation of technical performance, acceptability, and use was conducted using audit trails, questionnaires, standardized tasks, and information from comprehensive health insurance databases. ResultsPerceived improvements in continuity of care and professional autonomy were associated with physicians' expected use of MOXXI. Physician speed in using MOXXI improved substantially in the first three months; however, only the represcribing function was faster using MOXXI than by handwritten prescription. Physicians wrote electronic prescriptions in 36.9 per 100 visits and reviewed the patient's drug profile in 12.6 per 100 visits. Physicians rated printed prescriptions, the current drug list, and the represcribing function as the most beneficial aspects of the system. Physicians were more likely to use the drug profile for patients who used more medication, made more emergency department visits, had more prescribing physicians, and lower continuity of care. ConclusionPrimary care physicians believed an integrated electronic prescribing and drug management system would improve continuity of care, and they were more likely to use the system for patients with more complex, fragmented care.

Medical Bankruptcy: Myth Versus Fact

David Himmelstein and colleagues recently contended that medical problems contribute to 54.5 percent of personal bankruptcies and threaten the solvency of solidly middle-class Americans. They propose comprehensive national health insurance as a solution. A reexamination of their data suggests that medical bills are a contributing factor in just 17 percent of personal bankruptcies and that those affected tend to have incomes closer to poverty level than to middle class. Moreover, for national health insurance to have an impact, it would have to define "medical" expenses in a much broader way than is now typical of either private or government-funded plans.

What Do Health Savings Accounts Mean for the Emergency Department?

The insurance market is evolving, with increased emphasis on plans with high deductibles and a large degree of coinsurance. This article serves as an introduction to the defining characteristics of consumer-driven health care plans and their associated health savings accounts. We discuss the most recent evidence on the adoption of these plans and their effects on use and reimbursement. Compared to many specialties, the emergency department (ED) may be insulated from extensive shopping and price negotiation, because visits to the ED are often for urgent and time-sensitive conditions. However, ED utilization patterns may change if cost-conscious health savings account holders forgo other necessary medical care, or if they seek out substitutes to the ED for less urgent problems. In the long run, the ED may feel the impact of changes that stem from 2 areas: the ability of health savings accounts to control the increase in health care costs, and the potential of health savings accounts to replace or undermine more comprehensive health insurance plans. We note areas that emergency physicians should monitor as health savings accounts become more prominent.

David Charles Sloane and Beverlie Conant Sloane, Medicine moves to the mall, Center Books on Space, Place and Time, Baltimore and London, Johns Hopkins University Press, 2003, pp. xiii, 198, illus., £29.50 (hardback 0-8018-7064-X).

The American healthcare system is at a crossroads. With 41 million persons lacking comprehensive health insurance, and with hundreds of small rural, mid-size, and large urban hospitals teetering on the brink of insolvency, it is indeed an opportune moment to examine the function of architecture for health within its broader cultural contexts. This book, co-authored by David Charles Sloane and Beverlie Conant Sloane, writers based in Los Angeles, centres on the historical evolution and functions of healthcare institutions in the everyday American landscape. Their core thesis centres on the shopping mall's emergence as an economically and socially viable precursor, as well as alternative. The mall is examined as a precursor within the post Second World War automobile culture that enveloped America and that continues unchecked to this day. Mall settings provide an alternative, serving stringent economic and access to care requirements of the provider in ways that no longer can be fully met by traditional, highly centralized medical centre-based hospitals. Hospitals which have reinvented themselves in this manner are discussed at some length, notably the Dartmouth-Hitchcock Medical Center in New Hampshire. It is argued that due to its success as a type, it was natural to relocate services from what the late Roselyn Lindheim termed inflexible “pill hill” medical centre aggregations to smaller, far more flexible outpatient care settings. The focus on place—the relationship between the care recipient and the places where care is dispensed—is the book's key original contribution. This alone sets it apart from other recent books on the subject of twentieth-century transformations in the American healthcare landscape. This focus on geographic proximity between home, workplace, and care setting is admirably amplified throughout the book's prologue, titled ‘The evolving architecture of healthcare’, and its three major chapters: ‘The medical workshop’, ‘Humanizing the hospital’, and ‘Shopping for healthcare’. Three photo “galleries” are sandwiched between these chapters: ‘Machine medicine’, ‘Mall medicine’, and ‘Mini-mall medicine’. The book begins with an informative historical account of the rise of the American hospital as an institution and as a building type, from its nineteenth-century inauspicious origins. These institutions were often housed in large manor residences in cities, in stark contrast to the sprawling, monotonous, technology-obsessed contemporary medical centres of today. Many of the accompanying photographs will be of particular interest both to the architectural historian and to the general reader. The authors come out on the side of the mini mall, extolling its supposed “virtues”. These include their convenience, not unlike a short jaunt to one's neighborhood convenience store, closeness to home, and their clear, concise internal wayfinding attributes. These latter qualities contrast with the labyrinth of corridors encountered on the typical medical centre campus and are viewed as essential to the mini mall clinic's success; otherwise people will not come back to “shop” for healthcare, regardless of whether desirable non-health care amenities are close by. A question arises. Does not the quality of services diminish when the strip mall clinic comes to be perceived as little different from the payless shoe store next door? This is acknowledged by the authors as the Achilles heel of the strip mall clinic. In the second half, the significant share of the discussion is devoted to the ongoing tug of war between advocates of New Urbanism smart growth policies, and advocates (many of which are healthcare institutions, for better or worse) of unbridled suburban roadside sprawl. These opposing positions are not-so-subliminally underscored in the illustrations contained in the third photo gallery. Unfortunately, these are mostly of banal, formless buildings, bearing very little intrinsic architectural merit. This is precisely where the authors' de-emphasis on architectural design per se comes back to haunt them, for the buildings shown are architecturally uninspiring, and, ultimately, somewhat undermine the core thesis. This facet of their argument would have been greatly fortified had genuinely clever, architecturally innovative clinics been included. They are not impossible to find (particularly outside the US) if one looks hard enough. Regardless, in sum, this book fills an important void with respect to our understanding of recent developments in the milieu of the American everyday suburban healthcare landscape, and helps the reader understand how the current hub (mothership hospital) and spoke (spatially dispersed network of outpatient clinics) system became ubiquitous. Above all else, this book holds the potential to fuel much-needed further research and debate.

Health insurance and savings over the life cycle—a semiparametric smooth coefficient estimation

AbstractIndividuals save for future uncertain health care expenses. This is less efficient than pooling health risk through insurance. The provision of comprehensive health insurance may raise welfare by providing the missing market to smooth out consumption through the life cycle. We employ a semiparametric smooth coefficient model to examine the effects of the introduction of the National Health Insurance in Taiwan in 1995 on savings and consumption over the life cycle. The idea is to estimate the coefficients of health insurance which vary with age. Our results suggest that younger households are more sensitive to the risk reductions, and that they demonstrate a greater response in the reduction of their precautionary saving. Copyright © 2004 John Wiley & Sons, Ltd.

International report: current state and development of health insurance and emergency medicine in Germany. the influence of health insurance laws on the practice of emergency medicine in a European country

Germany has a comprehensive health insurance system, with only 0.183% of the population being uninsured. Access to office-based medicine and to hospitals is easy and convenient. Due to enormous financial pressures, Germany is currently decreasing the number of beds in hospitals, introducing the Diagnosis Related Groups (DRG), and restricting accessibility to specialists. In contrast to Anglo-American countries, Germany follows the concept of bringing the physician to the patient in the prehospital setting, with Emergency Medical Services (EMS) physicians responding to all Advanced Life Support (ALS) calls. Despite a mature EMS system with sophisticated medical equipment and technology, both in the prehospital and hospital setting, logistical issues such as a single emergency telephone number or multidisciplinary Emergency Departments have yet to be established. Within the hospital, this “Franco-German model” considers Emergency Medicine a practice model that does not merit specialty status. Spending restrictions in the health care system, with less access to hospital beds and office-based physicians, will increase the demand for hospital-based emergency care when patients experience problems accessing the medical system. Currently, the German hospital system is unprepared to care for greater numbers of emergency patients. This may call for changes in the German health care system as well as the medical education system, with the introduction of hospital-based Emergency Medicine as its own specialty, similar to Anglo-American countries.

Psychiatric outpatient care in Germany and the United States.

practitioners in the United States look enviously at the health care systems of other countries. The American Psychiatric Association’s “wish list” for health care reform (1) includes universal coverage, unconstrained access to specialists in a fee-for-service setting, and generous mental health benefits such as psychotherapy without copayments. Germany’s health care system meets these criteria. We compared 1997–1998 data on outpatient mental health care provided by physicians in Germany and the United States. We focused on data for patients with a primary diagnosis of a psychiatric disorder—ICD-9 codes 291–293, 295–298, and 300–314. The German data is proprietary and based on claims from sickness funds, and the U.S. data come from the National Ambulatory Medical Care Survey. Among all outpatient visits to a physician, the proportion by patients with a psychiatric disorder was much higher in the United States (Figure 1). Furthermore, U.S. patients with a psychiatric disorder were much more likely to visit a psychiatrist or a neurologist than their German counterparts (Figure 2). Thus it appears that the provision of comprehensive mental health insurance coverage and open access to specialists does not ensure a greater role for psychiatrists. Instead, patients with a psychiatric diagnosis in Germany relied more heavily on primary care physicians than did U.S. patients, where tightly managed care is the norm. In the seemingly ideal German system, what factors might lead to a less Psychiatric Outpatient Care in Germany and the United States

The Impact of Reimbursement Systems on Occupational Therapy Practice in Canada and the United States of America

Different funding and cost-control mechanisms in Canada and the United States of America (USA) have a powerful influence on occupational therapy practice in each country. Canada's public health insurance system emphasizes access to health care services based on medical need. Costs are controlled at the provincial government level by limiting the capacity of facilities and personnel. Occupational therapists in publicly-funded settings have considerable professional autonomy to use occupational therapy theoretical models and to be client-centred. The measurement of outcomes is not always required and the interventions of individual occupational therapists are infrequently scrutinized. The USA has no universal, publicly-funded, comprehensive health insurance. Health care policies are driven by financial priorities and cost control occurs at the service delivery level. Insurance companies define the scope of occupational therapy practice by identifying what services they will pay for and they scrutinize occupational therapy interventions. The emphasis on effectiveness and efficiency leads to critical examination of interventions by therapists. Canadian occupational therapists can learn much from their colleagues in the USA in this area.

National Health Insurance and precautionary saving: evidence from Taiwan

By reducing uncertainty about future medical expenses, comprehensive health insurance can reduce households’ precautionary saving. We examine this effect using Taiwan micro-data spanning the 1995 introduction of National Health Insurance. The effects of National Health Insurance are identified using employment-based variation in prior insurance coverage. Replacement of the households’ prior insurance coverage with National Health Insurance is exogenous to the household, so our estimates are not subject to selection bias. Compared with the preceding government insurance programs, National Health Insurance reduced saving by an average of 8.6–13.7% with the largest effects for households with the smallest saving.

Changes in finances, insurance, employment, and lifestyle among persons diagnosed with hairy cell leukemia.

While being cured of cancer generally leads to a life expectancy similar to that of the general population, the extent to which other aspects of life are affected is unknown. To address these concerns, patients with hairy cell leukemia, a cancer with a very high cure rate, were queried about employment, insurance, finances, and lifestyle during and following their treatment. Study participants (n = 31) ranging in age from 24 to 73 years at the time of diagnosis (median, 49 years) were surveyed regarding changes in health and life insurance, employment, out-of-pocket medical costs, exercise, diet, and use of mental and alternative health services that occurred during or following hairy cell leukemia treatment. Following a diagnosis of hairy cell leukemia, 61.3% of the respondents paid for some aspect of medical care in spite of having health insurance coverage at the time of diagnosis. Four respondents (12.9%) could not obtain health insurance following treatment, and the occupational choices of several individuals or their spouses were based in large part on a desire to obtain or maintain comprehensive health insurance. Of the 13 individuals who attempted to purchase life insurance, 10 had difficulty obtaining a policy or were denied coverage. Lifestyle changes were noted by 40% to 60% of respondents, and included reports of more frequent exercise, adoption of a healthier diet, and having a greater appreciation for life, loved ones, and physical health. While hairy cell leukemia is a highly curable malignancy, cancer survivors' lives and lifestyles are altered substantially after receiving treatment for the illness.

Companies Face Obstacles To Providing MH Benefits

Companies Face Obstacles To Providing MH Benefits

Dentistry in Taiwan, Republic of China: national health insurance reforms, illegal dentistry and plans for peer review quality control

The dental health care system in Taiwan, Republic of China is described in terms of demographics, structure, context of treatment and historical development of the dental health care payment system. A notable characteristic of the system is the existence of trade dentists, who operate without licensure. Their popularity and price advantage has maintained a political base that affects policy decisions. Health care reforms of March, 1995 with a comprehensive national health insurance, as well as ambitious plans for systematic peer review quality control of dentists' work are unique health care developments worthy of the attention of health care policy makers in other countries who are studying health care reform processes.

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort

The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims. Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes. There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001). The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Health Promotion and Managed Care:: Surveys of California’s Health Plans and Population

Introduction: The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competetive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. Methods: A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. Results: California’s HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%–3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%–45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. Conclusion: For the majority of California’s PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.

The Effect of Health Insurance Coverage on the Appropriate Use of Recommended Clinical Preventive Services

Lack of health insurance coverage has been shown to reduce use of some preventive services. However, even when care is free or fully covered by insurance, clinical preventive services are not used at recommended levels. This study investigates the impact of different levels of health insurance coverage (ranging from none, some, most, and all preventive services covered) on the use of recommended clinical preventive services for adult men and women. Logistic regression was used to estimate the effect of different levels of health insurance coverage for preventive care on the probability of receiving six different clinical preventive services including periodic health exam, blood pressure screening, cholesterol screening, Pap smear, clinical breast exam, and screening mammography, as well as all recommended services for a given age and gender group. The study sample of adults ages 18 to 64 is from the Centers for Disease Control's 1991 Behavioral Risk Factor Surveillance System (BRFSS) (n = 53,981). The results demonstrate a positive and statistically significant dose-response relationship between level of health insurance coverage for preventive care and receipt of recommended preventive services in adult men and women. The odds ratios (ORs) of men who had full coverage for preventive care receiving recommended preventive services compared to men with no coverage for preventive care ranged from 1.8 to 2.8. For women the ORs were 1.2 to 2.0. The ORs for men with "most" preventive services covered compared to none covered ranged from 1.3 to 2.1, and for women from 1.2 to 2.0. The level of health insurance coverage for preventive care is one of the most important determinants of receipt of recommended preventive services for adult men and women 18-64 years of age. These results suggest that comprehensive health insurance coverage for clinical preventive care may significantly increase receipt of recommended preventive services for this population.

Children's Medicaid Entitlement: What Have We Got to Lose?

Medicaid's efficacy as a safety net for children has been lost in the heated health policy debates of the last 2 years. The second year of the last Congress was dominated by competing proposals that would have cast aside Medicaid and assured universal coverage through comprehensive private health insurance plans. The first year of the current Congress has been spent debating legislation designed to reduce the federal government's role in the provision of health care services through constrained funding, regulatory rollback, and broadened latitude for state programs dependent on federal dollars, (eg, Medicaid). Over the past 2 years, taking the position that the Medicaid program should be exempt from proposed changes (at least with respect to children) has not been in vogue.

It's the institutions, stupid! Why comprehensive national health insurance always fails in America.

We argue that the United States does not have comprehensive national health insurance (NHI) because American political institutions are biased against this type of reform. The original design of a fragmented and federated national political system serving an increasingly large and diverse polity has been further fragmented by a series of political reforms beginning with the Progressive era and culminating with the congressional reforms of the mid-1970s. This institutional structure yields enormous power to intransigent interest groups and thus makes efforts by progressive reformers such as President Clinton (and previous reform-minded presidents before him) to mount a successful NHI campaign impossible. We show how this institutional structure has shaped political strategies and political outcomes related to NHI since Franklin D. Roosevelt. Finally, we argue that this institutional structure contributes to the antigovernment attitudes so often observed among Americans.

Extremes in Body Mass Index: Probability of Healthcare Expenditures

Background. This study was conducted as a first initiative to investigate the relationship between body mass index [BMI, weight(kg)/height(m) 2] and healthcare expenditures by third party providers for lifestyle-related diseases and disorders. Method. Data were analyzed for 383 individuals who were continuously employed and covered by the same comprehensive health insurance plan during a 2-year baseline period followed by a 5-year observation period. A multiple logistic regression analysis that adjusted for covariates was used to ascertain whether BMI and baseline expenditure status separately or in combination influenced the probability of healthcare expenditures during the observation period. Results. After controlling for age, gender, and smoking status, probability of healthcare expenditures for lifestyle-related medical problems was significantly ( P < 0.04) greater during the observation period for adults with high as well as low BMIs plus baseline expenditures and lowest for subjects whose BMIs were in the midrange regardless of their baseline expenditures. Odds of expenditures increased significantly ( P = 0.0079) with age of nonsmokers, but was approximately constant and high for smokers at all ages. The absence of any significant interaction of either smoking status or age with BMI indicated that the relationship between BMI and the log odds of expenditures was consistent across age and smoking categories. Conclusions. The analyses support the conclusion that the highest probability of expenditures occurs with the combination of baseline insurance expenditures and BMI extremes and the lowest probability occurs when BMIs are near 26 or 27 (∼19% above the ideal of 22). The findings also provide further justification for focusing on extremes in body weight as health priorities.

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.

A cost-outcome analysis of retransplantation: The need for accountability

T he selection of transplant recipients remains controversial. H5 Transplant teams and health care policymakers, alike, have argued against the use of social, economic, or psychological criteria. Social worth has been uniformly rejected as an acceptable criterion for deciding on which patients should benefit from the scarce supply of donor organs. In the United States, early experience with the treatment of end-stage renal disease (ESRD) tempered any enthusiasm for nonclinical criteria. 16-~1 As shown in Table 1, in 1967 women and minorities were routinely denied access to maintenance dialysis. 16 However, with comprehensive health insurance benefits under the Medicare program, the composition of the dialysis patient population changed dramatically.18,19,21 Clinical patient selection criteria are often viewed as objective. Their appeal lies in the fact that they remove the human element from complex interpersonal decisions. Apparently objective criteria are construed as making the patient selection process objective. Whereas no one doubts that clinical criteria are predictive of outcome, it now seems their role has been overemphasized to the point where patient selection has become both irrational and irresponsible. For example, while awaiting transplantation, virtually all patients deteriorate clinically. Interestingly, this presumably makes them more deserving