Current Health Insurance System Research Articles

Knowledge, perceptions and expectations of capitation payment system in a health insurance setting: a repeated survey of clients and health providers in Kumasi, Ghana.

BackgroundHealth insurance is improving access to quality health care in Ghana. However, there are implementation challenges which call for reform of the current health insurance system. There is no doubt that reforming the current health insurance in Ghana is besieged with a myriad of problems due to misconceptions and misinformation. This study explored the perceptions and understanding of clients and health providers on the capitation payment system in the Kumasi metropolis.MethodsThe study employed a cross - sectional design and repeated surveys were conducted with a cohort of 422 NHIS policy holders aged 18–69 years in each survey. The surveys were conducted in every three months. Health service providers and clients from thirteen (13) Hospitals, seven (7) Maternity homes and twenty (20) Clinics were also interviewed. Data was collected with interviewer–administered questionnaires. STATA software (version 11) was used for cleaning, standardizing and analysing data.ResultsA majority, 97.9% of the clients interviewed had heard of capitation payment although this did not translate into their level of understanding. About two-thirds, 61.2% disclosed that capitation was not important to them as clients are restricted to one Preferred Primary Provider (PPP) for a long period of time. About 94% of health providers also believed that people did not like the capitation payment system due to their misconception that it has been politicized (34%); does not give clients free choice of providers (26%) and capitation not covering most drugs (17%).ConclusionAlthough awareness of the capitation was high among clients, attitudes towards the capitation payment system were somewhat poor. A good understanding of the capitation payment system is key to ensuring client and provider acceptance and smooth implementation of the system.

A survey on the appropriate level of premiums for National Health Insurance

A the National Health Insurance Law was established in 2000, the finances of workplace health insurance and regional health insurance were integrated. However, since employee health insurance (workplace insurance) and self-employed health insurance (community insurance) still use different contribution rating systems, the problem of inequity of premiums has caused ongoing controversy. Therefore, to examine the public’s satisfaction with premiums calculation methods, and collect opinions on solving the problem of inequity of premiums, this survey was performed. A computer-assisted telephone interview with multi-stage stratified sampling of the population in Korea was performed. Responses were obtained from 1,016 people aged 25 to 64 years. The analyses showed that, to the question about the premiums calculation methods, more respondents answered that they were unsatisfied (41.4%) than satisfied (36.6%). The responses differed depending on the type of health insurance. The proportion of those who were satisfied with their insurance was relatively higher among those with employee health insurance. On the other hand, among those with self-employed health insurance, the proportion of those who were dissatisfied with insurance was 3 times more common than satisfaction with it, showing that those who belong to the self-employed health insurance group are less satisfied with the premiums calculation methods. It was also found that the majority people perceive that the current single payer health insurance system should be divided into mutually separate employee and self-employed health insurance systems or a multiple payer health insurance system (60.3%). To achieve premium equity in the future, the Health Insurance Corporation should make a greater effort to determine income levels correctly. In the institutional improvement process of the premiums contribution rating system in the future, it seems necessary to carry out further research on a multiple payer insurance system reflecting the attitudes and demands of the people.

Quantitative analysis of health insurance reform: Separating regulation from redistribution

Two key components of the recent U.S. health reform are a new regulation of the individual health insurance market and an increase in income redistribution in the economy. Which component contributes more to the welfare outcome of the reform? We address this question by constructing a general equilibrium life-cycle model that incorporates both medical expenses and labor income risks. We replicate the key features of the current health insurance system in the U.S. and calibrate the model using the Medical Expenditures Panel Survey dataset. We find that the reform decreases the number of uninsured more than twice and generates substantial welfare gains. These welfare gains mostly come from the redistributive measures embedded in the reform, rather than from the regulatory changes.

Macroeconomic Consequences of Alternative Reforms to the Health Insurance System in the U.S.

In this paper I employ a dynamic general equilibrium model to study macroeconomic effects and welfare implications of alternative reforms to the U.S. health insurance system. In particular, I focus on to what extent a health care reform can reduce inefficiency originating from market imperfections in the health insurance market. I consider a stochastic OLG framework with heterogeneous agents facing idiosyncratic health shocks. Individuals make optimal decisions on labor supply, health insurance, and medical services. Hence the model captures general equilibrium e ffects of health care policy. I calibrate the preference over health and health insurance using Medical Expenditure Panel Survey (MEPS) dataset. Numerical simulations indicate that appropriate modi fication to the current health insurance system can expand coverage and improve welfare through reducing adverse selection, enhancing health status and curtailing tax distortion on labor supply.

Out-of-pocket expenditures for hospital care in Iran: who is at risk of incurring catastrophic payments?

Since the beginning of 1980s, the Iranian health care system has undergone several reforms designed to increase accessibility of health services. Notwithstanding these reforms, out-of-pocket payments which create a barrier to access health services contribute almost half of total health are financing in Iran. This study aimed to provide a greater understanding about the inequality and determinants of the out-of-pocket expenditure (OOPE) and the related catastrophic expenditure (CE) for hospital services in Iran using a nationwide survey data, the 2003 Utilisation of Health Services Survey (UHSS). The concentration index and the Heckman selection model were used to assess inequality and factors associated with these expenditures. Inequality analysis suggests that the CE is concentrated among households in lower socioeconomic levels. The results of the Heckman selection model indicate that factors such as length of stay, admission to a hospital owned by private sector or Ministry of Health and Medical Education, and living in remote areas are positively associated with higher OOPE. Results of the ordered-probit selection model demonstrate that length of stay, lower household wealth index, and admission to a private hospital are major factors contributing to the increase in the probability of CE. Also, we find that households living in East Azarbaijan, Kordestan and Sistan and Balochestan face a higher level of CE. Based on our findings, the current employer-sponsored health insurance system does not offer equal protection against hospital expenditure in Iran. It seems that a single universal health insurance scheme that covers health services for all Iranian-regardless of their employment status-can better protect households from catastrophic health spending.

How to develop social consensus for the uninsured benefit in the social insurance system

he current national health-insurance system of the Republic of Korea uses the negative-list method to determine benefit coverage, which includes most medical services. However, financial limitations have led to frequent conflicts between medical-service providers and the Health Insurance Review and Assessment Service (HIRA) about the inclusion of specific service-providers' practices within benefit coverage. The role of HIRA is to determine whether payments claimed by service providers are clinically valid and formulated in a cost-efficient manner. This article describes the present state and structure of the benefit system in the Korean national health-insurance system. We focus on issues of arbitrary uninsured benefits that may arise when service providers request patients to pay in full (with their approval) for a service that is not included in the benefits, according to the National Health Insurance Act. We also consider the legal treatment of arbitrary uninsured benefits in Korea and other countries. We suggest measures to improve the payment system for arbitrary uninsured benefits in Korea. Laws and regulations should be revised to cover these arbitrary uninsured benefits in a manner that can be agreed upon by HIRA, service providers, and patients.

Making Health Care Reform Work

The health care reform laws enacted as the Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act of 2010 will have widespread and in some cases seismic impacts that will unfold and evolve over more than a decade. This new legislation will transform the health insurance industry, and its impact will be felt by citizens, state governments, and every organization involved in the health care delivery system. Now that health care reform is law, it is in the interests of all health insurers and organizations and professionals that provide health care (hereafter, “providers”) to navigate through the changes and make sure the law works for all North Carolinians. It took decades for our current health care payment system to develop and evolve, and it will take some time to move in a new direction that addresses costs, improves quality, and benefits patients. But even with the changes brought on by the ACA, the system is not sustainable. Doing nothing is not an option. This commentary discusses the factors leading to our current health insurance system, how the ACA might affect that system, the role of medical costs in driving up health insurance premiums, and the need for everyone in the health care system to work together in order to fulfill the letter and spirit of health care reform and overcome some of the challenges to achieving sustainable reform. Blue Cross and Blue Shield of North Carolina (BCBSNC), a not-for-profit insurer, has worked for years to reform the health care system in North Carolina through initiatives that encourage improved quality and efficiency from providers. But the ACA requires substantial new insurance reforms in the future, and much more progress in improving our health care system must be made to support these reforms. BCBSNC believes that, going forward, real reform can only be successful if there is collaboration among stakeholders from across the health care spectrum, including insurers, physicians, hospitals, pharmaceutical companies, employers, patients, and others. To that end, BCBSNC is already having conversations with leaders from around North Carolina to lower costs and ensure that health care reform works in our state. This collaboration is occurring in many forms. Some will be creative arrangements within BCBSNC’s provider network, but significant collaboration must occur across the wide range of stakeholders in the public and private sectors.

Could the employment-based targeting approach serve Egypt in moving towards a social health insurance model?

The current health insurance system in Egypt targets the productive population through an employment-based scheme bounded by a cost ceiling and focusing on curative care. Egypt Social Contract Survey data from 2005 were used to evaluate the impact of the employment-based scheme on health system accessibility and financing. Only 22.8% of the population in the productive age range (19-59 years) benefited from any health insurance scheme. The employment-based scheme covered 39.3% of the working population and was skewed towards urban areas, older people, females and the wealthier. It did not increase service utilization, but reduced out-of-pocket expenditure. Egypt should blend all health insurance schemes and adopt an innovative approach to reach universal coverage.

Financial Barrier against Access to Diagnostic Procedures among Enteric Fever Suspects in Highly-endemic Areas of China

There is currently no public financial system that fully covers enteric fever suspects in China. This study aimed at documenting the level of access to definitive diagnostic procedures, especially haemoculture, for these patients and examining the effect of health insurance on access to such care. A hospital-based cross-sectional study was conducted in six counties of Yunnan province, using a structured questionnaire and data extraction from medical records. In total, 714 subjects were recruited. Chi-square test and logistic regression were employed for analysis of data. The majority of the subjects were young adults (52%) and farmers (55%) from low-income families (49%). Only 407 (57%) could afford haemoculture routinely advised by their doctors. Of these, 123 (30%) had haemoculture positive for Salmonella Typhi. After adjustment for income, not getting haemoculture was marginally associated with percentage of reimbursement from the insurance (p value for trend=0.047). Illiteracy was also an independent risk factor for this outcome. The poor coverage of haemoculture for patients suspected of having enteric fever in this endemic area was due to financial barrier. The current health-insurance system inadequately relieved the problem. Further financial reform to help patients suspected with enteric fever is required.

Current status of pediatric home mechanical ventilation in Japan

The first nationwide survey of pediatric home mechanical ventilation (HMV) was conducted. From 35 out of 149 medical centers investigated, 49 cases of HVM were reported. The patients ranged in age from 1 to 20 years, and the causes of respiratory failure were neuromuscular diseases (51%), central hypoventilation (33%), respiratory disorders (10%) and cervical cord injury (6%). Since 1983 when 2 patients were discharged home on mechanical ventilation, more and more ventilator-dependent children have been sent home every year. However, home mechanical ventilation is not yet well recognized in Japan as an option for pediatric patients with chronic respiratory failure, and there are many problems to be solved. Firstly, very few, if any, hospitals have a designated home care team composed of physicians and other specialists. Secondly, the current health insurance system scarcely covers the cost of home ventilation. Thirdly, development of home use equipment, in particular, portable ventilators and monitors is imperative. There are 107 hospitalized patients in 56 institutions who are reportedly able to go home if a support system is established. A program for pediatric home mechanical ventilation should be urgently developed on a national basis.

Quantitative Analysis of Health Insurance Reform: Separating Community Rating from Income Redistribution

Two key components of the upcoming health reform in the U.S. are a new regulation of the individual health insurance market and an increase in income redistribution in the economy. Which component contributes more to the welfare outcome of the reform? We address this question by constructing a general equilibrium life cycle model that incorporates both medical expenses and labor income risks. We replicate the key features of the current health insurance system in the U.S. and calibrate the model using the Medical Expenditures Panel Survey dataset. We find that the reform decreases the number of uninsured more than twice and generates substantial welfare gains. However, these welfare gains mostly come from the redistributive measures embedded in the reform. If the reform only reorganizes the individual market, introduces individual mandates but does not include any income-based transfers, the welfare gains are much smaller. This result is mostly driven by the fact that most uninsured people have low income.

Health insurance system and provider payment reform in the Republic of Macedonia

This article gives an insight to the current health insurance system in the Republic of Macedonia. Specialemphasis is given to the specificities and practice of both obligatory and voluntary health insurance, to thescope of the insured persons and their benefits and obligations, the way of calculating and payment of thecontributions and the other sources of revenues for health insurance, user participation in health careexpenses, payment to the health care providers and some other aspects of realization of health insurance inpractice. According to the Health Insurance Law, which was adopted in March 2000, a person can become aninsured to the Health Insurance Fund on various modalities. More than 90% of the citizens are eligible to theobligatory health insurance, which provides a broad scope of basic health care benefits. Till end of 2008payroll contributions were equal to 9.2%, and from January 1st, 2009 are equal to 7.5% of gross earned wagesand almost 60% of health sector revenues are derived from them. Within the autonomy and scope of activitiesof the Health Insurance Fund the structures of the revenues and expenditures are presented. Health financingand reform of the payment to health care providers are of high importance within the ongoing health carereform in Macedonia. It is expected that the newly introduced methods of payments at the primary health carelevel (capitation) and at the hospital sector (global budgeting, DRGs) will lead to increased equity, efficiencyand quality of health care in hospitals and overall system.

Health insurance system and provider payment reform in the Republic of Macedonia

This article gives an insight to the current health insurance system in the Republic of Macedonia. Special emphasis is given to the specificities and practice of both obligatory and voluntary health insurance, to the scope of the insured persons and their benefits and obligations, the way of calculating and payment of the contributions and the other sources of revenues for health insurance, user participation in health care expenses, payment to the health care providers and some other aspects of realization of health insurance in practice. According to the Health Insurance Law, which was adopted in March 2000, a person can become an insured to the Health Insurance Fund on various modalities. More than 90% of the citizens are eligible to the obligatory health insurance, which provides a broad scope of basic health care benefits. Till end of 2008 payroll contributions were equal to 9.2%, and from January 1st, 2009 are equal to 7.5% of gross earned wages and almost 60% of health sector revenues are derived from them. Within the autonomy and scope of activities of the Health Insurance Fund the structures of the revenues and expenditures are presented. Health financing and reform of the payment to health care providers are of high importance within the ongoing health care reform in Macedonia. It is expected that the newly introduced methods of payments at the primary health care level (capitation) and at the hospital sector (global budgeting, DRGs) will lead to increased equity, efficiency and quality of health care in hospitals and overall system

Between a Rock and a Hard Place: The Question of Money at St. Petersburg Women's Clinics

The new financing mechanisms introduced into the Russian health care system since the beginning of the 1990s have not resolved its severe financial problems. This article examines the consequences for outpatient services and the daily work of individual doctors in St. Petersburg, using women's reproductive health services as a case example. Interview and observational data reveal a constant opposition between formal rules and informal practices at both the administrative and polyclinic levels. Polyclinics for women's reproductive health services have developed various strategies as a response to insufficient financing, but many of these strategies are questionable within the current mandatory health insurance system. Ordinary doctors perceive the development as mainly negative. The results raise the question of increasing arbitrariness, from patients' perspective, in the health services provided. The study illustrates how in a post-socialist context, the past constantly permeates the present in the form of novel adaptations to the new social context.

Paying for Disease Management

Disease Management (DM) first appeared in the United States in the early 1990s. Since then its incorporation into health plans has increased dramatically, yet proof of its effectiveness in terms of quality improvement and cost reduction remains to be seen. The following review provides an exploratory analysis of the basic principles of DM, its evolution and differences from traditional managed care, the ways in which programs are currently being used in the private and public sectors, and the challenges to determining a payment structure for incorporating DM into the current health insurance system.

Health Care and Public Opinion

Health Care and Public Opinion

Health Care and Public Opinion

Health Care and Public Opinion

Putting (Insurance) Consumers in Charge of Health Care

A recent journal article proposes an overhaul of the current health insurance system. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

International harmonization of bioequivalence studies and issues shared in common.

In the course of a review of the current health insurance system in Japan, promotion of the use of generic products of lower price is expected in direction for minifying the drug costs which occupy about 20% thereof. However, the use of generic products has not increased so much as expected. One of the reasons to explain the fact might be that concerns exist about switchability from an innovator product to a generic product or among generic products because of bias in bioequivalence. Namely, hesitation about the difference in quality between generic products and innovator products, particularly in bioequivalence due to differences in the manufacturing process and pharmaceutical technology, exists among professionals in medical practice. The bioequivalence study to guarantee that a generic product is bioequivalent to an innovator product in terms of effectiveness and safety is most important in assuring the quality of generic products. There are various specifications and study methods to prove bioequivalence which differ slightly from one to another in different countries. We have investigated bioequivalence studies which are conducted in the major countries. Consequently, we clarified that bioequivalence studies are in international harmonization in terms of the major portions thereof. However, different conditions, e.g., selection of subjects, food effect, application of multiple dose study, and in vitro dissolution study, are still employed for the studies. Therefore, we consider that these differences constitute the topics to be reviewed in future.

The uninsured, the working uninsured, and the public.

Recent opinion surveys show a high level of public support for the current employer-based health insurance system. Many Americans are not aware that this system is endangered or that the number of uninsured persons is growing. The public appears to favor a two-track system for the working uninsured--strengthening the existing employer-based system and developing a parallel system for those without employer coverage.