Context Of Health Insurance Research Articles

Effectiveness of a case management model for people with multimorbidity: Mixed methods study

The aim was to determine the impact of a case management model on indicators of health service utilization, polypharmacy, quality of life and dependency of patients with multimorbidity, and family caregiver overload in a group of patients insured with two insurance companies in the city of Bogotá (Colombia). This was a mixed methods study, which integrated a quantitative and qualitative component. The study was conducted between July 2019 and March 2020. A quantitative component is based on a pre-experimental study with a single group and pre- and post-test measurements. Patients with multimorbidity with a medium or high level of complexity were included in the study. A sample of 317 patients and their caregivers was estimated. Following the completion of the intervention, a descriptive study that explored the perspective of nurses, patients and caregivers was developed to better understand the process and results from their own words and experience. A total of 17 dyads of patients and caregivers were interviewed, as well as six nurse managers. The integration strategy was developed based on a comparison made from the perspective of multiple stakeholders. The model's impact on quality of life, particularly in terms of social functioning and mental health, has been documented. Caregiver overload was reduced and an improvement in the adoption of the role was observed, aspects that converge with the experience of the dyads and the caregivers in the support and backing provided by the model. The intervention was structured in five modules: case detection, complexity screening, comprehensive assessment with various instruments, individualized care and follow-up plan, and plan assessment. The nurse manager role is confirmed as that of a professional with the leadership capacity to articulate disciplines and actors, whilst also dealing with the day-to-day needs of people with complex health conditions. A comprehensive and integrated approach to patients with multiple diseases in a health insurance context marked by access barriers and fragmentation of health services. The study provides quantitative and qualitative evidence of the benefits of the case management model in Colombia for patients with multiple diseases and their family caregivers, particularly in terms of the psychosocial dimensions of health-related quality of life and dependence assessment. A significant impact on the caregiver role, as well as an improvement in perception and trust in the health system, was observed as a result of the overcoming of administrative barriers achieved by the nurse case manager. The findings are considered to be extremely useful for decision-makers and insurers in developing a case management model focused on comprehensive and individualized care plans, as well as for individuals with multiple diseases and their caregivers.

When full insurance may not be optimal: The case of restricted substitution.

Even when heavily subsidized, a substantial portion of people choose to forgo purchasing health insurance coverage. In this note, I introduce an explanation for this phenomenon which does not assume choice errors, incorrect beliefs, differently priced uncompensated care, or information asymmetries. When individuals are incapable of freely trading off health and wealth and the initial allocation of goods is suboptimal from their perspective, the standard result of demand for actuarially fair insurance in a single good world does not generalize to the health insurance context. Thus, people might not purchase full health insurance coverage even if it is priced at actuarially fair levels. I argue that this situation is particularly likely to occur in the low-income population, and hence it is relevant for the achievement of universal health coverage.

Influence of service quality on consumer loyalty: a mediation analysis of health insurance

PurposeThis study aims to examine the influence of service quality (SQ) on customer loyalty (CL) and the mediating role of customer satisfaction (CS) and customer perceived value (CPV) in health insurance products in Malaysia.Design/methodology/approachData were conveniently collected through a self-administered questionnaire from subscribers to health insurance products and services in Malaysia. A total of 456 available questionnaires were used in the analysis. Partial least square (PLS) structural equation modelling (V3.3) was used to obtain the study results.FindingsA positive relationship is observed amongst the studied variables. In addition, CPV partially mediates the proposed relationship and also indirectly mediates the relationship between SQ and CS. Lastly, CS partially mediates the proposed relationship. Hence, all proposed direct and indirect relationships are significant and positive.Research limitations/implicationsThis research increases the authors’ understanding of the role of CS, SQ and CPV on CL in the health insurance industry in a developing country. The study also shows that insurance companies must establish positive relationships between insurers and customers by providing excellent SQ to maintain CS and loyalty.Practical implicationsThis research will help managers and guide the policymakers to establish a national health financing scheme. Furthermore, these results will guide industry players on how to maintain existing and targeting customers.Social implicationsThis study has attempted to provide a comprehensive understanding of CL in the Malaysian health insurance industry. Considering the limited research in the Malaysian health insurance context, this study can provide theoretical contribution and a managerial basis for future studies, including implications for the managers. However, to date, research in this sector under the Malaysian context is not adequate to consider SQ, perceived values and CL factors.Originality/valueThis study has attempted to provide a comprehensive understanding of CL in the Malaysian health insurance industry. Considering the limited research in the Malaysian health insurance context, this study can provide theoretical contribution and a managerial basis for future studies, including implications for the managers.

Integrating wearable technology products and big data analytics in business strategy

PurposeThis study aims to explore the impact of the adoption of wearable technology products for Indian health insurance firms. It identifies the key dynamic capabilities that health insurance firms should build to manage big data generated by wearable technology so as to attain a competitive advantage.Design/methodology/approachA qualitative exploratory study using in-depth personal interviews with 53 Indian health insurance experts was conducted with a semi-structured questionnaire. The data were coded using holistic and pattern codes and then analyzed using the content analysis technique. The findings were based on the thematic and relational intensity analysis of the codes.FindingsAn empirical model was established where all the propositions were strongly established except for the moderate relationship between wearable technology adoption and product innovation. The study established the nature of the interaction of variables on technology policy, organizational culture, strategic philosophy, product innovation, knowledge management and customer service quality with wearable technology adoption and also ascertained its influence on firm performance and competitive advantage.Research limitations/implicationsFrom a dynamic capabilities perspective, this study deliberates on wearable technology adoption in the health insurance context. It also explicates the relationship between the variables on technology policy, organizational culture, strategic philosophy, product innovation, knowledge management and customer service quality with wearable technology adoption on firm performance.Originality/valueThis study is one of the first studies to add the context of wearable technology and health insurance to the existing body of knowledge on dynamic capabilities and sustainable competitive advantage for the service sector. It would help existing and prospective players in adopting or setting up appropriate business models.

Healthy Weight for Life programme: Evaluating the practice and effectiveness of a weight loss maintenance programme in the private health insurance setting.

Background:Australian private health insurers are increasingly involved in the delivery of chronic disease management programmes to their members, recognising the importance of decreasing and managing lifestyle risk factors and the impact such factors have on health service utilisation. One such secondary prevention programme is the Healthy Weight for Life programme, an intensive weight loss and lifestyle modification programme that has been designed for overweight and obese private health insurance members in Australia. Together with the insurer, the Healthy Weight for Life service provider developed and implemented a long-term maintenance programme that supports participants who complete the Healthy Weight for Life programme to maintain the weight loss they achieved during the programme. Various studies have shown that evidence-based weight management programmes can be effective; however, the results may vary in different contexts.Objective:This article presents the evaluation rationale and framework designed to assess the process and impact of the long-term maintenance programme on weight loss maintenance, other health-related benefits and participants’ experience with the programme.Methods:The evaluation will comprise a number of inter-related sub-studies balancing evaluation of programme effectiveness and implementation. The maintenance programme presented a unique opportunity for researchers to partner with private health insurance and a service provider to assess a real-world programme in the under-researched area of weight loss maintenance in this setting and emphasises the importance of evaluating such programmes given the potential the private health insurance context has in the future delivery of health care.

Equity in patient experiences of primary care in community health centers using primary care assessment tool: a comparison of rural-to-urban migrants and urban locals in Guangdong, China

BackgroundThe equity of rural-to-urban migrants’ health care utilization is already on China’s agenda. The Chinese government has been embarking on efforts to improve the financial and geographical accessibility of health care for migrants by strengthening primary care services and providing universal coverage. Patient experiences are equally vital to migrants’ health care utilization. To our knowledge, no studies have focused on equity in the patient experiences between migrants and locals. Based on a patient survey from Guangdong, China, which has a large number of rural-to-urban migrants, our study assessed the equity in the primary care patient experiences between rural-to-urban migrants and urban locals in the same health insurance context, since different forms of insurance can affect the patient experiences of primary care.MethodsWe stratified our samples by different insurance types into three layers. We assessed primary care patient experiences using a validated Chinese version of the Primary Care Assessment Tool (PCAT), including eight primary care attributes. A ‘PCAT total score’ was calculated. Data were collected through face-to-face and one-on-one surveys in 2014. Propensity score matching (PSM) was used for each layer to generate comparable samples between rural-to-urban migrants and urban locals. Based on the matched dataset, a t-test was employed to compare the primary care patient experiences of the two groups.ResultsUsing PSM, 220 patients in the rural-to-urban migrants group were matched to 220 patients in the urban locals group. After the matching, the observed confounding variables were balanced, and the PCAT scores were almost equal between the two groups. The only slight differences existed in the Urban Employee Basic Medical Insurance layer and in the without basic medical insurance coverage layer.ConclusionsEquity in the primary care patient experiences between rural-to-urban migrants and urban locals seems to have been achieved to some extent. However, there is room for improvement in the equity of coordination of care and comprehensiveness. Policy makers should consider strengthening these two dimensions by integrating the health care system. More attention should be focused on helping migrants break down language and cultural barriers and improving the patient-physician communication process.

Health Changes in Low Income Men Transitioning from a State Funded Prostate Cancer Program to Comprehensive Insurance

We evaluated the effect of transitioning from a prostate cancer specific treatment program to comprehensive insurance under the ACA (Patient Protection and Affordable Care Act) on the physical, mental and prostate cancer related health of poor, previously uninsured men. We assessed general and prostate cancer specific health related quality of life using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and the UCLA PCI (Prostate Cancer Index) at 3 time points in 24 men who transitioned to comprehensive insurance as the insured group relative to 39 who remained in the prostate cancer program as the control group. We used mixed effects models controlling for treatment and patient factors to measure health differences between the groups during the transition period. Demographics, prostate cancer treatment patterns, and mental, physical and general health were similar before transition in the control and insured groups. After transition men who gained insurance coverage reported significantly worse physical health than men who remained in the prostate cancer program (p = 0.0038). After adjustment in the mixed effects model physical health remained worse in men who gained insurance (p = 0.0036). Mental health and prostate cancer related quality of life did not differ with time between the groups. Compared to controls who remained in the state funded prostate cancer treatment program for poor, uninsured men, newly insured men reported worse physical health after transitioning to ACA coverage. Providers and policy makers may draw important lessons from understanding the mechanisms of this paradoxical worsening in physical health after gaining insurance. These results inform the development of disease specific models of care in the broader health insurance context.

Self-rated health, generalized trust, and the Affordable Care Act: A US panel study, 2006–2014

Previous research shows that generalized trust, the belief that most people can be trusted, is conducive to people's health. However, only recently have longitudinal studies suggested an additional reciprocal pathway from health back to trust. Drawing on a diverse body of literature that shows how egalitarian social policy contributes to the promotion of generalized trust, we hypothesize that this other ‘reverse’ pathway could be sensitive to health insurance context. Drawing on nationally representative US panel data from the General Social Survey, we examine whether the Affordable Care Act of 2010 could have had influence on the deteriorating impact of worsening self-rated health (SRH) on generalized trust. Firstly, using two-wave panel data (2008–2010, N = 1403) and employing random effects regression models, we show that a lack of health insurance coverage negatively determines generalized trust in the United States. However, this association is attenuated when additionally controlling for (perceived) income inequality. Secondly, utilizing data from two separate three-wave panel studies from the US General Social Survey (2006–10; N = 1652; 2010–2014; N = 1187), we employ fixed-effects linear regression analyses to control for unobserved heterogeneity from time-invariant factors. We demonstrate that worsening SRH was a stronger predictor for a decrease in generalized trust prior (2006–2010) to the implementation of the Affordable Care Act. Further, the negative effect of fair/poor SRH seen in the 2006–2010 data becomes attenuated in the 2010–2014 panel data. We thus find evidence for a substantial weakening of the previously established negative impact of decreasing SRH on generalized trust, coinciding with the most significant US healthcare reforms in decades. Social policy and healthcare policy implications are discussed.

The design of long term care insurance contracts

This paper studies the design of long term care (LTC) insurance contracts in the presence of ex post moral hazard. While this problem bears some similarity with the study of health insurance (Blomqvist, 1997) the significance of informal LTC affects the problem in several crucial ways. It introduces the potential crowding out of informal care by market care financed through insurance coverage. Furthermore, the information structure becomes more intricate. Informal care is not publicly observable and, unlike the insurer, caregivers know the true needs of their relatives. We determine the optimal second-best contract and show that the optimal reimbursement rate can be written as an A-B-C expression à la Diamond (1998). These terms respectively reflect the efficiency loss as measured by the inverse of the demand elasticity, the distribution of needs and the preferences for risk sharing. Interestingly, informal care directly affects only the first term. More precisely the first term decreases with the presence and significance of informal care. Roughly speaking this means that an efficient LTC insurance contract should offer lower (marginal) reimbursement rates than its counterpart in a health insurance context.

Assessing the antecedents of customer loyalty on healthcare insurance products: Service quality; perceived value embedded model

Purpose: This research aim to investigate the influence of service quality attributes towards customers’ loyalty on health insurance products. In addition, this research also tested the mediation role of perceived value in between service quality and customers’ loyalty on health insurance products. Design/methodology/approach: Based on the literature review, this research developed a conceptual model of customers loyalty embedded with service quality and perceived value. The study surveyed 342 healthcare insurance customers. Apart from assessing the reliability and validity of the constructs through confirmatory factor analysis, this research also used structural equation modelling (SEM) approach to test the proposed hypothesis. Findings: The results from the inferential statistics revealed that the healthcare insurance customers are highly influenced by service quality followed by the perceived value in reaching their loyalty towards a particular health insurance service provider. Research limitations/implications: The sample for this study is based on health insurance customers only and it is suggested that future studies enlarge the scope to include others type of customers of different insurance products. Practical implications: In order to encourage the customers to more loyal towards their service providers, this research will add value for the mangers to understand the items of service quality and considering the perceived value of the target customers in order to optimize their loyalty. As whole, the outcome of this research will assist managers for better understanding of the customers’ loyalty antecedents under the perspective of healthcare insurance products. Originality/value: This paper has tried to provide a comprehensive understanding about customers’ loyalty under the perspective of service quality and perceived values context in the Malaysian health care insurance industry. Since there was a lack of such research in Malaysian health insurance context, this research can provide theoretical contribution and managerial basis for future researches as well as implications for the managers. Yet, till now research in this sector under Malaysian context do not appear adequately to take into account service quality, perceived values and customers loyalty factors.

Participatory action approach for client-centered health insurance

This methodological paper systematically describes the steps towards exploring client-perceived barriers to enroll in the National Health Insurance Scheme in Ghana. To respond to the stagnating enrollment rate and to provide evidence-based information for developing policy and practice, the request for this study was made by the insurance authority. We adopted a Participatory Action Approach (PAA) and employed a linked trajectory of qualitative and quantitative methods to inquire deeply into clients’ motives and assumptions, and the root causes of these barriers, while transferring learning among multiple stakeholders in the system: the client, the healthcare provider, and the insurer. Data were collected in 2011 and 2012 among clients in their local communities in two regions in Ghana. Clients were participants in the research, expressing and sharing their emic perspectives and commonly shared opinions with the other stakeholders. This paper explores the contribution of the PAA to healthcare and health insurance studies. We claim that the PAA is a necessary approach for the study of a complex situation such as the health insurance context in Ghana as well as for the facilitation of learning and democratic decision-making. Making multidisciplinary stakeholders, including clients, part of the research contributes to finding solutions that are acceptable to different stakeholders. Our study contributes to PAA methodology knowledge and provides new insights on combining qualitative and quantitative research methods. We propose this as a model to be used within action research that can also be applied in other contexts outside of Africa.

Moral Hazard or Morality for Health: An Ethical Debate on Insurance Coverage for the Obese

Health insurance for individuals classified as obese is a topic of ethical debate given the rising costs of premiums and the pressures of an unstable health economy. Difficult questions arise relative to health insurance and coverage for obese populations. For instance, do the chronic disease claims, attributed to individuals classified as obese, cause an inequitable rise in the cost of healthcare to normal-weight populations? Facts indicate an increased cost of care for obese populations compared to normal-weight populations. Health insurance is a complex service industry with multiple stakeholders, which give rise to ethical uncertainty in fidelity, veracity, and social responsibility, especially since insurance is a business that must generate profit to sustain itself. It is important for health policy makers to consider variable ethical philosophies when designing legislation that guides health insurance coverage for populations classified as obese. Utilitarian and libertarian philosophies are used to compare viewpoints relative to health insurance policy for the obese in the United States. These philosophies contrast the “good for all” versus the “right of the individual” in ethical decision making for health policy. The context of health insurance as a foundation for moral debate health about healthcare of obese populations is presented and debated herein.

Developing inventories for satisfaction and Likert scales in a service environment

PurposeThe purpose of this paper is to produce up‐to‐date inventories for satisfaction and Likert scales that contain commonly used scale point descriptors and their respective mean scale values and standard deviations.Design/methodology/approachAll data were collected online using the SSI Survey Spot Panel. This panel is national (USA) in scope. Thirty‐nine satisfaction items and 19 agreement items were tested on a random sample consisting of individuals 21‐65 years old.FindingsThe mean value and the standard deviation were calculated for each of these descriptors. Even though only six of the items that had been tested by Jones and Thurstone (1955) were included in the list of satisfaction scale descriptors, the semantic meanings of those six have changed very little over the years.Research limitations/implicationsOne limitation might be that scale point descriptor inventories developed within the context of health insurance might not be valid in other service contexts.Practical implicationsSince the present study focuses on Likert and satisfaction scales which are frequently used in service environments, the major contribution of this study is to provide services marketers with quantitative measurement of the meanings of commonly used scale point descriptors. This permits the development of successive and/or equal interval scales and thus aids in the analyses of data sets. It will thus help service marketers to develop questionnaires that more accurately reflect actual consumer satisfaction and opinions.Originality/valueThe development of up‐to‐date inventories for satisfaction and Likert scales.

Employer-provided health insurance and the incidence of job lock: a literature review and empirical test

The incidence of ‘job lock’ in the health insurance context has long been viewed as a potential problem with employer-provided health insurance, a concept that was instrumental in the passage of the United States Consolidated Omnibus Budget Reconciliation Act of 1986, and later, the Health Insurance Portability and Accountability Act in 1996. Several recent developments in healthcare in the USA include declining healthcare coverage and a noticeable shift in the burden of medical care costs to employees. If these developments cause employees with employer-provided health insurance to feel locked into their jobs, optimal job matches in the labor force may not take place. A summary of the seminal papers in the current literature on the topic of job lock is given, followed by an empirical exercise using single individuals from the National Health Interview Survey (1997–2003) and the 1979 cohort of the National Longitudinal Survey of Youth (1989–2000). Econometric methods used include difference in differences, ordinary least squares and individual fixed effects models, in gauging the potential effect that employer-provided health insurance may have on job tenure and voluntary job departure. Our findings are consistent with recent assertions that there is some evidence of job lock. Individuals with employer-provided health insurance stay on the job 16% longer and are 60% less likely to voluntarily leave their jobs than those with insurance that is not provided by their employers. Productivity may not be optimal if incentives are altered owing to the existence of fringe benefits, such as health insurance. Further research in this area should determine whether legislation beyond the Consolidated Omnibus Budget Reconciliation Act and Health Insurance Portability and Accountability Act laws is needed.

Currents in Contemporary Ethics

The Genetic Information Nondiscrimination Act of 2008 (GINA)1 was signed into law on May 21, 2008, after a 13-year struggle in Congress. GINA prohibits genetic discrimination in employment and health insurance, thereby supplementing existing federal protections against genetic discrimination in employer-sponsored group health plans contained in the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)2 and state laws prohibiting genetic discrimination in employment and individual health insurance.3 Although there have been very few documented instances of genetic discrimination in health insurance and employment, the fear of such discrimination has led many at-risk individuals to decline genetic testing in both the clinical and research settings. The findings section of GINA specifically states that federal legislation “is necessary to fully protect the public from discrimination and allay their concerns about the potential for discrimination, thereby allowing individuals to take advantage of genetic testing, technologies, research, and new therapies.”4 The approach and relative merits of GINA are subject to debate, but even its supporters recognize that GINA has major shortcomings.5 Three of the most commonly noted deficiencies are the following.6 First, GINA’s ban on genetic discrimination is not comprehensive. GINA does not apply to life insurance, disability insurance, long-term care insurance, or other potential uses of genetic information. Consequently, it is not clear that its limited protections will be sufficient to allay the fears of individuals currently dissuaded from undergoing genetic testing. Second, GINA prohibits discrimination based on genotype, but not phenotype. Thus, GINA only applies to individuals who are asymptomatic. In the health insurance context, individuals are protected from discrimination based on their genetic risk of disease, but they are not protected if they develop the disease.7 In the overwhelming number of states, health insurance companies may lawfully raise the rates or refuse to renew the policies of individuals based on a change in their health condition. Third, the employment provisions of GINA prohibit employers from requiring or requesting an individual to undergo genetic testing or disclosing the results of a genetic test as a condition of employment.8 Nevertheless, GINA does not affect a key provision of the Americans with Disabilities Act (ADA),9 under which an employer may, after a conditional offer of employment, lawfully require an individual to sign an authorization to disclose all of his or her health records to the employer.10 Because there is currently no feasible way to segregate genetic from non-genetic information in either paper or electronic health records, it must be anticipated that, notwithstanding GINA, many – if not most – custodians of health records will continue the practice of sending requesting employers all of an individual’s health records upon receipt of an authorization.11 A previously unexplored but critical issue is how GINA’s limited coverage and the ADA’s limited coverage apply along the continuum from genotype to expressed disease. Although the same problem of determining when a condition is “manifested” exists under the health insurance provisions of GINA, this commentary is limited to genetic discrimination in employment.

Costs of Rheumatoid Arthritis: New Estimates from the Human Capital Method and Comparison to the Willingness-to-Pay Method

Individuals' valuation of changes in health states in monetary terms have been measured by examining changes in the direct and indirect costs of disease and by the willingness-to-pay (WTP) methodology. In 2002, a 2-part study was conducted in Quebec. In one part of the study, 121 rheumatoid arthritis (RA) patients from the McGill University Health Centre were mailed the Stanford Cost Assessment Questionnaire, which enabled the elicitation of direct costs and indirect costs, according to the friction cost and the human capital methods. The other part was a phone survey conducted in a representative sample of the general population and in the same sample of patients, aiming to elicit the societal WTP for a complete cure of RA in the context of 2 different scenarios: a public coverage or private insurance. These estimates were then compared. Estimates of the cost of illness of RA ranged from 11,717 to 28,498 Canadian Dollars (CAD) depending on the method. These estimates are higher than those previously published in Canada from the 1990s, which is partly due to the recent and costly biological therapies and to a change in the measurement of productivity losses. These estimates are somewhat lower than the societal WTP elicited from the WTP survey, that is, 26,717 and 36,817 CAD per RA case, depending on the public or private health insurance context in which the cure would be available. Given that neither method is ideal, data from both methods would provide an important sensitivity analysis when monetary estimates of health state changes are required.

The struggle for the soul of health insurance.

The politics of American health insurance is a struggle over which vision of distributive justice should govern: the solidarity principle or the logic of actuarial fairness. Actuarial fairness is central to American private health insurance. It is both an antiredistributive ideology and a method of organizing mutual aid by fragmenting communities into ever-smaller, more homogeneous groups, leading ultimately to the destruction of mutual aid. This fragmentation is accomplished by fostering in people a sense of their differences and their responsibility for themselves, rather than their commonalities and interdependence. Actuarial fairness developed as a business strategy for gaining market share. Medical underwriting, which is far more extensive than commonly known, is the information technology used for implementing actuarial fairness. Despite significant changes in the political context of health insurance which are leading toward restraints on underwriting, the logic of actuarial fairness is so deeply embedded in the structure of competitive markets in insurance and so deeply consonant with social divisions in American society that eradicating it will take more than any current reform proposals contemplate.