Insurance Categories Research Articles

Analysis of Adverse Selection and Moral Hazard in the Health Insurance Market of Iran

This paper aims to estimate a demand model for health insurance and medical care in Iran, in the presence of heterogeneous and latent health status of individuals; moreover it tests the asymmetry of information in the health insurance market. Our data set have been taken from the Households’ expenditures survey (2006) of Iran. Parameters of the model are estimated by the Generalized Method of Moments (GMM) and the presence of asymmetric information (adverse selection and moral hazard) is tested by a non-parametric econometric method. The analytical model is specified under minimal assumptions on the selection process of different insurance categories and the statistical distribution of individual's latent health status. The findings confirm the presence of adverse selection hypothesis in personally purchased health insurance and moral hazard in all health insurance categories.

Health Insurance Coverage Among Persons With Schizophrenia in the United States

This study estimated the rates of health insurance coverage in the U.S. civilian noninstitutionalized population with schizophrenia and assessed whether basic access to health care varied across health insurance categories. Data from the Medical Expenditures Panel Survey collected between 2002 and 2006 were used. The sample contained 328 records representing 493,006 noninstitutionalized civilian persons with schizophrenia. Eighty-seven percent had Medicaid or Medicare, 8% received care through the Veterans Health Administration, and 15% had private insurance for at least one day during the year. About 7% were uninsured all of the year. The uninsured tended to be male (92%), nonwhite (54%), and unmarried (97%), and 30% of the uninsured had not had a medical checkup in more than five years. Almost all U.S. adults with schizophrenia were found to receive government health insurance, yet a measurable minority remained uninsured. These national estimates highlight opportunities for improving health service delivery for this vulnerable population.

Economies of Scope in Financial Services: A Semi-Parametric Approach

This paper estimates the cost scope economies in U.S. banking and insurance after the adoption of Gramm-Leach-Bliley Act. We use semi-parametric methods to estimate a hybrid quadratic cost function for a unique data set that contains specialists and conglomerate banking and insurance firms. The advantage of the semi-parametric model is that it provides firm-level estimates for the coefficients of the objective function. These estimates in turn are functions of a set of variables that may help explain scope economies. In contrast to previous findings, our results provide evidence for the existence of cost economies of scope between U.S. banking and insurance industry. Most conglomerates benefit from synergies between marketing health and life insurance and information provided by loans and deposits as well as reductions in fixed costs and labor costs. Thrift assurbanks benefit the most from the synergies between loans and commercial property and liability insurance as well as reduction in employee cost savings. Notable synergies between deposits and property and liability insurance (mostly personal insurance products) are present only for thrift assurbanks. Reduction in fixed costs and employee costs are weakly correlated to scope economies between deposits and the two insurance categories. Our results show no significant cost synergies in offering the two categories of insurance products jointly.

Racial, Socioeconomic, and Rural–Urban Disparities in Obesity-Related Bariatric Surgery

Morbid obesity is associated with serious health and social consequences, high medical costs and is increasing in the USA, particularly among rural, socioeconomically disadvantaged populations. Bariatric surgery more often provides significant long-term weight loss than traditional weight loss treatments. We examined the likelihood of bariatric surgery among morbidly obese patients across rural/urban locales, racial/ethnic groups, insurance categories, socioeconomic, and comorbidity levels. We examined 159,116 records representing 774,000 patients with morbid obesity from the 2006 Nationwide Inpatient Sample. We determined the likelihood, expressed in odds ratios, of bariatric surgery associated with each patient characteristic using survey-weighted univariate logistic regression. We also performed multivariate logistic regression, assuming all patient factors were independent. After adjusting for patient-level characteristics, the most rural residents were 23% less likely to receive bariatric surgery than urban residents. Other demographic features associated with significantly lower odds ratios for bariatric surgery included minority status, male gender, lower income, older age, non-private insurance status, and higher comorbidity. Rural-dwelling patients who are non-white, male, poorer, older, sicker, and non-privately insured almost never received bariatric surgery (OR = 0.0089). Though obesity is more prevalent among middle-aged, rural, economically disadvantaged, and racial/ethnic minority populations, these patients are unlikely to access bariatric surgery. Because obesity is a leading cause of preventable morbidity and mortality in the USA, effective treatments should be made available to all patients who might benefit. Current Medicare/Medicaid policies that reimburse only high volume centers may effectively deny rural residents who rely on these insurance programs for bariatric surgery.

Statistical Note #1 Changes in Out-of-Pocket Expenses by Insurance Category (1999 to 2006)

This note uses data from the Household Component of the Medical Expenditures Panel Survey (MEPS-HC) for 1999 and 2006 to examine trend growth in household out-of-pocket health expenditures. Tabulations are presented for three different categories of insurance coverage - households where the household head has full-year coverage, households where the household head has part-year coverage, and households where the household head has no coverage. Tabulations are presented for the general working-age U.S. civilian non-institutional population and for the sub-population of households with at least one member with an overnight hospital stay. The results reveal an increase in the number of households with large out-of-pocket expenses, which is especially pronounced for households with at least one member with an overnight hospital stay.

Association Between Insurance Gaps and Continued Antihypertension Medication Usage in a US National Representative Population

Medication persistence is important for adequate control of blood pressure. In this article, we assess the association between gaps in insurance coverage and continued antihypertensive medication using a US national representative sample. We used three recent panels from the Medical Expenditure Panel Survey (MEPS). Our sample included hypertensive individuals 18-65 years of age. We identified four insurance categories: (i) continuous coverage by private insurance, (ii) continuous coverage by public insurance, (iii) single or multiple gaps in coverage, and (iv) continuously uninsured. Binary logit models were used to analyze the association between interruptions in medication and insurance after controlling for socioeconomic factors. Patients with continuous private insurance were used as the reference group. Results were weighted to adjust for oversampling and clustering in the survey. There was no statistically significant difference in the probability of medication persistence between individuals with continuous private insurance (the reference group) and individuals with continuous public insurance (adjusted odds ratio (AOR) 1.324, 95% confidence interval (CI) 0.774-2.266, P = 0.304). Compared to the reference group, individuals with insurance gaps had lower odds of continuing their medication (AOR 0.636, 95% CI 0.418-0.0.969, P = 0.035). Continuously uninsured individuals had even lower odds of medication persistence (AOR 0.462, 95% CI 0.282-0.757, P = 0.002). Age, marital status, body mass index (BMI) change, and years of education were also associated with continued medication usage. Studies focusing on current insurance status may underestimate the impact of health insurance gaps and the population at risk. Continuous insurance coverage is needed to increase continued antihypertensive medication usage.

Psychiatric Treatment Received by Primary Care Patients With Panic Disorder With and Without Agoraphobia

Psychiatric Treatment Received by Primary Care Patients With Panic Disorder With and Without Agoraphobia

The Economic Impact of Exposure to Secondhand Smoke in Minnesota

Using the risk categories established by the 2006 US surgeon general's report, we estimated medical treatment costs related to exposure to secondhand tobacco smoke (SHS) in the state of Minnesota. We estimated the prevalence and costs of treated medical conditions related to SHS exposure in 2003 with data from Blue Cross and Blue Shield (Minnesota's largest insurer), the Current Population Survey, and population attributable risk estimates for these conditions reported in the scientific literature. We adjusted treatment costs to the state level by health insurance category by using the Medical Expenditure Panel Survey. The total annual cost of treatment in Minnesota for conditions for which the 2006 surgeon general's report found sufficient evidence to conclude a causal link with exposure to SHS was $228.7 million in 2008 dollars-equivalent to $44.58 per Minnesota resident. Sensitivity analyses showed a range from $152.1 million to $330.0 million. The results present a strong rationale for regulating smoking in public places and were used to support the passage of Minnesota's Freedom to Breathe Act of 2007.

Health Insurance Coverage and Use of Eye Care Services

To compare realized access or use of eye care services in adults with self-reported vision problems in Canada and the United States. Using the Joint Canada/United States Survey of Health, we examined the differences in use of eye care services in 2018 Canadian respondents and 2930 American respondents with self-reported vision problems. We performed multivariate logistic regression analyses to estimate the probability that individuals with vision problems and various insurance categories would visit an eye care professional. Approximately 8.2% of Americans with self-reported vision problems did not have health insurance. Americans without health insurance had the lowest age-adjusted rate of use of eye care services (42%) compared with Americans with private health insurance (67%) or public health insurance (55%) and Canadians (56%). The difference in use of eye care services between Americans without health insurance and Canadians narrowed when adjusted for income level and was almost eliminated when adjusted for having optional vision insurance. Individuals with optional vision insurance and those with higher income levels were more likely to use eye care services. Americans with vision problems who had health insurance accessed eye care services at a rate higher than or equal to that of their Canadian counterparts. The gap in access between Canadians and Americans without health insurance narrowed after adjustments for income level and optional vision insurance.

Insurance status predicts access to care and outcomes of vascular disease

To determine if insurance status predicts severity of vascular disease at the time of treatment or outcomes following intervention. Hospital discharge databases from Florida and New York from 2000-2005 were analyzed for lower extremity revascularization (LER, n = 73,532), carotid revascularization (CR, n = 116,578), or abdominal aortic aneurysm repair (AAA, n = 35,593), using ICD-9 codes for diagnosis and procedure. The indications for intervention as well as the post-operative outcomes were examined assigning insurance status as the independent variable. Patients covered under a variety of commercial insurers, as well as Medicare, were compared to those who either had no insurance or were covered by Medicaid. Patients without insurance or with Medicaid were at significantly greater risk of presenting with a ruptured AAA compared to insured (non-Medicaid) patients; while insurance status did not seem to impact post-operative mortality rates for elective and ruptured AAA repair. The uninsured or Medicaid recipients presented with symptomatic carotid disease nearly twice as often as the insured, but stroke rates after CR did not differ significantly based on insurance status. Patients with Medicaid or without insurance were more likely to present with limb threatening ischemia than claudication. In contrast to AAA repair and CR, the outcomes of LER were worse in the uninsured and Medicaid beneficiaries who had higher rates of post-revascularization amputation compared to the insured (non-Medicaid) group. Insurance status predicts disease severity at the time of treatment, but once treated, the outcomes are similar among insurance categories, with the exception of lower extremity revascularization. This data suggests inferior access to preventative vascular care in the Medicaid and the uninsured populations.

The Effects of Race and Insurance on Potentially Avoidable Hospitalizations in Tennessee

This study examined effects of race and insurance on the risk of potentially avoidable hospitalizations (PAHs) in Tennessee. Applying the current Agency for Healthcare Research and Quality definitions for ambulatory-care-sensitive conditions to inpatient discharge data, the study found hospitalized Black patients more likely than their White counterparts to have experienced a PAH for chronic conditions. In contrast, Black inpatients' risk was lower than that of White inpatients for acute conditions after controlling for covariates. The results also showed the strong influence of insurance coverage. Finally, an analysis of racial differences in the relative risks for PAHs using data grouped by insurance status showed that hospitalized Blacks within each subset had a greater risk of having a PAH than hospitalized Whites, although the risk varied with insurance type. The variations of PAH risks across racial and insurance categories, together with the extra risks associated with chronic conditions, deserve greater examination.

Características demográficas dos idosos vinculados ao sistema suplementar de saúde no Brasil

To assess health coverage of elderly people receiving supplementary health care and these users' sociodemographic characteristics. Descriptive study of elderly population living in Brazil and in the states of São Paulo and Rio de Janeiro in 2006. Data was collected from the National Supplementary Care Beneficiary Information System and the National Household Sample Survey. The following variables were studied: gender, age, distribution by federal unit, category of health insurance, type of contract and plan segmentation. Higher coverage of the general population was seen in the age groups 70-79 years (26.7% and 80 years and more (30.2%). Of those aged 80 years and more, 33% had private health plans among women and 25.9% among men. Nearly 80% of health insurance beneficiaries were living in southeastern and southern Brazil, of which 55% were in Rio-São Paulo axis. Health maintenance organizations covered a higher proportion of younger compared to elderly population (39% and 34.5%, respectively) and self-management care plans covered a significantly higher proportion of elderly compared to younger population in Brazil (22.8% and 13.8%, respectively). Elderly health care coverage was significantly high and age groups over 70 years showed the highest coverage rates among the Brazilian population, especially among women.

Impact of socioeconomic status on Brazilian elderly health

To investigate the impact of socioeconomic status on elderly health. The study was based on cross-sectional data from Survey on Health, Well-Being, and Aging in Latin America and the Caribbean. The sample comprised 2,143 non-institutionalized elderly aged 60 years and older living in the urban area of São Paulo, southeastern Brazil. Linear regression models estimated the effect of socioeconomic status indicators (years of schooling completed, occupation and purchasing power) on each one of the following health indicators: depression, self-rated health, morbidity and memory capacity. A 5% significance level was set. There was a significant effect of years of education and purchasing power on self-rated health and memory capacity when controlled for the variables number of diseases during childhood, bed rest for at least a month due to health problems during childhood, self-rated health during childhood, living arrangements, sex, age, marital status, category of health insurance, intake of medicines. Only purchasing power had an effect on depression. Despite the bivariate association between socioeconomic status indicators and number of diseases (morbidity), this effect was no longer seen after including the controls in the model. The study results confirm the association between socioeconomic status indicators and health among Brazilian elderly, but only for some dimensions of socioeconomic status and certain health outcomes.

Impact of socioeconomic status on Brazilian elderly health Impacto do status socioeconômico na saúde de idosos brasileiros

OBJECTIVE: To investigate the impact of socioeconomic status on elderly health. METHODS: The study was based on cross-sectional data from Survey on Health, Well-Being, and Aging in Latin America and the Caribbean. The sample comprised 2,143 non-institutionalized elderly aged 60 years and older living in the urban area of Sao Paulo, southeastern Brazil. Linear regression models estimated the effect of socioeconomic status indicators (years of schooling completed, occupation and purchasing power) on each one of the following health indicators: depression, self-rated health, morbidity and memory capacity. A 5% signifi cance level was set. RESULTS: There was a signifi cant effect of years of education and purchasing power on self-rated health and memory capacity when controlled for the variables number of diseases during childhood, bed rest for at least a month due to health problems during childhood, self-rated health during childhood, living arrangements, sex, age, marital status, category of health insurance, intake of medicines. Only purchasing power had an effect on depression. Despite the bivariate association between socioeconomic status indicators and number of diseases (morbidity), this effect was no longer seen after including the controls in the model.

Public Health Insurance Enrollment among Immigrants and Nonimmigrants: Findings from the 2001 California Health Interview Survey

We examine whether adult immigrants in California had the same likelihood of having public health insurance as nonimmigrants with comparable characteristics, using 44,434 non-elderly adult samples of the 2001 California Health Interview Survey public use data. Multinomial logistic regression was used to assess the likelihood of public health insurance relative to private (employment-based or privately purchased) health insurance by generation status, controlling for individual characteristics. The outcome of interest was public health insurance among three health insurance categories: private health insurance, public health insurance, and uninsured. Both first and second generation immigrants were more likely to have public health insurance than were nonimmigrants. However, the difference vanished, when demography, socioeconomic status, health status, employment sector, and English facility were controlled for. The combined effect of lower returns to education and lower employment-based insurance offer rates seems to be the underlying cause of higher prevalence of public health insurance among ethnic minorities.

Children's Health Services in a “System of Care”: Patterns of Mental Health, Primary and Specialty Use

This study was designed to investigate demonstrable impacts of the Mental Health Services Program for Youth (MHSPY), a highly coordinated, intentionally integrated "system of care," on patterns of health service utilization for youth with multiple needs. The MHSPY intervention is available to a target population of urban youth who face barriers to health care and are at risk for out-of-home placement. These youth are enrolled in a non-profit managed care organization (MCO). Patterns of medical, pharmacy, and mental health and substance abuse service use were compared for children aged 3 to 19 across insurance categories. Despite risks for access and engagement barriers to care, and for greater medical expense due to greater morbidity, MHSPY enrollees received significantly more ambulatory care per person-year than either the privately insured population or the Medicaid Standard population, and medical expense for MHSPY members was significantly lower than expected. During the four years studied, individuals in the privately insured and Medicaid Standard populations were less likely than MHSPY enrollees to have had an ambulatory pediatric visit (odds ratio [OR] 0.833, 95% confidence interval [CI] 0.765, 0.908 and OR 0.823, 95% CI 0.775, 0.897, respectively). Medical expenses per member per month for MHSPY enrollees were significantly less than that for the similarly impaired Medicaid Disabled population with any medical claim (p < 0.001) or with any outpatient mental health claim (p < 0.01). Patterns of health care for subpopulations with known risk are important to identify to evaluate system-of-care effectiveness. The service utilization patterns for youth enrolled in the MHSYP system of care vs. those for similar MCO youth suggest health care access for individuals can be affected by delivery system design variables.

El seguro de accidentes de trabajo en España: de la obligación al negocio (1900–1940)

The institutional changes which took place with the law of industrial accidents of 1900 and the later regulations caused substantial changes in the Spanish insurance market. A new insurance field was created in which both specialist Spanish companies and foreign insurance agencies operated. This article aims to analyse the evolution of this new field, industrial accident insurance, from its beginning to the 1940s, when it become the most important insurance category. For that purpose premiums and companies have been reconstructed. It is observed too how from the start some industrialists understood the necessity to participate in this business and therefore they sometimes allied with insurance businessmen to form specialist companies. The interest in industrial accidents insurance increased during the 2nd Republic due to government's obligatory insurance requirements, what originated an uprising competition between mutual employer's associations and insurance agencies.

Unscheduled Revisits to a Pediatric Emergency Department

Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV. This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV. Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10). These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.

Emergency department management of mild traumatic brain injury in the USA

Objective: To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types. Methods:...

Using the ecology model to describe the impact of asthma on patterns of health care.

BackgroundAsthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care.MethodsThis is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings.ResultsIn 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas.ConclusionThe ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services.