Insurance Department Research Articles

Genesis and Prospects of Higher Insurance Education Development in Russia

The article discusses the history and stages of development of insurance education in Russia in comparison with the development of the insurance market in 1990–2020, determines the prospects and conditions for development of insurance education. The internal and external factors that influenced the direction and rate of the market of educational services development in the field of insurance are highlighted, the reasons for the creation and liquidation of specialized departments in Russian universities are analyzed. Based on the analysis of the Russian insurance market in 1990-2020, an understanding of the real and reported indicators of the insurance market is being formed, the differences in which caused at the first stage the creation of a significant number of insurance departments in Russian universities, not supported by a real need for specialists, and then the liquidation of the departments with the loss of the already established competencies for training insurance specialists. In the late 2010s, the modernization processes in the requirements for insurance organizations took place, the financial stability and solvency standards were being raised, mandatory actuarial valuation and new forms of financial reporting were being introduced that required specialized knowledge, basic and professional standards were being developed and adopted with the participation of self-regulatory organizations of insurers. All of that actualized the activities of specialized insurance departments based on the integration of professional requirements fixed in professional and basic standards, and educational standards, which should allow the implementation of economically successful undergraduate and master’s programs.The history of insurance departments in modern Russia may be of interest to researchers of the history of education in modern Russia, the origins and causes of the current state of the educational services market, periods of growth and decline in the number of active players. Based on the analysis of archival and current insurance development strategies, the article highlights the adopted basic and professional standards, prospects for the development of insurance departments, gives recommendations for interaction with professional participants of the insurance market. The revealed trends are also typical for other highly professional departments.

Enforcement of the Mental Health Parity and Addiction Equity Act: State Insurance Commissioners' Statutory Capacity.

State insurance departments enforce the federal Mental Health Parity and Addiction Equity Act (MHPAEA) for fully insured employer-sponsored health plans and plans on the individual marketplace. Variable enforcement among states may drive patients' difficulties in accessing behavioral health treatment. This study explored insurance commissioners' statutory capacity for enforcing the MHPAEA. Legal mapping of insurance office powers and responsibilities was conducted for MHPAEA-enforcing states. Relevant state laws and regulations were gathered from the Westlaw database. Sections were coded in the categories commissioner selection, frequency of examinations, fines, licenses, subpoenas, investigations and hearings, rehabilitation or liquidation of insurers, and initiation of legal actions. The sample included 450 sections of states' codes and regulations. The 46 states that enforced the MHPAEA showed only small differences in the powers and responsibilities of insurance commissioners. Similarities across states in statutory capacity of commissioners suggest that it is not a primary source of variation in MHPAEA enforcement.

A historical review of performance appraisal of public hospitals in China from the perspective of historical institutionalism.

The government performance appraisal of public hospitals serves as an effective management tool to promote high-quality development. It is also an important means of realizing the “Healthy China” initiative. Since the founding of the People's Republic of China, changes in performance appraisal have been divided into the following four periods: the early stage of performance appraisal (1949–1977), the exploration period (1978–2008), the development period (2009–2018), and the integration period (2019–present). This clarifies the regional practice of public hospital performance and identifies the institutional factors of the evolution. It also demonstrates that administrative forces, market-driving forces, and mission-driving forces combine to bring about change in the public hospital performance appraisal system. However, problems such as insufficient application of performance appraisal and coordination between health administrative departments and medical insurance departments still loom large.

Factors Affecting State-Level Enforcement of the Federal Mental Health Parity and Addiction Equity Act: A Cross-Case Analysis of Four States.

The Mental Health Parity and Addiction Equity Act (MHPAEA) requires coverage for mental health and substance use disorder (MH/SUD) benefits to be no more restrictive than for medical/surgical benefits in commercial health plans. State insurance departments oversee enforcement for certain plans. Insufficient enforcement is one potential source of continued MH/SUD treatment gaps among commercial insurance enrollees. This study explored state-level factors that may drive enforcement variation. The authors conducted a four-state multiple-case study to explore factors influencing state insurance offices' enforcement of MHPAEA. They interviewed 21 individuals who represented state government offices, advocacy organizations, professional organizations, and a national insurer. Their analysis included a within-case content analysis and a cross-case framework analysis. Common themes included insurance office relationships with other stakeholders, policy complexity, and political priority. Relationships between insurance offices and other stakeholders varied between states. MHPAEA complexity posed challenges for interpretation and application. Policy champions influenced enforcement via priorities of insurance commissioners, governors, and legislatures. Where enforcement of MHPAEA was not prioritized by any actors, there was minimal state enforcement. Within a state, enforcement of MHPAEA is influenced by insurance office relationships, legal interpretation, and political priorities. These unique state factors present significant challenges to uniform enforcement.

Race discrimination in the adjudication of claims: Evidence from earthquake insurance

AbstractCatastrophic events affect many people simultaneously. We exploit earthquake claim characteristics to test for racial discrimination in the adjudication of insurance claims. Using data from the Oklahoma Department of Insurance, the US Geological Survey, and the US census, we study eight earthquakes between 2010 and 2016 that were linked to oil and gas drilling activities. We test whether claim resolutions differ among zip‐code areas with different racial compositions, all else equal. We find evidence that claims from areas with higher percentages of Black population were less likely to result in payment, and when those claims did get paid, payments were lower in those areas. We further investigate the mechanisms through which such discrimination may exist. We do not find evidence that the percentages of Black, Native, or Asian population in an area are associated with the filing of marginal claims. We do find that areas with higher percentages of Hispanic population file fewer marginal claims.

Members Report Uptick in Plans’ Claims Denials, Scrutiny, and Hassles

Members Report Uptick in Plans’ Claims Denials, Scrutiny, and Hassles

Vaccinating Veterans for COVID-19 at the U.S. Department of Veterans Affairs

IntroductionWith the COVID-19 (most recent) Omicron variant surge across the U.S., more research is needed to better understand how vaccination and booster uptake can be increased. COVID-19 vaccinations have proven to help decrease the likelihood of becoming seriously ill, getting hospitalized, or dying. Studies examining patient characteristics of individuals who received COVID-19 vaccinations are limited. This study examines the patient characteristics of veterans who were vaccinated during the first 8 months (December 2020–July 2021) of the vaccination rollout at the U.S. Department of Veterans Affairs.MethodsUsing the U.S. Department of Veterans Affairs administrative and clinical data, bivariate and multivariate analyses were conducted to determine sociodemographic and health factors associated with the likelihood of receiving COVID-19 vaccination at the U.S. Department of Veterans Affairs.ResultsThe analytic sample included 5,914,741 U.S. Department of Veterans Affairs users (49.7% vaccinated). Among the U.S. Department of Veterans Affairs medical facilities nationwide, COVID-19 vaccination rates (≥1 dose) varied from 33.9% to 73.7%. Veterans who were non-Hispanic American Indian/Alaskan natives, younger, living in rural areas, male, and unmarried; had U.S. Department of Veterans Affairs health insurance only; had fewer chronic conditions; did not receive the seasonal influenza vaccine; and were not living in community living centers or nursing homes were less likely to get vaccinated.ConclusionsUnderstanding which groups of veterans are less likely to be vaccinated allows the U.S. Department of Veterans Affairs to develop targeted interventions to improve uptake in these groups. These results can also guide non–U.S. Department of Veterans Affairs organizations to create evidence-based educational outreach programs that reduce vaccine hesitancy among veterans who do not use U.S. Department of Veterans Affairs.

The conflict and burden of insurer appointments for brokers and the need for regulatory reform

Brokers are supposed to be independent to represent the insured, rather than the insurer; yet, the law in many states still requires insurers to appoint a broker as an agent actually to transact insurance with the insurer. This dual agency creates well-known conflicts and burdens. We contend that the requirement that insurers appoint agents in each state with the department of insurance (DOI) has outlived its usefulness and should be abolished for independent insurance brokers, at least those of a minimum size. Insurers with exclusive agents should retain the appointment requirement. Protection of the insured against rogue brokers is not accomplished by this appointment requirement. Protection against rogue brokers is already achieved by malpractice claims and malpractice insurance, which can be strengthened by requirements for higher malpractice insurance limits. Removing the appointment for brokers will further the goals of simplified regulatory burdens, business efficiency, and customer protection by removing one conflict of interest of the dual agency situation.

Identifying fraud in medical insurance based on blockchain and deep learning

With the rapid growth of medical costs, the control of medical expenses has been becoming an important task of Health Insurance Department. Traditional medical insurance settlement is paid on a per-service basis, which leads to lots of unreasonable expenses. To cope with this problem, the single-disease payment mechanism has been widely used in recent years. However, the single-disease payment also has a risk of fraud. In this work, we propose a framework to identify fraud of medical insurance based on consortium blockchain and deep learning, which can recognize suspicious medical records automatically to ensure valid implementation on single-disease payment and lighten the work of medical insurance auditors. An explainable model BERT-LE is designed to evaluate the reasonability of ICD disease code for Medicare reimbursement by predicting the probability of a disease according to the chief complaint of a patient. We also put forward a storage and management process of medical records based on consortium blockchain to ensure the security, immutability, traceability, and auditability of the data. The experiments on two real datasets from two 3A hospitals demonstrate that the proposed solution can identify fraud effectively and greatly improve the efficiency in medical insurance reviews.

Guidance on Navigating Insurance Plans for TMS-Eligible Patients

Guidance on Navigating Insurance Plans for TMS-Eligible Patients

Health insurance, pediatric asthma, and emergency department usage.

This study synthesized current research on the relationships between type of insurance and emergency department usage for children with asthma in the United States. Thematic analysis is in the context of the Affordable Care Act (ACA). A systematic mapping review yielded 20 articles published in the last 10years on topics of insurance, emergency department usage, and pediatric asthma. Analysis indicates continued trends of increased emergency department use among asthmatic children since enactment of the ACA, running counter to the goal of fiscal efficiency for the healthcare system and reduction of health inequities. Barriers to care persist, particularly among communities of color, despite provisions to improve access to primary and preventive care. Inadequate access to primary care is associated with poor adherence among asthmatic children with public insurance. Those with health insurance through their parents' employer experience barriers due to cost-sharing expenses. This leads to increased asthma severity and low medication adherence, resulting in the need for emergency care. A disconnect between increased health insurance coverage and utilization of primary care in some populations implies unmet service needs that warrant further investigation. Findings inform policymakers and public health leaders of persistent health inequities resulting in preventable emergency department usage.

Comparison of Utilization, Costs, and Quality of Medicaid vs Subsidized Private Health Insurance for Low-Income Adults

There has been little rigorous evidence to date comparing public vs private health insurance. With policy makers considering a range of policies to expand coverage, understanding the trade-offs between these coverage types is critical. To compare months of coverage, utilization, quality, and costs between low-income adults with Medicaid vs those with subsidized private (Marketplace) insurance. This cross-sectional study used a propensity score-matched sample of adults enrolled in either Medicaid or Marketplace plans at any point between January 1, 2014, and December 31, 2015. The sample was restricted to individuals with incomes narrowly above and below 138% of the federal poverty level (FPL), which represented the eligibility cutoff between the programs. Data were obtained from 3 state agencies merging comprehensive insurance claims with income eligibility data for Colorado Medicaid expansion and Marketplace enrollees. Income data were linked with an all-payer claims database, and generalized linear models were used to adjust for clinical and demographic confounders. Participants included 8182 low-income nonpregnant adults aged 19 to 64 years enrolled in Medicaid or Marketplace coverage during the 2014 to 2015 period, with incomes between 134% and 143% of the FPL. Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. The primary analytical approach was a multivariate regression analysis of the propensity score-matched sample. Primary outcomes were months of coverage in Medicaid or Marketplace insurance, office and emergency department (ED) visits, ambulatory care-sensitive hospitalizations, and total costs. For secondary quality outcomes, the propensity score-matched sample was widened to 129% to 148% of the FPL to ensure adequate sample size. Secondary outcomes included prescription drug utilization, types of ED visits, hospitalizations, out-of-pocket costs, and clinical quality measures. Primary data analysis was between September 2018 to July 2019, with revisions finalized in November 2020. The propensity score-matched narrow-income sample included a total of 8182 participants (4091 Medicaid eligible [50%]: mean [SD] age, 42.8 [13.6] years; 2230 women [54.5%]; 4091 Marketplace eligible [50%]: mean [SD] age, 42.7 [13.9] years; 2229 women [54.5%]). Demographic differences across the 2 groups were well balanced, with all standardized mean differences less than 0.10. Marketplace coverage was associated with fewer ED visits (mean, 0.36 [95% CI, 0.32-0.40] visits vs 0.56 [95% CI, 0.50-0.62] visits; P < .001) and more office (outpatient) visits than Medicaid (mean, 2.22 [95% CI, 2.11-2.32] visits vs 1.73 [95% CI, 1.64-1.81] visits; P < .001). No differences in ambulatory care-sensitive hospitalizations were found (0.004 [95% CI, 0.001-0.006] vs 0.007 [95% CI, 0.002-0.011]; P = .15). Total costs were 83% higher in Marketplace coverage (mean, $4553 [95% CI, $3368-$5738] vs $2484 [95% CI, $1760-$3209]; P < .001) owing almost entirely to higher prices, and out-of-pocket costs were 10 times higher (mean, $569 [95% CI, $337-$801] vs $45 [95% CI, $26-$65]; P < .001). Five of 12 secondary quality measures favored private insurance, and 1 favored Medicaid. In this cross-sectional propensity score-matched study, Medicaid and Marketplace coverage differed in important ways. Public coverage through Medicaid was associated with more ED visits and fewer office visits than private Marketplace coverage, which may reflect barriers to outpatient care or lower cost-sharing barriers to ED care in Medicaid. Results suggest that Medicaid coverage was substantially less costly to beneficiaries and society than private coverage, with mixed results on health care quality.

State Standards for Insurance Access to Oncologists.

As the market for health insurance plans expands, each state is responsible for setting standards to ensure that plans contain adequate coverage for cancer care. Little is currently known about what criteria states use for network adequacy of insurance plans. We contacted representatives of the Department of Insurance (or equivalent) for 50 states and the District of Columbia, as well as searched official state websites to compile data on network adequacy standards for cancer care nationwide. The standards of 16 (31.4%) states contained only qualitative elements for access to an oncologist (eg, “reasonable access”), 7 (13.7%) states included only quantitative elements (eg, travel distance and time restrictions), and 24 (47.1%) states included standards with both qualitative and quantitative elements. Standards from 4 states were not available. States should make certain that robust, transparent protections exist to ensure that patients are able to access high-quality cancer care without experiencing the financial toxicity associated with out-of-network billing.

Redesigning Widespread Insurance Coverage Disputes: A Case Study of the British and American Approaches to Pandemic Business Interruption Coverage

In the 18 months since the pandemic’s onset in March 2020, businesses have filed approximately 2,000 different lawsuits in state and federal courts seeking insurance coverage under their business interruption policies. Notwithstanding this “nationwide flood of insurance-related litigation,” clear answers regarding insurers’ coverage obligations remain elusive: although courts have dismissed many of these cases, policyholders have scored a meaningful number of victories in federal, and especially state, courts. The United States’ chaotic and costly process for resolving pandemic-related business interruption coverage disputes contrasts sharply with the experience of the United Kingdom. Within eight months of the pandemic’s onset, the legal obligations of British business interruption insurers had been definitively resolved through a novel “test case scheme” led by the country’s primary market conduct regulator for financial firms, the Financial Conduct Authority (FCA). Focusing on these divergent experiences, this Article suggests that the U.S. can substantially improve its process for resolving future widespread insurance coverage disputes by adopting a limited reform that is inspired by the British test case scheme. In particular, the Article proposes that states should consider empowering their insurance department and attorney general to request that federal courts adjudicating cases raising novel coverage questions implicated in emerging and widespread coverage disputes certify those questions to the state’s supreme court.

An Efficient Traffic Incident Detection and Classification Framework by Leveraging the Efficacy of Model Stacking

Automatic incident detection (AID) plays a vital role among all the safety‐critical applications under the parasol of Intelligent Transportation Systems (ITSs) to provide timely information to passengers and other stakeholders (hospitals and rescue, police, and insurance departments) in smart cities. Moreover, accurate classification of these incidents with respect to type and severity assists the Traffic Incident Management Systems (TIMSs) and stakeholders in devising better plans for incident site management and avoiding secondary incidents. Most of the AID systems presented in the literature are incident type‐specific, i.e., either they are designed for the detection of accident or congestion. While traveling along the road, one may come across different types of traffic incidents, such as accidents, congestion, and reckless driving. This necessitates that the AID system detects and classifies not only all the popular traffic incident types, but severity as well that is associated with these incidents. Therefore, this study aims to propose an efficient incident detection and classification (E‐IDC) framework for smart cities, by incorporating the efficacy of model stacking, to classify the incidents with respect to their types and severity levels. The experimental results showed that the proposed E‐IDC framework achieved performance gains of 5%–56% in terms of incident severity classification and 1%–14% in terms of incident type classification when applied with different classifiers. We have also applied the Wilcoxon test to benchmark the performance of our proposed framework that reflects the significance of our approach over existing individual incident predictors in terms of severity and type classification. Moreover, it has been observed that the proposed E‐IDC framework outperforms the existing ensemble technique, such as XGBoost used for the classification of incidents.

Addressing National Workforce Shortages by Funding Child Psychiatry Access Programs.

* Abbreviations: CPAP — : Child Psychiatry Access Program PediPRN — : Pediatric Psychiatry Resource Network For decades, the medical community has been dealing with a shortage of child psychiatrists in the United States. A study published in Pediatrics in November 2019 demonstrated that although the number of child psychiatrists increased in the last 10 years, there are still not enough to meet demand, and counties in the United States with lower levels of income and education particularly struggle to meet demand.1 Thirty-six states have fewer than 10 child psychiatrists per 100 000 children, with only 3.3 child psychiatrists per 100 000 in the most extreme case.1 This imbalance translates into wait times of over 11 months for an appointment with a child psychiatrist in some areas.2 Furthermore, up to 20% of children in the United States have a mental health disorder, with suicide the second most common cause of death among 12 to 17 year olds.3 A commentary by David Axelson, MD,4 published alongside the Pediatrics study, called for innovation in the delivery of mental health services to children to leverage the existing workforce to make the greatest possible impact. Over the years, many proposed solutions have addressed the workforce shortage, including developing accelerated training pathways for child psychiatrists, recruiting nurse practitioners to the field, and expanding federal loan forgiveness programs, but the shortage has persisted despite these efforts. One … Address correspondence to Kathryn Sullivan, BA, Warren Alpert Medical School of Brown University, Box G-9040, Providence, RI 02912. E-mail: kathryn_sullivan{at}brown.edu

Zur Ersetzung des CHF-Libor durch den SARON Compound Index SAR3MC in laufenden

LIBOR interest rates will no longer be available from the end of 2021; this also applies to the 3M CHF-LIBOR, which is often used in practice in the context of sliding interest rate clauses. In a study carried out for the Bank and Insurance Department of the Austrian Chamber of Commerce Jankowitsch/Pichler examined the question of whether there are other comparable index values that could take the place of the 3M CHF-LIBOR. According to their findings, the SARON Compound Index SAR3MC is the primary substitute value. This paper examines from a legal point of view whether the 3M CHF-LIBOR can be replaced by SAR3MC in consumer credit agreements.

Designing a Knowledge Management Deployment Model with an Organizational Learning Approach

PurposeThe aim of this study was to design a knowledge management establishment model with an organizational learning approach in the Social Security Organization of North Khorasan Province.MethodologyThe research method was hybrid. The statistical population in the qualitative section included experts and specialists in management sciences and senior managers of the Social Security Organization, 20 of whom were selected using the principle of theoretical saturation as a non-probabilistic sampling method (purposeful and judgmental). In the quantitative part of the statistical population, including 1475 managers and employees of the Social Security Organization in the insurance and medical departments in 2016, who had at least a university degree with five years of service in the Social Security Organization, a sample of 314 people The two-stage stratified sampling method was selected with proportional allocation. The main research tool was the Knowledge Management Questionnaire, the validity of which was formally guaranteed using content and scientific components and components. The reliability of the questionnaire with Cranach’s alpha coefficient was 0.89 for knowledge management and 0.85 for organizational learning.FindingsAfter analyzing the information and testing the proposed model and the results obtained from structural equations, the final model of knowledge management deployment with 6 dimensions including (culture and value, organizational structure, organizational strategy, technology, process and human resources) and organizational learning It was finalized in 4 dimensions including (knowledge acquisition, knowledge dissemination, information interpretation and organizational memory). Also Findings showed that the human resources dimension has the greatest impact on the establishment of knowledge management and the two dimensions learning.ConclusionThe results also showed that organizational learning is effective at 0.74 on the establishment of knowledge management. Based on this, it can be concluded that in order to establish knowledge management in the Social Security Organization of Khorasan Razavi Province, in addition to paying attention to the six dimensions of establishing knowledge management, attention to organizational learning and its four dimensions, especially the two dimensions of knowledge acquisition and knowledge dissemination is necessary.

Effects of COVID-19 on the mental health of black and brown racialized populations in the U.S.

Effects of COVID-19 on the mental health of black and brown racialized populations in the U.S.

Age effect of antipsychotic medications on the risk of sudden cardiac death in patients with schizophrenia: A nationwide case-crossover study.

Research regarding the effects of age in patients with schizophrenia taking antipsychotics on the risk of sudden cardiac death is lacking. We determined the effect of patient age on the association between exposure to antipsychotics and the risk of sudden cardiac death in a nationwide schizophrenia cohort. From the Taiwan National Health Insurance Research Database and Department of Health Death Certification System, data of 1836 patients with schizophrenia who had experienced sudden cardiac death between 2000 and 2016 were included. A case-crossover design by using a 14-day window was applied, and subgroup analyses were performed by stratifying patients into three age subgroups (<45, 45-65, and >65 years) to assess the effect of age on the risk of sudden cardiac death in patients taking antipsychotics. No association between exposure to antipsychotic agents and sudden cardiac death risk was found in patients aged >65 years who were characterized by a high burden of medical illnesses. However, zotepine significantly increased the risk of sudden cardiac death in patients aged <45 years (adjusted relative risk [RR] = 2.68, P = 0.046). Flupentixol (adjusted RR = 5.30, P = 0.004) and risperidone (adjusted RR = 1.68, P = 0.01) significantly elevated the risk of sudden cardiac death in patients aged 45-65 years. This study suggests that individual antipsychotics pose different risks of sudden cardiac death in patients with schizophrenia across their lifespan. Clinicians should consider patient age when evaluating the risks and benefits of antipsychotic treatment.