Private Health Maintenance Organization Research Articles

PP27 The Private Healthcare Responses Against COVID-19 Emergencies In Brazil

IntroductionThe Corona Virus Disease 2019 (COVID-19) pandemic is the biggest public health crisis of all time. Private health care plays a major role in health globally. We conducted a study to document the engagement of a Brazilian private health care organization to influence decisions to private and public health emergencies of COVID-19.MethodsThis retrospective study evaluated the outputs of the health technology assessment (HTA) group of Unimed-BH, a private Health Maintenance Organization (HMO) with 1.5 million participants in Belo Horizonte, Minas Gerais state. The study evaluated the impacts on the overview of health local decisions in the municipality and the national supplementary health agency (ANS) during the period from March 2020 to December 2022.ResultsDuring the pandemic, Unimed-BH made all its sanitary decisions based on scientific research, such as the use of masks and appropriate medications. Even though some medicines, such as regdanvimab, were authorized for emergency use by the Brazilian Health Regulatory Agency (ANVISA), Unimed-BH did not recommend their use due to uncertain evidence, and months later, ANVISA withdrew the registration.Unimed-BH also conducted a systematic review of ivermectin for COVID-19 treatment, which showed no effect, and therefore did not recommend its use. Additionally, Unimed-BH provided weekly updates on COVID-19 data, including suspected and confirmed cases, hospitalizations, and deaths in their customer portfolio. The organization also actively supported the decisions made by ANS and municipal managers using evidence and statistics on the pandemic. The Unimed-BH HTA group produced a total of 167 reports from March 2020 to December 2022.ConclusionsBelo Horizonte had the lowest in-hospital mortality rates with COVID-19 in Brazil. Unimed-BH’s HTA reports provided evidence-based assessments for decision-making, proposed partnership with policymakers, fomented information transparency, and strict follow-up on pandemic numbers, which may have contributed to the lower fatality rate in our city. These findings underscore the importance of private healthcare organizations in responding to COVID-19 emergencies, and their potential to support evidence-based decision-making and minimize the impact of the pandemic.

Association Between Hospice Enrollment and Total Health Care Costs for Insurers and Families, 2002-2018

Use of hospice has been demonstrated to be cost saving to the Medicare program and yet the extent to which hospice saves money across all payers, including whether it shifts costs to families, is unknown. To estimate the association between hospice use and total health care costs including family out-of-pocket health care spending. This retrospective cohort study of health care spending in the last 6 months of life used data from the nationally representative Medicare Current Beneficiary Survey (MCBS) between the years 2002 and 2018. Participants were MCBS participants who resided in the community and died between 2002 and 2018. Covariate balancing propensity scores were used to compare participants who used hospice (n = 2113) and those who did not (n = 3351), stratified by duration of hospice use. Total health care expenditures were measured across payers (family out-of-pocket, Medicare, Medicare Advantage, Medicaid, private insurance, private health maintenance organizations, Veteran's Administration, and other) and by expenditure type (inpatient care, outpatient care, medical visits, skilled nursing, home health, hospice, durable medical equipment, and prescription drugs). The study population included 5464 decedents (mean age 78.7 years; 48% female) and 38% enrolled with hospice. Total health care expenditures were lower for those who used hospice compared with propensity score weighted non-hospice control participants for the last 3 days of life ($2813 lower; 95% CI, $2396-$3230); last week of life ($6806 lower; 95% CI, $6261-$7350); last 2 weeks of life ($8785 lower; 95% CI, $7971-$9600); last month of life ($11 747 lower; 95% CI, $10 072-$13 422); and last 3 months of life ($10 908 lower; 95% CI, $7283-$14 533). Family out-of-pocket expenditures were lower for hospice enrollees in the last 3 days of life ($71; 95% CI, $43-$100); last week of life ($216; 95% CI, $175-$256); last 2 weeks of life ($265; 95% CI, $149-$382); and last month of life ($670; 95% CI, $530-$811) compared with those who did not use hospice. Health care savings were associated with reductions in inpatient care. In this population-based cohort study of community-dwelling Medicare beneficiaries, hospice enrollment was associated with lower total health care costs for the last 3 days to 3 months of life. Importantly, we found no evidence of cost shifting from Medicare to families related to hospice enrollment. The magnitude of lower out-of-pocket spending to families who enrolled with hospice is meaningful to many Americans, particularly those with lower socioeconomic status.

Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005–2015): a retrospective cohort study

Background/objectiveTrauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is...

Direct Medical Costs of Chronic Urticaria in a Private Health Organization of Buenos Aires, Argentina

BackgroundScarce studies address the issue of resource consumption and direct health care costs of patients diagnosed with adult-onset chronic urticaria (CU). ObjectivesTo estimate medical resource consumption and direct health care costs of affected patients in a private health maintenance organization in Buenos Aires, Argentina. MethodsPatients diagnosed with adult-onset CU (International Classification of Diseases, Ninth Revision, Clinical Modification code 708.1, 708.8, or 708.9) and who were members of the Italian Hospital Medical Care Program were included in the study. All data on hospitalizations, drug prescription, outpatient episodes, consultations, and investigations/tests in the 12 months before inclusion in the study were considered for the estimation of medical resource consumption and direct health care costs. Third-quarter 2014 costs were obtained from the Italian Hospital Medical Care Program and converted into US dollars (using the November 2014 exchange rate). ResultsA total of 232 patients were included in the study. The mean age at diagnosis was 54.2 ± 20.0 years, and the mean disease duration was 5.4 ± 2.6 years (range, 2–22 years). Of the total number of patients, 75% had allergists as their usual source of care, 23% had dermatologists, 18% had internists, and 3% had rheumatologists. Only 7.8% of the patients had an emergency room admission to manage CU symptoms. To manage the disease, 57.8% of patients used antihistamines and 11.6% used oral corticosteroids. The most relevant source of cost was the medical treatment received, followed by physician visits. The average yearly direct cost per patient was US $1015 ± $752 (95% confidence interval 803–2003). ConclusionsThis is the first Argentine study that evaluated the costs of CU considering the direct medical costs of the disease. The study provides information on resource utilization and the disease-related economic burden, which is valuable to better understand CU in the local setting. Future research that takes into consideration the direct and indirect costs of the disease will expand knowledge and improve management of the disease.

Admissions for CABG Procedure in the Elderly: Was There a Change in Access to Teaching Hospitals After 1997?

The purpose of the study is to identify patient attributes associated with teaching hospital admissions in the elderly for coronary artery bypass graft (CABG), and to determine whether admission patterns in teaching hospitals by vulnerable subgroups of the elderly changed during 1997 to 2001, a period with significant changes in CABG admission patterns and financial situation faced by teaching hospitals. The study sample comprises elderly residents in two states, New York and Pennsylvania, and uses Healthcare Cost and Utilization Project State Inpatient data of the Agency for Health Care Research and Quality. Patient characteristics in major teaching hospitals are compared with those in rest of hospitals in a logistic regression framework using a pre-/postdesign, and controlling for county characteristics and resources, distance to hospitals, and hospital size and volume of procedures. Significant patient characteristics associated with a higher likelihood of admission to teaching hospitals included racial/ethnic minority status, transfer cases, Medicaid and private health maintenance organization insurance. A lower volume of CABG cases and an increased propensity to admit more complex cases characterized the admission patterns in teaching hospitals during 1997 to 2001. Although higher use of teaching hospitals by racial/ethnic minorities persisted, access for Medicaid patients disproportionately declined.

Pregnancy Associated Smoking Behavior and Six Year Postpartum Recall

This study examined predictors and behaviors of pregnancy-related smoking among women who belonged to a private health maintenance organization and the recall accuracy of pregnancy-related smoking behaviors after 6-years. A cohort of 725 pregnant women was followed for six years. Major predictors for smoking behavior before, during, and one-year following pregnancy were determined. In addition, accuracy of recall six years postpartum of smoking behavior at the time of pregnancy and one-year postpartum was tested. Mother's education, asthma status, amount of pre-pregnancy smoking, gravidity, and father's smoking status were important in the prediction of pregnancy associated smoking. Agreement for recall of smoking behavior during pregnancy (6 year recall) and one-year postpartum (5 year recall) were 90% and 91%, respectively. Despite potentially adverse outcomes, a proportion of women continue to smoke throughout pregnancy. A number of variables proved to be important predictors of pregnancy associated smoking behavior. These factors should be considered by smoking cessation programs targeting women of reproductive age. Additionally, there was substantial agreement for maternal recall at six years postpartum of smoking behavior at the time of pregnancy and one-year postpartum. This should be considered in retrospective study designs that are primarily based on maternal recall of smoking behaviors before, during, and following pregnancy.

DO HMO PLANS REDUCE HEALTH CARE EXPENDITURE IN THE PRIVATE SECTOR?

I. INTRODUCTION Since the HMO Act was passed in 1973, health maintenance organizations (HMOs) have become one of the most popular types of managed care plans in the U.S. health delivery system. Faced with a dramatic increase in health care costs, HMOs are designed to implement a tight utilization review and authorization process, along with restricted choice of providers, as a means of managing utilization and quality. By comparing health care expenditure patterns of HMO members with those of non-HMO members among the privately insured, nonelderly population, this study seeks to understand the impact that HMOs have on health care expenditure in the private insurance sector. Our data come from the 2000 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the U.S. civilian, noninstitutionalized population. Despite the dramatic growth in the number and proportion of individuals enrolled in private HMO plans, much of existing research on this issue has focused on the relationship between HMO enrollment and use of health care services (Miller and Luft 1994, 2002), whereas only a limited number of studies have been conducted on the role of prevalent HMO enrollment in saving health care expenditure (Kralewski et al. 2000). Analyses on expenditure performance are mostly carried out on the performance of the Medicaid or Medicare managed care plans (Buchanan et al. 1996; Mello et al. 2002). This study extends previous research in several ways. First, rather than using localized or insurance, group-wise data (Johnson and Aquilina 1986; Kralewski et al. 2000; McLaughlin et al. 1983; McLaughlin 1987; Robinson 1996) or employer data (Baker and Corts 1996; Feldman et al. 1993), we use data provided directly by HMO members through nationally representative surveys. Second, by using decomposed expenditure data, we are able to ascertain whether the provision of financial incentives to both consumers and providers in HMO plans makes any differences in medical care expenditure by each party, compared with traditional plans. Furthermore, by testing the hypothesis of selectivity in health insurance choice, we try to avoid the biased findings that often find in favor of HMO plans. Trends and Relevance During the past two decades, the number of HMO enrollees has proliferated from 9.1 million (4% of the total population) in 1980 to 76.1 million (26.4%) in 2001 (Health, United States 2003). Between 1977 and 2001, the percentage of the U.S. population under age 65 that joined private insurance HMOs increased dramatically from 3.7% to 27.9% (Table 1). Over the same time period, per capita national health expenditure increased from $1,980 to $4,773 (in 1995 constant dollars), and total national health expenditure as a percentage of gross domestic product rose from 8.8% to 14.1%. Out of total national health expenditure, the share of private expenditure decreased from 57.3% to 54.1%. Motivated by the prevalence of HMOs in the private insurance market and the insufficiency in understanding its cost containment performance, we investigate the patterns of health care expenditure among HMO members to understand whether HMOs contribute to limiting medical expenditure relative to non-HMO arrangement. There are two main complications to our empirical analysis. The first is selection bias due to endogenous health plan choice decisions. Previous studies (Buchanan and Cretin 1986; Jackson-Beeck and Kleinman 1983) suggest that the utilization reduction effect of HMOs may be a consequence of the selective enrollment of a healthier population in HMO plans, rather than the more efficient medical care delivery management of HMOs. Thus, we first estimate the probit model of health insurance plan choice decisions and test this hypothesis in line with the analysis of Taylor et al. (1995). The second complication is that the dependent variables are nonnegative with a high frequency of zero observations. …

Association between Insurance Status and Admission Rate for Patients Evaluated in the Emergency Department

Abstract Objectives: To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. Methods: This was a retrospective, cross‐sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis‐related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for underinsured (self‐pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Results: Compared with the other insured group, underinsured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed underinsured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Underinsured patients with DRG of “menstrual and other female reproductive system disorders” (OR, 0.17; 95% CI = 0.06 to 0.51) or “esophagitis, gastroenteritis, and miscellaneous digestive disorders” (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Conclusions: Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single‐center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference.

Association between insurance status and admission rate for patients evaluated in the emergency department.

To determine if differences exist in hospital and intensive care unit (ICU)/operating room admission rates based on health insurance status. This was a retrospective, cross-sectional study of data from hospital clinical and financial records for all 2001 emergency department (ED) visits (80,209) to an academic urban hospital. Hospital admission and intensive care unit (ICU)/operating room admissions were analyzed, controlling for triage acuity, primary complaint, diagnosis, diagnosis-related group (DRG) severity, and demographics. Multivariate logistic regression models identified factors associated with hospital admission for under insured (self-pay and Medicaid) compared with other insured (private health maintenance organization, preferred provider organization, worker's compensation, and Medicare) patients. Compared with the other insured group, under insured patients were less likely, overall, to be admitted to the hospital (odds ratio [OR], 0.82; 95% CI = 0.76 to 0.90), controlling for all other factors studied. Subgroup analysis of common complaints showed under insured patients with a chief complaint of abdominal pain (OR, 0.67; 95% CI = 0.55 to 0.80) or headache (OR, 0.61; 95% CI = 0.39 to 0.95) had the lowest adjusted ORs for admission to the hospital, compared with other insured patients. Under insured patients with DRG of "menstrual and other female reproductive system disorders" (OR, 0.17; 95% CI = 0.06 to 0.51) or "esophagitis, gastroenteritis, and miscellaneous digestive disorders" (OR, 0.55; 95% CI = 0.28 to 0.96) also were less likely to be admitted compared with the other insured group. No significant differences in ICU/operating room admission rates were found between insurance groups. Whereas there was no difference in admission rates to the ICU/operating room by insurance status, this single-center study does suggest an association between insurance status and admission to a general hospital service, which may or may not be causally related. Factors other than provider bias may be responsible for this observed difference.

Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus.

Previous studies concerning disparities in Human Immunodeficiency Virus (HIV) services use among vulnerable groups did not control for specific clinical need for care such as symptom events. Using the Andersen Behavioral Model of Health Services Use, the authors determined whether minorities, women, and the less educated (vulnerable groups) were less likely to receive care for HIV symptoms. Persons enrolled in the HIV Cost and Services Utilization Study were asked whether they received care for their most bothersome symptom. Surprisingly, minorities and women were no more likely to go without care than other groups. Those with Medicaid, Medicare, private health maintenance organization (HMO) insurance, or no insurance were less likely to receive care for symptoms than those with private-non-HMO insurance. Vulnerable groups were no less likely to use services for HIV-related symptoms when need for care was considered. However, disparities may exist for symptom-specific care among HIV infected persons covered by public or HMO insurance.

Participation in research and access to experimental treatments by HIV-infected patients.

Although there is concern that minority groups and women are underrepresented in research involving patients with human immunodeficiency virus (HIV) infection, the available data are inconclusive. We used nationally representative data from the HIV Cost and Services Utilization Study to determine the characteristics of the participants and nonparticipants in trials of medications for HIV infection and whether or not patients had access to experimental treatments. A probability sample of 2864 persons, representing all 231,400 adults with known HIV infection who are cared for in the contiguous United States, were interviewed on three occasions between 1996 and 1998. They were asked about participation in clinical research studies of medications and past receipt of experimental medications for HIV. We estimate that 14 percent of adults receiving care for HIV infection participated in a medication trial or study; 24 percent had received experimental medications; and 8 percent had tried and failed to obtain experimental treatments. According to multivariate models, non-Hispanic blacks and Hispanics were less likely to be participating in trials than non-Hispanic whites (odds ratio for participation among non-Hispanic blacks, 0.50 [95 percent confidence interval, 0.28 to 0.91]; odds ratio among Hispanics, 0.58 [95 percent confidence interval, 0.37 to 0.93]) and to have received experimental medications (odds ratios, 0.41 [95 percent confidence interval, 0.32 to 0.54] and 0.56 [95 percent confidence interval, 0.41 to 0.78], respectively). Patients who were cared for in private health maintenance organizations were less likely to participate in trials than those with fee-for-service insurance (odds ratio, 0.43 [95 percent confidence interval, 0.21 to 0.88]). Women were not underrepresented in research trials and had a similar likelihood of receiving experimental treatments. Among patients with HIV infection, participation in research trials and access to experimental treatment is influenced by race or ethnic group and type of health insurance.

Strategic hospital alliances: impact on financial performance.

Acute care hospitals have increasingly been forming local strategic hospital alliances (SHAs), which consume considerable resources in forming and may affect the competitiveness of provider markets. This research shows that SHAs and market factors, which have been perceived to be threats to hospitals, are related to hospitals' financial performance. Among the findings are that SHA members have higher net revenues but that they are not more effective at cost control. Nor do the higher net revenues result in higher cash flow. However, increasing SHA penetration in a market is related to lower net revenues per case. In addition, the penetration of private health maintenance organizations in markets is associated with lower revenues and expenses.

The Future of the Department of Veterans Affairs

<h3>To the Editor.</h3> —The recent article by Drs Fisher and Welsh¹and the Editorial by Dr Pittman²illustrate that the future of the Department of Veterans Affairs (VA) is no less than the future of academic medicine. The future of both relies on solving the health care crisis, which itself is due to the following three main problems: escalating costs, lack of preventive health care for 40 million uninsured Americans, and the impending bankruptcy of academic medical centers.³ The VA's future is grim because of both demographic and financial considerations. The VA will soon lose its major patient base for the past 50 years—World War II and Korean War veterans now in their 60s and older. Even if the VA could lure more veterans and their families away from the private health care sector, it still faces the impossible task of competing with private health maintenance organizations

Pregnancy weight gain in adolescents and young adults.

We examined whether adolescents required greater prenatal weight gains than nonadolescents to deliver equal weight babies following a low-risk pregnancy. Maternal characteristics and monthly weight gains were collected from medical records obtained from a private health maintenance organization (n = 423). Maternal weight gain, gestational age, parity, and cigarette use during pregnancy were significant predictors of infant birth weight in our regression models. Subjects were nonsmokers with a gestational age greater than 37 weeks and a parity equal to 0 who entered prenatal care during the first trimester of pregnancy. Mean total weight gains for the adolescents (16.2 +/- 4.8 kg; n = 51) and adults (15.2 +/- 5.4 kg; n = 65), and infant birth weights were similar. Mean infant birth weight was 3473 +/- 394 g for the adolescents and 3339 +/- 453 g for the young adults, whereas the optimal weight range for newborns is about 3500-3999 g. Modifiable risks are the important predictors of infant birth weight, and adolescents do not appear to require a greater weight gain than young adults to deliver similar weight babies.

Regulated Competition: The Time Has Arrived

I 5 choice" proposal in a book entitled Health Plan: The 6' Only Practical Solution to the Soaring Cost of Medical k s Care (z). In the meantime, there has been wide acceptance of health care market strategies as well as tremendous growth in Health Maintenance Organizations (HMOs); but there has been very little done to promote "socially desirable competition" through government regulation (3). Given a choice among (i) direct government delivery of health services, (z) government regulation of private medical prices (rate setting) and the supply of private medical facilities (certificate of need), and (3) competition between private HMOs, as three archetypical methods of rationalizing health services and controlling health care costs, it is our judgment that the last option may be the best for the United States. Competition between HMOs (including staff, group and independent practice models) has a number of features which are very appealing: (i) the delivery of health care remains in the private sector, relatively distanced from bureaucratic and political entanglements; (z) capitation reimbursement provides a financial incentive for cost control; (3) providers of health care have the freedom and flexibility to innovate in services, facilities, equipment and personnel deployment; and (4) consumers have the ability to vote with their feet, keeping the health service delivery system sensitive and responsive to patient concerns. However, all of the potential advantages of HMO competition are for naught if HMOs are geared to maximize profits rather than promoting

Kaiser-Permanente: a model American health maintenance organization.

The Kaiser-Permanente medical care program, a prepaid group practice that has been operating in California for over 30 years, is one of the most successful Health Maintenance Organizations (HMOs) in the United States. Kaiser's membership in California, Portland, Hawaii, Denver, and Cleveland exceeds 2.5 million. The main success that HMOs can claim is cost reduction. Kaiser can provide a package of services at lower cost than identical services would cost in “mainstream” medicine. The way in which an HMO reduces cost is by lowering the use of services by its members. Kaiser members spend half as many days in the hospital as a similar population of Blue Cross/Blue Shield subscribers. But Kaiser also tends to lower the availability of services that are not presently performed in excess. Ambulatory care is not easily accessible-large numbers of patients complain of waiting several weeks for appointments, of receiving rushed impersonal treatment, and of being unable to find and keep a personal physician. Thus Kaiser cost reduction goes hand-in-hand with a general inaccessibility of services. The reason for this is the working of the profit motive. Whether for-profit or technically “nonprofit,” private corporations have always committed themselves to maximizing their income, reducing their expenditures, and using the surplus for expansion. The profit incentive leads private HMOs to limit services by hiring an inadequate number of physicians and other personnel so that patients will be discouraged from seeking care. In this way, expenses go down and surplus goes up. This is a revision of an article, “Kaiser Plan,” that appeared in the Health-PAC Bulletin, No. 55, pp. 1-18, November 1973.