Private Health Plans Research Articles

Rural Affordable Care Act outreach and enrollment: what we learned during the first marketplace open enrollment period.

As part of the Patient Protection and Affordable Care Act (Affordable Care Act) of 2010, 2 new opportunities for health care coverage were established for many uninsured individuals beginning on January 1, 2014. The first opportunity was through Medicaid expansion where states had the opportunity to expand Medicaid coverage to individuals with household incomes up to 133% of the federal poverty level. The second opportunity was through the establishment of Health Insurance Marketplaces where individuals could purchase private health plans and potentially qualify for financial assistance in paying for their plans. The Office of Rural Health Policy (ORHP) provided supplemental grant awards to help stimulate Affordable Care Act outreach and education efforts in rural communities that were being served by the Rural Health Care Services Outreach (Outreach) Grant Program. As a result, Outreach grantees enrolled 9,300 rural Americans during the initial Open Enrollment period. Valuable outreach and enrollment lessons were learned from rural communities based on discussions with the Outreach grantees who received the supplemental funding. These lessons will help rural communities prepare for the next Open Enrollment period.

Orphan drugs: expensive yet necessary.

Whether the prices of certain orphan treatments are justified is highly controversial. One argument is that such therapies should not be funded through the public purse or private health plans because a patient with a rare disease requires more than their 'fair share' of a limited health care budget. Orphan medications can also be denied because they fare poorly in the cost-effectiveness assessments of drugs. This paper takes the unusual line that life-saving treatments should be provided regardless of their cost. This contention is based on the Harvard philosopher John Rawls' theory of justice. We offer three rules to limit the use of cost-effectiveness approaches: efficiency assessments should not be deployed (i) when the choice is between an only treatment and no treatment, or to (ii) prioritise between different patients and patient groups. However a well considered cost efficiency calculation may have its place (iii) where a patient has a choice between two or more equally safe and effective treatments. We rebut potential objections to this analysis, and conclude that there has been a tendency to classify appeals for orphan treatments as a minority interest and in conflict with the aims of public health and society at large. Rawls' concept of societal justice shows that a distinction between the individual and society in this context is bogus. The funding of orphan therapies is as much a matter for public health as the funding of treatments for other conditions. Treatment must not be withheld on economic grounds.

More Doctors: Thoughts about a Controversial Health Care Policy

The recent economic downfall has affected health care systems worldwide, sparking renewed discussions about the need for major reforms in many countries. In the wake of social protests, the Brazilian government swiftly proposed reforms addressing the poor distribution and shortage of medical personnel in underserved communities. The topic has gained substantial laymedia attention, but most debates have been driven by political motivations, rather than consensus of public health experts. We use the case of Brazil to illustrate potential problems of hasty efforts to solve systemic issues without addressing the underlying causes that have led to insufficient training, scarce infrastructure, and lack of public engagement on decision making. Brazil, a country of 198,000,000 people, has a decentralized universal health care system in which states and municipalities manage health care services [1,2]. The “Unified Health System” is considered by many an exemplary model [3]. The country has a broad free vaccination program, and nearly all children receive the full schedule [3,4]. It hosts an internationally renowned program that provides universal access to HIV prevention and treatment services [3,5]. And recent substantial investments have been effective in decreasing cases of tuberculosis [6]. Maintenance of this large enterprise, however, is costly, and federal health care spending is minimal [3]. Despite an increase in the per capita expenditure on health from US $107 to US $466, it is still below the world average of US $599 [4]. In Latin America, Brazil is behind Argentina (US $489), Costa Rica (US $553), and Uruguay (US $619) [4]. Compared with developed countries, the gap is abysmal; for instance, The Netherlands spends US $4820 per person [4]. According to the World Health Organization, health care spending in Brazil represents approximately 9.0% of its gross domestic product [4], yet half of the expenditures predominantly benefit 20% of the population with access to private health plans [7]. One of the indexes the World Health Organization uses to determine whether the health workforce is sufficient to address a

Prevalence of self-medication and associated factors in an elderly population: a systematic review.

The aging of the world populat ion together with changes in the epidemiological profile of diseases have led to increases in both the consumption of medicines and health expenses. In this context, self-medication has gained importance as a rapid treatment that bypasses bureaucracy and, in some instances, delays in obtaining medical assistance. Verification of self-medication prevalence and associated factors in the elderly, as well as identification of the main categories of non-prescription drugs utilized. The following databases were utilized: Cochrane, PubMed, Scopus, LILACS, SciELO, PAHO, MedCarib and WHOLIS. Studies on the prevalence of self-medication in community-dwelling elderly were included. Review studies were excluded, as well as MSc dissertations, PhD theses and research with convenience sampling. Community-dwelling individuals aged 60 years or over. A systematic review of population-based articles published up until September 1, 2014, is presented. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Statement was applied for critical assessment of the articles, and those with a minimum score of 60% were selected for inclusion in the review. Thirty-six articles were selected, of which 28 were included after critical reading. The prevalence of self-medication varied between 4 and 87%, and the majority of studies reported values between 20 and 60%. The mean prevalence reported in the articles was 38%, but several criteria were utilized to measure self-medication. The most commonly utilized non-prescription drugs were analgesics and antipyretics, followed by non-hormonal anti-inflammatories, cardiovascular agents, dietary complements and alternative medicine components. The variables that presented positive associations with self-medication were female sex, visits to pharmacists, depression, functional dependency, recent hospitalization, oral pain, restriction of activities and physical inactivity. The variables with negative associations were medical appointments, married status, use of health services, satisfaction with living arrangements, living in institutional settings and private health plans. Different definitions of self-medication were employed in the identified articles, which hindered the comparison between studies and meta-analysis. Only 15 studies analysed associated factors and a minority carried out multivariate data analysis. Self-medication is frequent among the elderly, with different prevalence values found in the selected studies, probably because of heterogeneity in definitions and samples. Future studies are necessary, utilizing a standard self-medication criterion to facilitate comparison and elucidate the factors associated with this behaviour.

Impact of a value-based insurance design for back pain on health plan member satisfaction and its implications for patient outcomes.

Back pain is one of the most common reasons for seeking care, and physical therapy (PT) can be an effective treatment option. However, PT coverage for back pain varies widely among private health plans, usually requiring high cost sharing, thereby potentially leading to member dissatisfaction and worse outcomes. In this study, a quasi-experimental design was used to estimate the impact of a new value-based insurance design for back pain-related PT on selected Consumer Assessment of Healthcare Providers and Systems survey items. Under this design, eligible members receive a bundle of 5 PT sessions for a 1-time co-payment; if deemed necessary, the bundle is renewable for 1 additional co-payment. The results indicate that the proportion of members reporting the highest satisfaction rating was higher by about 6 to 10 percentage points among those who received the PT bundle. The data also indicate that those PT bundle members who reported the highest satisfaction rating had improvements in their functional status scores that were roughly 3 to 4 times higher than those who reported a lower satisfaction rating. These findings suggest that providing a value-based insurance design for back pain-related PT can potentially improve health plan members' care experiences and their overall satisfaction. Further study is needed to determine its impact on back pain-related medical care utilization and cost of care.

Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update

BackgroundThe Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013. Study designData for this study come from a subset of the 1842 women aged 18–39years who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice. ResultsBetween fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the intrauterine device. ConclusionsThe implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time. ImplicationsThis study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.

Medication oversupply in patients with diabetes.

Studies in integrated health systems suggest that patients often accumulate oversupplies of prescribed medications, which is associated with higher costs and hospitalization risk. However, predictors of oversupply are poorly understood, with no studies in Medicare Part D. The aim of this study was to describe prevalence and predictors of oversupply of antidiabetic, antihypertensive, and antihyperlipidemic medications in adults with diabetes managed by a large, multidisciplinary, academic physician group and enrolled in Medicare Part D or a local private health plan. This was a retrospective cohort study. Electronic health record data were linked to medical and pharmacy claims and enrollment data from Medicare and a local private payer for 2006-2008 to construct a patient-quarter dataset for patients managed by the physician group. Patients' quarterly refill adherence was calculated using ReComp, a continuous, multiple-interval measure of medication acquisition (CMA), and categorized as <0.80=Undersupply, 0.80-1.20=Appropriate Supply, >1.20=Oversupply. We examined associations of baseline and time-varying predisposing, enabling, and medical need factors to quarterly supply using multinomial logistic regression. The sample included 2519 adults with diabetes. Relative to patients with private insurance, higher odds of oversupply were observed in patients aged <65 in Medicare (OR=3.36, 95% CI=1.61-6.99), patients 65+ in Medicare (OR=2.51, 95% CI=1.37-4.60), patients <65 in Medicare/Medicaid (OR=4.55, 95% CI=2.33-8.92), and patients 65+ in Medicare/Medicaid (OR=5.73, 95% CI=2.89-11.33). Other factors associated with higher odds of oversupply included any 90-day refills during the quarter, psychotic disorder diagnosis, and moderate versus tight glycemic control. Oversupply was less prevalent than in previous studies of integrated systems, but Medicare Part D enrollees had greater odds of oversupply than privately insured individuals. Future research should examine utilization management practices of Part D versus private health plans that may affect oversupply.

A Boost for Central Auditory Processing Disorder Services

A Boost for Central Auditory Processing Disorder Services

Chlamydia screening for sexually active young women under the Affordable Care Act: new opportunities and lingering barriers.

The Affordable Care Act of 2010 (ACA) contains a provision requiring private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, preventive services recommended by US Preventive Services Task Force (grades A and B), among other recommending bodies. As a grade A recommendation, chlamydia screening for sexually active young women 24 years and younger and older women at risk for chlamydia falls under this requirement. This article examines the potential effect on chlamydia screening among this population across private and public health plans and identifies lingering barriers not addressed by this legislation. Examination of the impact on women with private insurance touches upon the distinction between coverage under grandfathered plans, where the requirement does not apply, and nongrandfathered plans, where the requirement does apply. Acquisition of private health insurance through health insurance Marketplaces is also discussed. For public health plans, coverage of preventive services without cost sharing differs for individuals enrolled in standard Medicaid, covered under the Medicaid expansion included in the ACA, or those enrolled under the Children's Health Insurance Program or who fall under Early, Periodic, Screening, Diagnosis and Treatment criteria. The discussion of lingering barriers not addressed by the ACA includes the uninsured, physician reimbursement, cost sharing, confidentiality, low rates of appropriate sexual history taking by providers, and disclosures of sensitive information. In addition, the role of safety net programs that provide health care to individuals regardless of ability to pay is examined in light of the expectation that they also remain a payer of last resort.

Making the Most of the Affordable Care Act's Contraceptive Coverage Mandate for Privately-Insured Women

Under the Patient Protection and Affordable Care Act of 2010 (ACA), most women of reproductive age with private health insurance have, or will soon have, first-dollar coverage of contraception and contraceptive counseling. The need for contraceptive coverage is great, because most American families want two children, resulting in the average woman spending three decades of her reproductive life trying to avoid pregnancy (Guttmacher Institute, 2012; Finer & Philbin, 2014). Contraceptive coverage without cost sharing is a sea change in women’s health insurance. This policy change has the potential to dramatically shift contraceptive use patterns, to reduce the U.S. unintended pregnancy ratedwhich stands at approximately half of all pregnancies (Finer & Zolna, 2014)dand to improve the health of women and families. In this commentary, we argue that realizing the potential of this policy change requires more action on the part of public health practitioners, insurers, health care providers, and researchers than is currently evident, andwe offer some suggestions for making the most of first-dollar contraceptive coverage.

Medicaid Politics: Federalism, Policy Durability, and Health Reform

Medicaid Politics: Federalism, Policy Durability, and Health Reform

AMA Approves Recommendations for Telemedicine

AMA Approves Recommendations for Telemedicine

The Berkeley Forum – A Roadmap for Improving Healthcare in California

Calif. J. Politics Policy 2014; 6(2): 207–224 Liora G. Bowers*, Richard M. Scheffler, Stephen M. Shortell and Brent D. Fulton The Berkeley Forum – A Roadmap for Improving Healthcare in California Abstract: The ACA’s passage was followed by great uncertainty about how the healthcare landscape would transform. During this tumultuous period, a unique group of California’s private sector health systems, medical groups and health plans, alongside public sector leaders, came together to help shape a more effective healthcare system. The Berkeley Forum, facilitated by the School of Public Health at the University of California-Berkeley, provided an opportunity for healthcare leaders to engage with peers and stakeholders in an intimate, collaborative manner, and address what they viewed as the largest threat – uncontrolled healthcare spending, detached from quality and outcomes. The group issued a report, endorsed by each of the private sector participants, containing far-reaching recommendations. The report’s central tenant is the “Forum Vision”, a rapid shift towards paying providers using risk- adjusted global budgets rather than fee-for-service, coupled with greater use of integrated systems that coordinate care across settings, providers and time. Implementation of the Forum Vision along with six other initiatives, such as increased physical activity and palliative care access, could reduce healthcare spending by $110 billion in the coming 10 years. Today, these high-level leaders continue to provide a unified voice to promote better health and higher-quality, affordable care for Californians. Keywords: accountable care organizations; cost curve; global budgets; health- care; integrated care; multi-stakeholder collaborative. DOI 10.1515/cjpp-2014-0020 *Corresponding author: Liora G. Bowers, University of California-Berkeley, School of Public Health, 50 University Hall, MC7360 Berkeley, California 94720, USA, e-mail: lgbowers@berkeley.edu; liora.bowers@gmail.com Richard M. Scheffler and Brent D. Fulton: Nicholas C. Petris Center on Health Care Markets and Consumer Welfare, School of Public Health, University of California-Berkeley, 50 University Hall, MC7360 Berkeley, California 94720, USA Stephen M. Shortell: University of California-Berkeley, School of Public Health, 50 University Hall, MC7360 Berkeley, California 94720, USA

Cobertura populacional do Sistema de Vigilância Alimentar e Nutricional no Estado de São Paulo, Brasil

This article sets out to estimate the population coverage of the Food and Nutrition Surveillance System (SISVAN) at different phases of life and to evaluate its operation in the state of Sao Paulo. The study included 65 cities divided in 14 state regions. The coverage of SISVAN was estimated using data from nutritional status monitoring available in public reports and on government websites, as well as the number of users attended by the public health services. Total users of public health services were obtained by the difference between the total number of inhabitants of 65 cities and the number of beneficiaries of private health plans. Most regions presented reduced population coverage (< 10%). Approximately 57% revealed population coverage of between 5 and 10%. There was a preponderance of records of the nutritional status of children for all regions of the state. A startling statistic was the low coverage for the elderly population, which was zero or near zero in most regions. Despite the efforts by the government to expand and enhance SISVAN, nutritional monitoring in Sao Paulo is still insufficient. This condition hinders the use of SISVAN to produce effective changes in food and nutrition policies.

Obama 2015 Budget Would Extend Medicaid Pay Bump

Many physicians would continue to see higher payments through 2015 for treating Medicaid ­patients under President Obama's proposed budget for the upcoming fiscal year. The budget request submitted to Congress March 4 includes $5.4 ­billion to extend the Affordable Care Act (ACA) provisions that pay physicians at Medicare levels for certain primary care services to Medicaid patients. Otherwise, the increase will end this year. Under the budget proposal, nurse practitioners and physician assistants also would be eligible for the higher payment rates. “Allowing [the higher rates] to expire would result in a deep, across-the-board cut to primary care physicians who are taking care of the most vulnerable populations, at a time when millions more are becoming eligible for Medicaid,” Molly Cooke, MD, president of the American College of Physicians (ACP), said in a statement. The budget proposes $77.1 billion in discretionary spending for Health and Human Services (HHS), down $1.3 billion from 2014. This includes investments in the primary care workforce, expanded mental health services, and continued implementation of the ACA insurance marketplaces. The president's budget also calls for Medicare cuts of more than $400 billion over 10 years. Proposed in previous budgets, these include payment cuts for inpatient rehabilitation facilities, long-term care hospitals, and home health agencies; reduction in Medicare coverage of hospitals’ bad debts; reductions to indirect graduate medical education payments; and payment cuts to critical-access hospitals. In addition, the budget would introduce readmission penalties for skilled nursing facilities and strengthen the controversial Independent Payment Advisory Board (IPAB). The proposal would require the IPAB to recommend cost-cutting targets to Congress if the Medicare growth rate exceeds gross domestic product plus 0.5 percentage points. Current law sets that level at GDP plus 1 percentage point. The 2015 budget proposal would increase investment in the primary care workforce. It requests more than $5 billion over the next decade to train 13,000 new residents as part of a new competitive grant program available to teaching hospitals, children's hospitals, and community-based consortia of teaching hospitals or other health care institutions. The budget also beefs up funding for the National Health Service Corps. It includes nearly $4 billion in new funding over 6 years to increase the number of health providers in rural areas and federally funded health centers to 15,000. And it would invest $4.6 billion in community health centers in 2015 and another $8.1 billion for the next 3 years. For mental health services, the budget includes $55 million for Project AWARE, which encourages community and school officials to work together to keep schools safe, refer students to mental health services, and provide mental health “first aid” training so that teachers can detect early signs of mental illness. The budget request includes $50 million to train about 5,000 new mental health professionals, $20 million to help young adults aged 16-25 years navigate behavioral health services, and $5 million to change attitudes about people who have behavioral health needs in the workplace. The budget also provides funding for a demonstration project in Medicaid to help reduce the use of psychotropic medications prescribed to children in foster care by improving access to other mental health services. The release of the president's budget request came just weeks before the end of open enrollment in private health plans through the ACA's marketplaces. The budget includes $1.8 billion in funding for 2015 to cover the cost of running the federally facilitated marketplace. However, most of the funding – $1.2 billion – would be covered by user fees from health plans in the marketplaces. If Congress fails to provide the remaining funds, HHS officials said they could transfer monies from other agency accounts to cover marketplace costs.

Answers to Your DSM-5 Questions

Answers to Your DSM-5 Questions

Is the negative evaluation of dental services among the Brazilian elderly population associated with the type of service?

This study aimed at identifying the prevalence of the negative evaluation of dental services among elderly Brazilians and at investigating whether the prevalence was higher among those using public or philanthropic provider services than among those paying privately or using private health plans. Additionally, factors associated with this negative assessment were identified. Interview and survey data were collected in the residences of participants by trained and calibrated examiners as part of a national epidemiological survey of oral health conditions of the Brazilian population in 2002/2003. The dependent variable was obtained in response to questions regarding whether the participant had ever used dental services, the frequency of use, and the quality of this service. Potential responses to the questions regarding the quality of service were very poor or poor, fair, and good or very good. The main independent variable was the system of health care used with potential responses being health plan or private, public, and philanthropic services. We conducted univariate (linear tendency χ2 test) and multiple descriptive analyses, and the partial proportional Odds model for ordinal logistic regression. Among the elderly, 196 (3.7%) evaluated the provided services negatively (very poor or poor). Participants with the following responses were more likely to evaluate the services negatively: those who had used public or philanthropic services, men, those with higher education, the ones who had not received information about preventing dental problems, those who perceived pain in their teeth and gums in the last six months, and those who self-reported their oral health and speech was poor. In conclusion, elderly Brazilian users of public and philanthropic services were more likely than users of private or insurance-based plans to evaluate their dental services negatively, regardless of the other investigated variables.

In Private Practice: 10 Steps to ICD-10

In Private Practice: 10 Steps to ICD-10

Inequities in access to health care in different health systems: a study in municipalities of central Colombia and north-eastern Brazil

IntroductionHealth system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia.MethodsA cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need.ResultsThere are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization.ConclusionsTwenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.

Equity of access to Pap smears: population-based study in Campinas, São Paulo, Brazil.

To determine the prevalence of the Papanicolaou exam among women aged 20 to 59 years in the city of Campinas (state of São Paulo, Brazil) and to analyze associations between this test and affiliation to private health insurance plans as well as socioeconomic/demographic variables and health-related behavior. To do so, a population-based, cross-sectional study was carried out. Statistical analyses took the study design into account. Despite the significant socioeconomic differences between women with and without private health plans, no differences between these groups were found regarding having been submitted to the Papanicolaou test. In fact no differences were found as to socioeconomic and health variables analyzed. Among all variables analyzed, only marital status was significantly associated with having undergone the test. The Brazilian public health system accounted for 55.7% of the exams. The present findings indicate social equity in the city of Campinas regarding the preventive exam for cervical cancer in the age group studied.