Public Insurance System Research Articles

Public Liability Insurance

ABSTRACT Festivals in rural communities have their own unique ambience that can powerfully act as a catalyst for community development, stimulate community planning and mobilise communities towards tourism development (Getz & Frisby, 1988; Falassi, 1987; Pyo, 1995; Getz & Cheyne, 2001). Sudden increases in public liability insurance, however, have forced festival organisers to rethink the feasibility of hosting festivals in their communities. The problems currently besetting liability insurance are the result of interrelated factors to do with increasing claims, declining industry profitability and poor risk management practices. Investigations reveal that the cost of claims has been rising for many years. These costs have been driven by personal injury claims and underpriced insurance premiums during most of the 1990s. These trends, exacerbated by the collapse of the insurance giant HIH and the acts of terrorism in the United States on September 11, 2001, have impacted on the rural communities which in many cases, cannot afford to pay the higher insurance premiums. This paper examines the factors that have influenced the current circumstances of festival management in relation to the public liability insurance crisis in Australia. Its purpose is to provide an overview of the current state of the public liability insurance system available to festival organisers in Australia by investigating how the public liability crisis has emerged and to what extent it has impacted on the festival sector, particularly on rural communities that host them. The literature reviewed for this research has been drawn from diverse fields such as law, insurance, risk management, politics, tourism and event management. The research process was undertaken utilising an interpretive paradigm within a grounded theory ontology to explain the extent of the phenomenon. The research was conducted by making qualitative and quantitative analyses of data produced by a questionnaire which was administered via telephone. Discussions with the 82 respondents confirmed that the public liability insurance crisis has had a significant impact on festivals in rural Australia.

ドイツとオランダにおける知的障害者グループ・ハウジングに関する研究 : 公的介護保険制度国における知的障害者の住居水準と地域生活について(建築計画)

ドイツとオランダにおける知的障害者グループ・ハウジングに関する研究 : 公的介護保険制度国における知的障害者の住居水準と地域生活について(建築計画)

Protecting the Vulnerable: The Trade-Off Between Risk Reduction and Public Insurance

In a risky world, should governments provide public goods that reduce risk or compensate the victims of bad outcomes? We examine the allocation of public expenditures in the context of a risky environment between the provision of a public good with risk-reducing characteristics, and the expansion of a tax-financed public insurance system. We allow for the existence of a private insurance market as well, and therefore for the possibility of crowding out by a public insurance scheme. Nevertheless, we find there is scope for substantial spending on insurance, especially as risk aversion and the size of the total budget grows.

Low back pain after traffic collisions: a population-based cohort study.

A population-based, incidence cohort study was conducted. To measure the incidence and prognosis for collision-related low back pain before and after a change in the insurance compensation system. Low back pain is a common and costly occupational injury. It also occurs after traffic collisions, but less is known about its frequency and recovery in this setting. An incidence cohort of 4473 low back pain injury claims was formed between July 1, 1994 and December 31, 1995 in Saskatchewan. On January 1, 1995 the public insurance system changed from a tort system to a no-fault system, eliminating compensation for pain and suffering. The incidence of claims and the time to claim closure were calculated before and after this change. Prognostic models were built using baseline and follow-up data. The 6-month incidence of claims decreased from 256 to 176 per 100,000 after the insurance change. The median time to claim closure dropped from 505 days for tort claims to 210 days and 216 days for claims made during the first and second 6 months of the no-fault period. Improvements in bodily pain and physical functioning and the absence of depressive symptoms were associated with faster claim closure. High pain intensity, female gender, full-time employment, concentration problems, and lawyer involvement early in the claim process delayed claim closure. Low back pain is a common traffic injury with a prolonged recovery. Its incidence and prognosis are affected by multiple factors, including the type of compensation system. Our study suggests that biopsychosocial factors are important in determining prognosis.

Embarazo no deseado en adolescentes, y utilización de métodos anticonceptivos posparto

To describe the proportion of unwanted pregnancies among all pregnant adolescents, its association with sociodemographic characteristics, and the use of post-partum contraceptive methods. A cross-sectional study was conducted among 220 women between 13 and 19 years of age, in two semi-urban municipalities of the State of Morelos, Mexico, interviewed between 1992 and 1994. Women were interviewed at home, six to twelve weeks after their delivery date. Women were asked whether they had wanted their last pregnancy, and about knowledge and use of contraceptive methods after delivery. Adolescent pregnancies accounted for 17% of all births registered in these two municipalities. Among all adolescent mother 22.73% reported that their pregnancy had not been wanted. A positive association was found between the lack of access to health services provided by public medical insurance systems (Instituto Mexicano del Seguro Social IMSS and Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado ISSSTE) and unwanted pregnancy (adjusted OR = 3.03, 95% CI (1.31, 7.) An association was also found between living in an urban community (adjusted OR = 2.16, 95% CI (1.08, 4.33) and an unwanted pregnancy. Among all adolescent mothers, 91.3% were familiar with "the pill" as a contraceptive method; 84.72% knew about the IUD, and 63.68% knew about the condom. However, only 35% of them were actually using an effective contraceptive method six weeks after delivery. No difference in frequency of contraceptive use was found among the adolescent mothers, according to whether they wanted their last pregnancy. Only 43.39% of mothers who delivered at hospitals or health centers were using an effective contraceptive method. These findings suggest that there is a great potential for family planning programs to target adolescents, and that the use of contraceptive methods after delivery should be promoted among adolescent mothers, especially those lacking access to public medical insurance and those living in semi-urban settings. It is also recommended to conduct studies on family planning education programs that can be introduced earlier in the school system in Mexico.

Burden on family caregivers of frail elderly persons one year after the introduction of public long-term care insurance service in the Onga District, Fukuoka Prefecture: evaluation with a Japanese version of the Zarit caregiver burden interview

The present study was conducted to investigate the factors related to the feeling of psychological stress, called heavy burden, in caregivers who took care of frail elderly persons 1 year after the introduction of the public long-term care insurance system (i.e., kaigo hoken) in the northern part of Fukuoka Prefecture, Kyushu, Japan. Forty-seven caregivers answered a self-administered questionnaire involving the Japanese version of the Zarit Caregiver Burden Interview (ZBI) and thus described their own caregiving situation. Compared to caregivers with a light burden, heavily burdened caregivers were less likely to have time to go out without their frail elderly, but tended to spend a longer time with them in providing for their physical care. Compared with less burdened caregivers, heavily burdened caregivers tended to be concerned with what others thought or said and more likely to use a short-stay service (i.e., temporary nursing home assistance). More social services should be provided to let caregivers have their own time without caring for their patients. In addition, local governments and caremanagers should help caregivers to understand the benefits of services available for the elderly and their caregivers.

The German Public Pension System: How it Was, How it Will Be

Germany still has a very generous public pay-as-you-go pension system. It is characterized by early effective retirement ages and very high effective replacement rates. Most workers receive virtually all of their retirement income from this public retirement insurance. Costs are almost 12 percent of GDP, more than 2.5 times as much as the U.S. Social Security System. The pressures exerted by population aging on this monolithic system, amplified by negative incentive effects, have induced a reform process that began in 1992 and is still ongoing. This process is the topic of this paper. It has two parts. Part A describes the German pension system as it has shaped the labor market until about the year 2000. Part B describes the three staged reform process that will convert the exemplary and monolithic Bismarckian public insurance system after the year 2000 into a complex multipillar system. The paper delivers an assessment in how far these reform steps will solve the pressing problems of a prototypical pay-as-you-go system of old age provision, hopefully with lessons for other countries with similar problems.

The Current State of Neurosurgery in Japan

JAPAN HAS TWO large neurosurgical societies, the Japan Neurosurgical Society (JNS) and the Japanese Congress of Neurological Surgeons (Japanese CNS). The JNS was founded in 1948, and the Japanese CNS in 1981. The total number of neurosurgeons in Japan exceeds 7500, with 5432 board certified. There are 1340 training centers for neurosurgery in Japan; they are classified into two categories: Category A centers and Category C centers (training subcenters). For a neurosurgeon to be eligible to take the specialty board examination, he or she is required to have finished at least 6 years of training at a designated training center. A characteristic of Japanese neurosurgery is that neurosurgeons are engaged not only in surgical operations but also in various related activities, including performing radiological diagnostic procedures, such as angiography and endovascular surgery; working in the emergency room; and sometimes participating in neurorehabilitation and gamma knife treatment. In addition, a large number of neurosurgeons are engaged in research in various related fields. The JNS began to publish its official journal in 1948, initially in the Japanese language. Since 1990, the journal has been published exclusively in English (Neurologia Medico-chirurgica), whereas the official journal of the Japanese CNS is published in Japanese (Japanese Journal of Neurosurgery). Japan is blessed with advanced diagnostic and surgical technologies and instruments. They are available as needed throughout the country. Medical insurance is fully covered by the government or public insurance system; there is basically no private insurance in Japan. This article mentions socioeconomic problems relating to neurosurgical practice.

The Current State of Neurosurgery in Japan

JAPAN HAS TWO large neurosurgical societies, the Japan Neurosurgical Society (JNS) and the Japanese Congress of Neurological Surgeons (Japanese CNS). The JNS was founded in 1948, and the Japanese CNS in 1981. The total number of neurosurgeons in Japan exceeds 7500, with 5432 board certified. There are 1340 training centers for neurosurgery in Japan; they are classified into two categories: Category A centers and Category C centers (training subcenters). For a neurosurgeon to be eligible to take the specialty board examination, he or she is required to have finished at least 6 years of training at a designated training center. A characteristic of Japanese neurosurgery is that neurosurgeons are engaged not only in surgical operations but also in various related activities, including performing radiological diagnostic procedures, such as angiography and endovascular surgery; working in the emergency room; and sometimes participating in neurorehabilitation and gamma knife treatment. In addition, a large number of neurosurgeons are engaged in research in various related fields. The JNS began to publish its official journal in 1948, initially in the Japanese language. Since 1990, the journal has been published exclusively in English (Neurologia Medico-chirurgica), whereas the official journal of the Japanese CNS is published in Japanese (Japanese Journal of Neurosurgery). Japan is blessed with advanced diagnostic and surgical technologies and instruments. They are available as needed throughout the country. Medical insurance is fully covered by the government or public insurance system; there is basically no private insurance in Japan. This article mentions socioeconomic problems relating to neurosurgical practice.

Choosing Health Insurance in a Dual Health Care System: The Chilean Case

In Chile there is a public insurance system where people contribute a fixed percentage of their income, and also a private system where people pay a premium based on their personal characteristics. Using a large survey for 1996, we study the determinants of the decision to buy a private health plan. We find that the probability of buying a private health plan is positively correlated with income and living in areas with private health services providers. This probability decreases as families become older, and with a larger proportion of fertile age females. We also find that people who are more likely to demand health services prefer to buy a private health plan, and that people enrolled in a private health plan increase their use of health services. The segmentation observed in the health sector relates with the way private insurers and the public insurance system set their premiums.

Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States.

Ectopic pregnancy is a common condition with significant health consequences; complications are a major cause of maternal mortality in the United States. Accurate ascertainment of the number of ectopic pregnancies occurring in the United States has been dramatically affected by changing medical practices, causing estimates based on hospital data to be falsely low. This study was performed to identify nationally representative data on ectopic pregnancies and determine overlap of these data, to calculate the annual weighted number of ectopic pregnancies and confidence intervals for these estimates, and to determine barriers to estimation of ectopic pregnancy incidence. To assess whether a national estimate of the incidence of ectopic pregnancy could be calculated, we analyzed 1992-99 data from the six nationally representative data sets that include information on ectopic pregnancy. We examined relevant data in each data set and assessed whether any combination of data sets could be used to estimate ectopic pregnancy incidence. We calculated weighted estimates and 95% confidence intervals for hospitalizations, outpatient surgeries, outpatient medical procedures, and physician visits for and self-reports of ectopic pregnancy. Small sample sizes severely limited calculation of estimates of ectopic pregnancy. Data needed for assessing multiple counting was not available consistently. The likelihood of multiple counting of cases was substantial when data set counts were combined. A reliable incidence rate for ectopic pregnancy in the United States could not be estimated from existing nationally representative data sources. Major advances in diagnosis and treatment of ectopic pregnancy have affected surveillance in two ways: inpatient hospital treatment of ectopic pregnancy has decreased, and multiple health care visits for a single ectopic pregnancy have increased. Alternate means of surveillance are needed to improve understanding of risk factors and trends for ectopic pregnancy, and we recommend examination of the databases of public and private insurance systems and managed care systems. Similar alternate means of surveillance may be needed for other health conditions with comparable changes in management of care.

Severely disabled employees and their experiences with corporate policies concerning job retention. Selected results of an empirical study

While the public has been paying attention to the topics illness and disability with respect to public health, long-term care insurance and public old age insurance systems for years, the risk of becoming disabled at work has been considered less. Research in this area has for a long time been focused on questions regarding first-time entry and return to work of disabled persons into the regular labour market. Also, much policy research has tended to deny an active role of the enterprise as an independent player and creator of policy in the management of disability. Hence only little documentation of employers' programmes and strategies as well as analysis concerning the question of job retention is available. In order to cover the research deficit a study with regard to employment careers of severely disabled was conducted in Rhineland-Palatinate from 1997 to 1999. The study pursues two different paths: On the one hand living and working conditions of this group are analysed, on the other the study's purpose is to give an overview of employers' disability management practices from the severely disabled employees' point of view. This article deals with the results of the policies within the enterprise study. It concerns the analysis of the following issues: Does disability have a negative impact on the employees' careers? Which measures are preferred by the persons interviewed and why? The final question, whether the need for supporting measures ascertained may be satisfied by the existing instruments available under the German Severely Disabled Persons Act must be answered with a clear "No"! Employers and disabled employees need alternative measures of support.

The effect of public long-term care insurance plan on care management and care planning in Japanese geriatric hospitals

Japan, a society facing demographic aging at an incomparable speed, decided to introduce a new public long-term care insurance system to meet the expected need for elders to be cared for in the near future. The purpose of this study was to examine the change in knowledgeability on the side of managers of Japanese geriatric hospitals regarding (1) the concept of care-management as the methodology to supply care services to the elderly smoothly, and (2) comprehensive assessment for the elders as the technical skill in the process of materializing care management. Subjects were interviewed and questioned over the telephone according to a structural questionnaire. Managers (directors and office managers) of geriatric hospitals in 1996 and 1999. In 1996, the rate of knowledgeability for care management on the side of managers of geriatric hospitals was 70.0% (28/40) as a whole, increasing to 97.3% (71/73) in 1999. With regard to MDS-RAPs, the knowledgeability rate increased from 57.5% (23/40) in 1996 to 95.9% (70/73) in 1999. However, regarding care planning, almost all of the hospitals that performed care planning were those in the category required to submit care plans to the municipal government. Geriatric hospitals that were not required to submit such plans did not perform such planning either in 1996 or in 1999. It can be concluded that the decision to introduce a long-term care insurance system in Japan has led to a deeper understanding of the methodology of care management and a comprehensive assessment on the side of managers of geriatric hospitals.

The mandatory health insurance system in Chile: explaining the choice between public and private insurance.

In Chile, dependent workers and retirees are mandated by law to purchase health insurance, and can choose between private and public health insurance. This paper studies the determinants of the choice of health insurance. Earnings are generally considered the key factor in this choice, and we confirm this, but find that other factors are also important. It is particularly interesting to analyze how the individual's characteristics interact with the design of the system to influence choice. Worse health, as signaled by age or sex (e.g., older people or women in reproductive ages), results in adverse selection against the public health insurance system. This is due to the lack of risk adjustment of the public health insurance's premium. Hence, Chile's risk selection problem is, at least in part, due to the design of the Chilean public insurance system.

Time trends in obesity surgery 1987 through 1996 in Sweden--a population-based study.

The Swedish health-care system is well suited for surveys of incidence of surgical procedures including those for morbid obesity, since almost all hospital care is provided by public hospitals funded by a public health-care insurance system. The National Board of Health and Welfare keeps a nation-wide registry of all in-patient hospital care. In order to describe the practice of obesity surgery, we extracted data for all patients who had undergone obesity surgery between 1987 and 1996. 6,339 patients had at least one obesity surgery procedure between Jan. 1987 and Dec. 1996. A total of 7,176 procedures were identified. 77.2% were women, and the mean age was 39 years. Hospital stay averaged 8 days. There was a 3-fold increase in the annual incidence from 312 procedures/year in 1987 to 952 in 1996. 14% of the patients operated in1996 had previously undergone obesity surgery during the study period. The hospital mortality was 0.4%. Simple gastric restrictive procedures dominated (76%), and gastric bypass and jejuno-ileal bypass were performed in 7.5% and 5%, respectively. There was a trend that gastric bypass was performed more frequently towards the end of the study period. An increased number of procedures were performed in smaller hospitals during 1994-96, and there were obvious geographical variations. There has been 3-fold increase in obesity surgery in Sweden between 1987 and 1996, accounted for by increased performance of simple gastric restrictive procedures. The operative mortality is low, but the incidence of a second obesity surgery procedure is high.

“It's the Health-Care Costs, Stupid!”: Ideas, Institutions, and the Politics of Organized Labor and Health Policy in the United States

In 1978, organized labor formally abandoned its longstanding commitment to public-sector solutions to achieve universal health care. Over the following fifteen years, it embraced private-sector solutions premised on a government mandate that would require employers to pay a portion of their employees health insurance premiums. In many respects, this about-face on the part of organized labor is neither remarkable nor puzzling. After all, labor's prior commitment to national health insurance1. The term national health insurance has many meanings. As used here, it refers to health-care reform proposals modeled on the Canadian experience in which the government replaces private insurance with its own public insurance system, thus eliminating the commercial health insurers. Commonly referred to as “single-payer” plans today, proposals for national health insurance can vary enormously on important details like financing, budgeting, taxation, and the role of individual states. had coexisted with its deep and abiding attachment to the private welfare state of job-based benefits dating back to the 1940s.2. Donna Allen, Fringe Benefits: Wages or Social Obligation? (Ithaca, NY: Cornell University Press, 1964); Joseph W. Garbarino, Health Plans and Collective Bargaining (Berkeley: University of California Press, 1960); Raymond Munts, Bargaining for Health: Labor Unions, Health Insurance, and Medical Care (Madison: University of Wisconsin Press, 1967); Beth Stevens, “Labor Unions, Employee Benefits, and the Privatization of the American Welfare State,” Journal of Policy History 2 (1990): 233–60; and David Rosner and Gerald Markowitz, “Hospitals, Insurance, and the American Labor Movement: The Case of New York in the Postwar Decades,” Journal of Policy History 9 (1997): 74–95. American labor unionists have tended to be strident pragmatists compared to their European counterparts, who have been more consistently animated by a larger social democratic vision. Furthermore, American unions have a long history of deferring to the Democratic party.3. Indeed, some analysts characterize labor's relationship with the Democratic party as a “barren marriage” or “abusive relationship.” Mike Davis, Prisoners of the American Dream: Politics and Economy in the History of the U.S. Working Class (London: Verso, 1986), 52; and Joel Rogers, “The Folks Who Brought You the Weekend: Labor and Independent Politics,” in Audacious Democracy: Labor, Intellectuals, and the Social Reconstruction of America, ed. Steven Fraser and Joshua B. Freeman (Boston: Mariner, 1997), 255. Arguably, labor's support for national health insurance had been primarily rhetorical since the early 1950s, when the industrial unions began to rely on collective bargaining to achieve health-care security for their members. Once President Jimmy Carter and Sen. Edward Kennedy (D-MA) retreated from national health insurance in the face of the new anti-government, dereg- ulatory, deficit-conscious environment that emerged in the mid-to-late 1970s, one may conclude that labor “naturally” abandoned ship as well.

Market, Family, and State Sources of Income Instability in Germany and the United States

The public tax and transfer mechanisms of the welfare state are important sources of income stability for individuals and families. In comparisons of the stability of income in the United States and the states of the former West Germany, we found that household income tends to be more stable in Germany than in the United States. This disparity is partly due to greater turbulence in labor earnings in the United States and partly due to the more effective public social insurance system in Germany. These differences, however, are tempered by mechanisms that amount to a private, family-based insurance system in the United States, where, more so than in Germany, labor income from other family members and other, nonlabor sources of private income provide considerable stability.

Changing patterns of psychiatric inpatient care for children and adolescents in general hospitals, 1988-1995.

The authors examine patterns in utilization of psychiatric inpatient services by children and adolescents in general hospitals during 1988-1995. National Hospital Discharge Survey data were used to describe utilization patterns for children and adolescents with primary psychiatric diagnoses in general hospitals from 1988 to 1995. During the study period, there was a 36% increase in hospital discharges and a 44% decline in mean length of stay, resulting in a 23% decline in the number of bed-days, from more than 3 million to about 2.5 million. The number of nonpsychotic major depressive disorders increased significantly. Discharges from public hospitals have declined, and those from proprietary hospitals have risen. Concurrently, the role of private insurance declined and the role of Medicaid increased. During the period of study, the mean and median length of stay declined most for children and adolescents who were hospitalized in private facilities and those covered by private insurance. Across the United States, the mean length of stay declined significantly; this decline was almost 60% in the West. Discharges also declined in the West, in contrast to the Midwest and the South, where they significantly increased. Increased numbers of discharges and decreased length of stay may reflect evolving market forces and characteristics of hospitals. Further penetration by managed care into the public insurance system or modifications in existing Medicaid policy could have a profound impact on the availability of inpatient resources.

The impact of workers' compensation on wage premiums for job hazards

The existence of a trade-off between occupational risk and earnings is well known. Most studies, however, ignore how public insurance systems, like workers' compensation (WC) affect this trade-off. This paper incorporates the workers' compensation system into a hedonic earnings function for paid employees. The results show that workers' compensation lowers the wage-risk trade-off for a sample of Ontario workers. In the absence of workers' compensation, employees would receive a significantly higher risk premium for exposure to the possibility of occupational injuries. This implies that labour markets will provide more than the socially optimal degree of risk if experience rating of workers' compensation is incomplete.

Analysis of the Cost‐effectiveness of PhotodynamicTherapy in Early Stage Lung Cancer

Methods A cost-effectiveness analysis was carried out for photodynamic therapy (PDT) performed in early stage lung cancer cases, which by definition have no lymph node metastasis. The alternative treatment method was lobectomy, which conventionally would have been the first choice of treatment. Costs (C) and effectiveness (E) both of the PDT group and operation group were compared. Effectiveness was determined using quality adjusted life years saved (QALYs) which is the 5-year survival rate adjusted in terms of the quality of life of the patient, and the cost-effectiveness rate was obtained based on the costs of treatment methods during the patient's stay in the hospital. Health care costs, including drugs, were calculated according to the 1992 National Health Insurance list in yen. Costs which were non-reimbursable by the public insurance system, such as for special rooms and sun block cream, were also expressed in yen. Results The total cost of the operated group was ¥1,793,832 and that for the PDT group was ¥1,017,104. The cost-effectiveness rate of the operated group, that is the average cost of treatment per postoperative living month, was ¥37,537, while that of the entire PDT group was ¥30,003. This indicates that the cost-effectiveness rate for the operated group is apparently 1.3 times higher than that of the PDT group. The monthly cost-effectiveness rate for the PDT group of lesions smaller than 2 cm was ¥25,533. Therefore the cost in the operated group is 1.5 times higher. Conclusions This study demonstrated the merits of PDT for early stage lung cancer from the point of view of cost-effectiveness.