Type Of Health Care Coverage Research Articles

University of Nevada School of Medicine

University of Nevada School of Medicine

Perverse Incentives in the Medicare Prescription Drug Benefit

This paper analyzes some of the perverse incentives that may arise under the current Medicare prescription drug benefit design. In particular, risk adjustment for a stand-alone prescription drug benefit creates perverse incentives for prescription drug plans when making coverage decisions and/or for pharmaceutical companies when setting prices. This problem is new in that it does not arise with risk adjustment for other types of health care coverage. For this and other reasons, Medicare's drug benefit requires especially close regulatory oversight, now and in the future. We also consider a relatively minor change in financing the benefit that could lead to significant changes in how the benefit functions. In particular, if all plans were required to charge the same premium, there would be less diversity in quality, but also less need to regulate formulary composition, less budgetary uncertainty, and less upward pressure on drug prices.

Inhaled corticosteroids vs leukotriene receptor antagonists: health care costs across varying asthma severities

The burden of asthma is substantial, and the overall cost of its management is growing. To compare asthma-related charges and resource utilization across disease severity levels in the year after initial asthma treatment with any inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA). This was a longitudinal, retrospective cohort study of claims data from managed care plans in the United States. All patients had a new prescription for an ICS or an LTRA between January 1999 and December 2000 and were enrolled in a managed care plan for at least 12 months before (preindex) and 12 months after (postindex) the initial claim. Asthma-related charges, hospitalizations, emergency department (ED) visits, physician visits, and asthma medication use were compared between the 2 cohorts. Propensity scores were calculated to control for baseline differences in patient characteristics and types of health care coverage. Claims from 31,860 patients were evaluated. Total postindex asthma-related charges were significantly lower in the ICS cohort than in the LTRA cohort (dollars 613 vs dollars 902, respectively; P < .001), as were asthma-related pharmacy charges (dollars 305 vs dollars 564, respectively; P < .001). Results were consistent for all propensity subclasses and all age groups. Results from this cohort study suggest that, across varying disease severities, treating asthma with an ICS as initial controller therapy leads to less health care resource utilization than does using an LTRA as initial therapy.

What Do Consumers Want to Know about the Quality of Care in Hospitals?

To guide the development of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Hospital Survey by identifying which domains of hospital quality included in a survey of recent hospital patients, and which survey items within those domains, would be of greatest interest to consumers and patients. Primary data were collected in four cities (Baltimore, Los Angeles, Phoenix, and Orlando), from a demographically varied mix of people of whom most, but not all, had recently been hospitalized or had a close loved one hospitalized. STUDY DESIGN/DATA COLLECTION METHOD: A total of 16 focus groups were held in these four cities. Groups were structured to be homogeneous with respect to type of health care coverage (Medicare, non-Medicare), and type of recent hospital experience (urgent admission, elective admission, maternity admission, no admission). They were heterogeneous with respect to race/ethnicity, gender, and educational attainment. In addition to moderated discussions, focus group participants completed a pregroup questionnaire and various paper and pencil exercises during the groups. A wide range of features were identified by participants as being relevant to hospital quality. Many were consonant with domains and items in the CAHPS Hospital Survey; however, some addressed structural features of hospitals and hospital outcomes that are not best derived from a patient experience survey. When shown the domains and items being considered for inclusion in the CAHPS Hospital Survey, participants were most interested in items relating to doctor communication with patients, nurse and hospital staff communication with patients, responsiveness to patient needs, and cleanliness of the hospital room and bathroom. Findings were quite consistent across groups regardless of location and participant characteristics. Consumers and patients have a high degree of interest in hospital quality and found a very high proportion of the items being considered for the CAHPS Hospital Survey to be so important they would consider changing hospitals in response to information about them. Hospital choice may well be constrained for patients, but publicly reported information from a patient perspective can also be used to support patient discussions with facilities and physicians about how to ensure patients have the best hospital experience possible.

Characteristics of Individuals Who Fell While Receiving Home Health Services

Many patients receiving home health services are at risk for falling, but fall risk factors have not been previously investigated in this population. A retrospective record review was used to describe individuals who fell while being served by a home health agency. The 98 individuals who fell while receiving home health services were compared with a random sample of 98 subjects served by the home health agency during the same period who did not report falling. Subjects were compared by age, sex, days of receiving home health services, number of falls prior to admission to the home health agency, diagnosis, medication category, home health services received, and type of health care coverage. In the group with falls, causes of falls and interventions were described. The group with falls had comorbidities of neurological and cardiovascular impairment, took more medications associated with increased risk of falling, and had almost 3 times the number of falls prior to admission than the group without falls. Home care providers should consider medical history, medication usage, and fall history as risk factors for falls in the home environment.

The Effect of Health Care Coverage on Circumcision Rates Among Newborns

Social and personal biases are thought to have a role in the decision to circumcise newborns. However, economic factors such as the type of health care coverage may determine which parents are offered circumcision during the newborn period. Therefore, we examined the rates of newborn circumcision among patients with and without insurance at a midwestern community hospital and tertiary care center. A retrospective analysis of all patients undergoing circumcision at 2 different labor and delivery facilities between January 1997 and December 2001 was performed. Female gender, prematurity and all congenital anomalies comprised exclusion criteria. Circumcision rates were stratified by health care coverage and race. To assess characteristics of patients who did not undergo circumcision during the newborn period the indications for circumcision and insurance status were examined at a children's hospital. Health care coverage differed significantly between the 2 labor and delivery facilities. Medicaid or uninsured patients comprised approximately 72% of the population at the tertiary care facility and slightly less than 10% of the total deliveries at the community hospital. Despite the difference in health care coverage status, there was no statistically significant difference between the rates of circumcision among newborns. The circumcision rates were 81% (4,021 of 4,992 cases) and 82% (8,059 of 9,859) at the community and tertiary care facilities respectively. Similarly, there was no difference between circumcision rates when stratified by health care status or race. At the children's hospital there were 2 distinct populations seeking circumcision. Of Medicaid patients 87% younger than 3 years sought circumcision because they were denied circumcision during the newborn period. In contrast, adoption was cited 90% of the time as the reason for seeking circumcision in the privately insured patients. Although health care coverage may influence the indications for circumcision in older children, health care coverage does not appear to influence newborn circumcision rates in the Midwest.

Type of health care coverage and the likelihood of being screened for cancer.

This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

Utilization of Health Care for Infectious Illnesses at a Pediatric Practice 549

Objective: To determine the frequency of health care utilization for infectious illnesses in a pediatric practice and factors that affect utilization. Study Population: Children aged 6 weeks to 5 years who received health care at a large pediatric practice in Norfolk and Chesapeake, VA enrolled between 3/96 and 10/97 into an ongoing 3-year surveillance study. Methods: Attempts were made to enroll all age-eligible children in the practice. Demographic and medical history data were collected at enrollment and updated monthly. Office visit records were reviewed 2 weeks prior to enrollment for all children and when children were sick. Associations between parental education level and type of health care coverage on frequency of visits for illness were analyzed using Poisson regression analysis. Results: This analysis includes 506 (9%) of age-eligible children in the practice followed for 6618 child months (range 1-21 mos/child). 414 (82%) children had 1861 illness visits (mean 3.4/child-year) that resulted in 2526 diagnoses including 1615 (64%) that involved the upper respiratory tract. Otitis media (OM) was the most frequent primary diagnosis (21%) followed by uncomplicated upper respiratory infections (URI) (15%), sinusitis (4%), and Group A Streptococcus (GAS) pharyngitis (1%). 23% of diagnoses were combinations of the above. The mean number of visits for OM (1.0/child-year) was greater than for the other diagnoses (URI.6/child-year, sinusitis.1/child-year, GAS pharyngitis.06/child-year). 73% of parents had more than a high school education. 98% of families were covered by third party health insurance including: 82% by employer-administered health insurance(private insurance, HMO, PPO), Medicaid 9%, and CHAMPUS 7%. Children of parents with more than a high school education had more sick visits than parents with a high school education or less (Rate ratio=1.18, p=.002). Families with no insurance visited the physician the least often (Rate ratio=0.43, p=.008), followed by CHAMPUS (Rate ratio=.80, p=.03), private insurance, HMO, and PPO (reference group), and Medicaid (Rate ratio=1.13, p=.12). When level of education and type of health care coverage were adjusted, each influenced health care utilization (p<.03). Conclusions: Health care utilization in this pediatric practice was associated with type of health care coverage and parents' level of education. These findings may help target high-use and low-use groups of parents to improve appropriate health care utilization.

Health-Insurance Coverage for Adults With Diabetes in the U. S. Population

To compare the extent and types of health insurance coverage for adults with diabetes to coverage for those without diabetes in the U.S. population. Nationally representative samples of 2,405 adults with diabetes and 20,131 adults who were not known to have diabetes in the U.S. completed a questionnaire on current health insurance, including coverage through Medicare, private insurance, the military, and Medicaid and other public programs. Among all adults with diabetes, 92.0% have some form of health insurance, including 86.5% of those 18-64 years of age and 98.8% of those > or = 65 years of age. Approximately 41% are covered by more than one health insurance mechanism, but almost 600,000 people with diabetes do not have any form of health-care coverage. Little difference was found by type of diabetes in the proportion who have health insurance. Only small differences exist between people with diabetes and those without diabetes in the percentages covered and the types of health-care coverage. Government-funded programs are responsible for health-care coverage of 57.4% of adults with diabetes, including 26.4% of those 18-64 years of age and 96.0% of those > or = 65 years of age. Private health insurance is held by 69.3% of diabetic people. Lack of private insurance appears to be attributable primarily to lower income. Almost all patients with diabetes who are > or = 65 years of age have health-care coverage, but 13.5% of those 18-64 years of age have no health insurance. Few differences exist in coverage between individuals with and without diabetes. However, the absence of insurance should have a substantially greater impact on the ability of patients with diabetes to obtain services necessary for care of their disease, compared with those without diabetes. Government-funded insurance mechanisms cover a large proportion of diabetic patients, which indicates a significant societal burden associated with diabetes. Any changes in government reimbursement and coverage policies could have a major impact on health care for patients with diabetes.

Small business leaders' viewpoints on health care insurance: a marketing and social perspective.

A mail survey, which generated 270 responses from Virginia small business CEOs, reveals that the vast majority (95%) offer their full-time employees the opportunity to enroll in a health care insurance plan through their employer. The typical premium for employee-only coverage is from $75-99, and in 52% of the firms, the employer pays the entire cost. Employer-sponsored coverage of part-time employees is quite different, however, as the vast majority of the CEOs indicate a low percentage of these workers can enroll in a company health care plan, due to cost concerns. The CEOs feel hospitalization is the most important type of health care coverage to their employees as 93% rate it as being "very important" and 7% as "important." This rating is followed closely by the CEOs' perceived priority of coverage for lab and X-ray tests and for catastrophic costs, as 97% and 89%, respectively, feel these areas are "very important" or "important." In addition, over 80% of the CEOs rate three additional areas as having high importance, including prescription drugs, maternity care, and doctors visits and physicals. Overall, a generally high degree of satisfaction exists among the CEOs regarding their firm's health care insurance plan. However, while 90% feel "very satisfied" or "satisfied" regarding the coverage, and 82% feel similarly about the service, over 60% are "dissatisfied" or "very dissatisfied" regarding the cost. Regarding covering the health care costs of those who are uninsured, the CEOs feel an approximately equal role should be borne by four groups, namely the state and federal governments, employers of uninsured workers, and hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)