Job-based health insurance, 1977-1998: the accidental system under scrutiny

This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research (AHCPR) in 1977, 1987, and 1996; and surveys of employers by the AHCPR in 1977, by the Health Insurance Association of America in 1988, and by KPMG Peat Marwick/Kaiser Family Foundation in 1998. During the study years, in 1998 dollars, the cost of job-based insurance increased 2.6-fold, and employees' contributions for coverage increased 3.5-fold. The percentage of nonelderly Americans covered by job-based insurance plummeted from 71 percent to 64 percent. This decline occurred exclusively among non-college-educated Americans. An information-based global economy is likely to produce not only greater future wealth but also greater inequalities in income and health benefits.     

The insurance gap and minority health care, 1997-2001

Gaps in access to medical care among working-age white Americans, African Americans and Latinos failed to improve between 1997 and 2001, despite a booming economy and increased national attention to narrowing and eliminating minority health disparities. African Americans and Latinos continue to have less access to a regular health care provider, see a doctor less often and lag behind whites in seeing specialists, according to recent findings from the Center for Studying Health System Change (HSC). Ethnic and racial disparities in access among uninsured Americans are much greater than disparities among the insured. Uninsured whites' greater financial resources may explain why they have fewer problems accessing care. Eliminating disparities in minority health care will be difficult without first eliminating these gaps in minority health insurance.     

Low-income Californians' experiences with health insurance and managed care.

California is rapidly implementing mandatory managed care for most of its Medicaid (Medi-Cal) beneficiaries. To assess the impact of this delivery system change, the authors analyzed a 1996 statewide population-based random-sample telephone survey of 3,563 adults between the ages of 18 and 64. Respondents with Medi-Cal managed care and Medi-Cal fee-for-service rated access to care and quality of care significantly higher than uninsured respondents yet lower than low-income privately insured individuals. While the authors did not find a difference in health care access and quality among Medi-Cal managed care enrollees compared with Medi-Cal fee-for-service enrollees, they also did not find that managed care provided any observed advantages to Medi-Cal recipients.     

The transfer of a health insurance/managed care business

The owners of a health insurance/managed care business may want to sell that business for a variety of reasons. Health care provider systems may want to exit that business due to operating losses, difficulty in complying with regulations, the inherent conflict in operating that business as part of a provider system, or the desire to focus on being a health care provider. Health insurers/HMOs may want to sell all or a portion of their business due to operating losses, difficulty in servicing a particular market, or a desire to focus on other markets. No matter what reason prompts a seller to undertake a sale, a sale of health insurance/managed care business can be a complicated transaction involving a multitude of issues. This article will focus first on the ways in which such a sale may be structured. The article will then discuss some transactional issues that may arise in the negotiations for the sale of a health insurance/managed care business. The article will then focus on some particular legal issues that arise in each sale-e.g., antitrust, HIPAA, regulatory approvals, and charitable issues. Finally, this article will provide an overview of tax structuring considerations.     

The doctor as double agent: information asymmetry, health insurance, and medical care

In a model incorporating uncertainty and state-dependent utility of health services, as well as information asymmetry between patients/buyers and physicians/sellers, two types of equilibria are compared: (1) when consumers have conventional third-party insurance and doctors are paid on the basis of fee-for-service; and (2) when insurance is through an HMO which provides health services through its own doctors. Conditions are found under which contractual or legal incentives can overcome the information asymmetry problem and bring about an efficient allocation of resources to health services provision.     

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.     

Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures

The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people.     

From managed care to consumer health insurance: the fall and rise of Aetna

This paper documents Aetna's fall as the nation's largest managed care plan and its subsequent reemergence as a smaller but more profitable multiproduct insurer. The paper emphasizes the transformation in corporate goals, product design, organizational structure, information technology, product mix, premiums, cash flow, net income, and share prices. Disciplined underwriting and pricing have restored the firm to profitability and set the foundation for new growth. The implications for the health care system as a whole are less unambiguously positive.     

Community rating and choice between traditional health insurance and managed care.

This paper analyses the consequences of allowing a choice between traditional insurance and managed care under community rating. A model of a competitive health insurance market is developed; with the risk equalization scheme being imperfect. There are two types of individuals who are characterized by different costs with respect to traditional insurance. Compared with a situation where traditional insurance is compulsory, allowing choice can make both types better off, can increase the utility of low-cost types at the expense of high-cost types, as well as having no effect. Inefficiencies under compulsory traditional insurance can be eliminated and new inefficiencies can be created. Market equilibria are not necessarily second best.     

管理型医疗保险方案与补偿型健康保险方案的比较研究

管理型医疗是已被国外普遍证实的控制成本、提高保险公司利润的一种卓有成效的保险方案.它要求保险人与保险计划的提供者更多的了解和掌握评价医疗服务的技能.它通过市场竞争和选择与医疗服务供方实现风险分担,由特定的组织结构和管理手段达到控制成本的目的,并取得几乎没有差别的医疗质量.传统的补偿型健康保险方案采用的是按服务项目付费的事后理赔计划.由于按服务项目付费的相关医疗决策几乎完全由医生和患者进行,且技术上很难确定合理的服务总量,这就在很大程度上增加了难以控制的道德风险.文章介绍了管理型医疗的定义及主要组织形式,着重从支付方式、医疗质量、合作医疗机构的选择等3个层面与传统的补偿型健康保险方案做了全面深入的比较研究.     

The impact of managed care on the existence of equilibrium in health insurance markets

This study examines the existence of equilibrium in insurance markets when the number of insurance policy attributes is increased (i.e., managed care is introduced). Individuals choose an insurance contract from an endogenous choice set. The introduction of managed care improves the ability of low risks to distinguish themselves from high risks. This may yield equilibrium in cases when it would not exist in an FFS-only environment. However, managed care expands the product space in which a pooling policy could break a separating equilibrium. Thus, existence of equilibrium in an FFS-only environment does not imply existence with managed care.     

Switching Swiss enrollees from indemnity health insurance to managed care: the effect on health status and stisfaction with care.

OBJECTIVES. In 1992, most members of a Swiss indemnity health insurance plan were automatically transferred into a newly created managed care organization. This study examined whether this semivoluntary change affected enrollees' health status and satisfaction with care. METHODS. Three groups of enrollees were compared: 332 plan members who accepted the switch (managed care joiners); 186 plan members who opted to maintain indemnity coverage (non-joiners); and 296 persons continuosly enrolled in another indemnity plan (indemnity plan members). Health status, health related behaviors, and satisfaction with care received in the previous year were surveyed at baseline and 1 year later. RESULTS. Health status remained unchanged in all three groups. Smoking prevalence decreased among managed care joiners but remained constant in the other groups. Satisfaction with insurance coverage increased between baseline and follow-up in managed care joiners, but decreased in nonjoiners and indemnity plan members. The latter groups had higher satisfaction with health care, particularly with continuity of care. CONCLUSIONS. A semivoluntary switch from indemnity health insurance to managed care reduced satisfaction with health care but increased satisfaction with insurance coverage. There were no changes in self-perceived health status.     

Kinder and gentler: physicians and managed care, 1997-2001

Despite the managed care backlash, an overwhelming majority of U.S. physicians continue to contract with managed care health plans. In fact, according to a new Center for Studying Health System Change (HSC) study, between 1997 and 2001 physicians reported a modest increase in the proportion of practice revenue from managed care contracts and the average number of contracts. At the same time, the nature of physicians' relationships with health plans changed, with a significant decrease in plans' use of capitation, or fixed monthly payments for each patient regardless of the amount of care provided. Meanwhile, physician practices moved away from using direct financial incentives to influence doctors' clinical decision making, but did experience an increase in the overall influence of treatment guidelines and other practices commonly associated with managed care.     

管理式医疗保险模式下的社区卫生服务

本文尝试将管理式医疗保险模式引入社区卫生服务,发挥管理式医疗保险在控制医疗费用增长方面的积相作用,根据Black—Scholes模型,构建和推导出最优保费期权定价公式。最后结合我国发展社区卫生服务的具体国情设计由社会保障部门作为管理式医疗保险组织者,从投保人个人账户中划出一部分资金购买社区卫生服务的管理式医疗保险模式。