Low cognitive ability and poor skill with numbers may prevent many from enrolling in medicare supplemental coverage

Because traditional Medicare leaves substantial gaps in coverage, many people obtain supplemental coverage to limit their exposure to out-of-pocket costs. However, some Medicare beneficiaries may not be well equipped to navigate the complex supplemental coverage landscape successfully because of their lower cognitive ability or numeracy-that is, the ability to work with numbers. We found that people in the lower third of the cognitive ability and numeracy distributions were at least eleven percentage points less likely than those in the upper third to enroll in a supplemental Medicare insurance plan. This result means that many Medicare beneficiaries do not have the financial protections and other benefits that would be available to them if they were enrolled in a supplemental insurance plan. Our findings suggest that policy makers may want to consider alternatives tailored to these high-need groups, such as enhanced education and enrollment programs, simpler sets of plan choices, or even some type of automatic enrollment with an option to decline coverage.     

Effects of supplemental coverage on use of services by Medicare enrollees

This article estimates the extent to which private insurance supplements affect use of services by Medicare enrollees. Three types of supplements to Medicare's coverage are examined--Health Maintenance Organizations (HMOs), medigap (MGP) plans, and employment-based indemnity (EBI) plans. While each kind of supplement reduces cost sharing on Medicare-covered services, only HMOs do so without increasing enrollees' overall use of services. Use of services by HMO enrollees is about 4 percent lower than use by similar Medicare enrollees with no insurance supplement. By contrast, use of services by enrollees with MGP coverage is 28 percent higher, and use of services by enrollees with EBI plans is 17 percent higher.     

IPT coverage and determinants of care coverage in Tanzania

BACKGROUND:TB is a major cause of mortality worldwide, with the highest risk in people living with HIV/AIDS (PLWHA). Isoniazid preventive therapy (IPT), in combination with antiretroviral therapy (ART), reduces the overall incidence and mortality from TB by up to 90% among PLWHA. Tanzania has limited published data on IPT coverage among PLWHA.OBJECTIVE:To investigate coverage and determinants of IPT among PLWHA receiving care in selected care and treatment clinics in Dar es Salaam, Tanzania.METHODS:An analytical cross-sectional design to study 31,480 HIV-positive adults. Proportions and comparisons were obtained using χ² tests, while determinants for IPT were assessed using adjusted multivariable analysis.RESULTS:The IPT coverage among eligible PLWHA was generally low (28.9%), with increased coverage over time. The determinants for IPT coverage included age >36 years, having WHO Clinical Stages 1 and 2 compared to 3 and 4, and having normal weight, or being overweight and obesity compared to underweight.CONCLUSION:IPT coverage in Dar es Salaam is very low; individuals with minor HIV disease severity were more likely to initiate IPT. This shows a possible gap in the prescribing practices among healthcare providers. More efforts to ensure IPT coverage implementation in Dar es Salaam are required.     

The economic determinants of specialty choice by medical residents

This paper analyzes how economic factors (relative expected earnings, relative expected hours worked, and relative length of training period) affect the distribution of medical residents across specialties. The results show that the percent of residents in a given specialty changes more than proportionately when relative hours change (hours elasticities averaged between -1.2 and -2.0) and less than proportionately when relative earnings change (earnings elasticities averaged between 0.3 and 0.6). Residents appear to be quite unresponsive to changes in the length of training period.     

Social determinants of food choice

Food choice is influenced by a large number of factors, including social and cultural factors. One method for trying to understand the impact of these factors is through the study of attitudes. Research is described which utilizes social psychological attitude models of attitude-behaviour relationships, in particular the Theory of Planned Behaviour. This approach has shown good prediction of behaviour, but there are a number of possible extensions to this basic model which might improve its utility. One such extension is the inclusion of measures of moral concern, which have been found to be important both for the choice of genetically-modified foods and also for foods to be eaten by others. It has been found to be difficult to effect dietary change, and there are a number of insights from social psychology which might address this difficulty. One is the phenomenon of optimistic bias, where individuals believe themselves to be at less risk from various hazards than the average person. This effect has been demonstrated for nutritional risks, and this might lead individuals to take less note of health education messages. Another concern is that individuals do not always have clear-cut attitudes, but rather can be ambivalent about food and about healthy eating. It is important, therefore, to have measures for this ambivalence, and an understanding of how it might impact on behaviour.     

Sickness risk coverage of the poor and low income population

Among regimes of sickness risk coverage, those who are managed by the government to the profit of the poor and low income population offer advantages in nature, in the form of total exempt from payment or a strong subsidy of care in public sanitary structures of the ministry of public health. These two regimes, known as "Gratuitous Medical Assistance", existed under other names since the 1950's and has undergone various modifications that had all for objective to adapt the benefit of the gratuitous of care to the economic conditions and financial of the targeted population.     

Issues in the consumer choice of health care coverage plans

Developing and implementing successful marketing strategies for prepaid health care coverage plans is becoming an important issue as managers of these plans struggle to remain competitive in the market place. This paper provides insight into the reasons why consumers make choices among varying types of health care coverage plans. Some suggestions are made to plan managers for incorporating these results into the development of marketing strategies for prepaid health care coverage plans.     

Trends and determinants of contraceptive method choice in Kenya

This study uses data from the 1989, 1993, and 1998 Kenya Demographic and Health Surveys to examine trends and determinants of contraceptive method choice in Kenya. The analysis, based on two-level multinomial regression models, shows that, over time, the use of modern contraceptive methods, especially long-term methods, is higher in urban than in rural areas, whereas the pattern is reversed for traditional methods. Use of barrier methods among unmarried women is steadily rising, but the levels remain disappointingly low, particularly in view of the HIV/AIDS epidemic in Kenya. One striking result from this analysis is the dramatic rise in the use of injectables. Of particular program relevance is the notably higher levels of use of injectables among rural women, women whose partners disapprove of family planning, uneducated women, and those less frequently exposed to family planning media messages, compared with their counterparts who have better access to services and greater exposure to family planning information.     

The effectiveness of consumer choice in the Medicare supplemental health insurance market.

This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.     

The social class determinants of income inequality and social cohesion.

The authors argue that Wilkinson's model omits important variables (social class) that make it vulnerable to biases due to model mis-specification. Furthermore, the culture of inequality hypothesis unnecessarily "psychopathologizes" the relatively deprived while omitting social determinants of disease related to production (environmental and occupational hazards) and the capacity of the relatively deprived for collective action. In addition, the hypothesis that being "disrespected" is a fundamental determinant of violence has already been refuted. Shying away from social mechanisms such as exploitation, workplace domination, or classist ideology might avoid conflict but reduce the income inequality model to a set of useful, but simple and wanting associations. Using a nonrecursive structural equation model that tests for reciprocal effects, the authors show that working-class position is negatively associated with social cohesion but positively associated with union membership. Thus, current indicators of social cohesion use middle-class standards for collective action that working-class communities are unlikely to meet. An erroneous characterization of working-class communities as noncohesive could be used to justify paternalistic or punitive social policies. These criticisms should not detract from an acknowledgment of Wilkinson's investigations as a leading empirical contribution to reviving social epidemiology at the end of the century.     

Duplicate health insurance coverage: determinants of variation across states.

Although it is recognized that many people have duplicate private health insurance coverage, either through separate purchase or as health benefits in multi-earner families, there has been little analysis of the factors determining duplicate coverage rates. A new data source, the Survey of Income and Education, offers a comparison with the only previous source of state level data, the estimates from the Health Insurance Association of America. The R2 between the two sets is only .3 and certain problems can be traced to the methodology underlying the HIAA figures. Using figures for gross and net coverage, the ratio of total policies to people with private coverage ranges from .94 in Utah to 1.53 in Illinois. Measures of industry distribution, per capita income and employment explain a large portion of the variance, but it appears that these factors operate in opposite directions for group and non-group policies. Similar sociodemographic variables also explain net coverage. These findings have substantial implications for research and the structuring of employee health benefits.     

Prevalence and determinants of influenza vaccine coverage at tertiary pediatric hospitals

Despite long-standing recommendations, the uptake of influenza vaccination in children with high risk medical conditions is low. This study aimed to examine the uptake of influenza vaccination amongst a cohort of Australian children and factors associated with vaccine acceptance. Three hundred and sixteen parents of children attending outpatient clinics at the two pediatric hospitals in Sydney were recruited. The reported vaccination coverage rate was 41% among children with high risk conditions and 14% among standard risk children. There was a median of three clinic visits per high risk child at which an opportunity to vaccinate was apparently missed. Healthcare worker recommendation, having a high risk condition and parental beliefs about influenza and influenza vaccination were the most important determinants of vaccine uptake. Further studies on the beliefs and practices of doctors in this area will help guide interventions to improve vaccination rates in high risk children.     

Maternal determinants of timely vaccination coverage among infants in rural Bangladesh

Background

Timely vaccination, i.e., the receipt of all scheduled vaccinations in an age-appropriate fashion, is critical for the prevention of deadly diseases in infants and achievement of the UN Millennium Development Goal to reduce infant mortality. Infants, especially in rural or underprivileged settings often receive delayed vaccinations leaving them susceptible to vaccine-preventable illnesses early in the first year of life. In this study, we examined rates of timely vaccination among 24,435 infants born in Gaibandha and Rangpur rural districts of Bangladesh from 2001 to 2007.

Methods

Vaccinations due by 14 weeks of age and administered through routine government immunization services were assessed using interviews with enrolled mothers between 11 and 18 weeks postpartum. We created a Timely Vaccination (TV) score to classify infants as vaccinated fully and on schedule (TV = 1) or not (TV = 0), and used multivariable logistic regression to identify maternal characteristics associated with infant's timely vaccination status.

Results

Our results suggest that only 19% of infants in this cohort received scheduled vaccinations on time by 11–18 weeks postpartum. Mothers’ engagement in paid employment [OR = 1.13, 95% CI: 1.03–1.23], receipt of tetanus toxoid vaccination [OR = 1.24, 95% CI: 1.11–1.38], history of antenatal care [OR = 1.22, 95% CI: 1.12–1.32], or higher socioeconomic status [OR = 1.07, 95% CI: 1.03–1.11] were positively associated with timely vaccination of their infants. Mother's perception of small infant size at birth was negatively associated with timely vaccination [OR = 0.89, 95% CI: 0.82–0.97].

Conclusion

Timely vaccination coverage of infants in rural Gaibandha and Rangpur districts is extremely low. This analysis identifies important shortcomings associated with the 1-year vaccination benchmark of routine immunization performance and suggests the need for specific interventions based on potential maternal determinants as well as known system and programmatic barriers of timely vaccination among infants in rural Bangladesh.