Uterus at a price: Disability insurance and hysterectomy.

Taiwanese Labor, Government Employee, and Farmer Insurance programs provide 5 to 6 months of salary to enrollees who undergo hysterectomies or oophorectomies before their 45th birthday. These programs create incentives for more and earlier treatments, referred to as inducement and timing effects. Using National Health Insurance data between 1997 and 2011, we estimate these effects on surgery hazards by difference-in-difference and bunching-smoothing polynomial methods. For Government Employee and Labor Insurance, inducement is 11-12% of all hysterectomies, and timing 20% of inducement. For oophorectomies, both effects are insignificant. Enrollees' behaviors are consistent with rational choices. Each surgery qualifies an enrollee for the same benefit, but oophorectomy has more adverse health consequences than hysterectomy. Induced hysterectomies increase benefit payments and surgical costs, at about the cost of a mammogram and 5 pap smears per enrollee.

Impact of Payer Constraints on Access to Genetic Testing.

BACKGROUND: With increased demand for hereditary cancer genetic testing, some large national health-care insurance payers (LNHPs) have implemented policies to minimize inappropriate testing by mandating consultation with a geneticist or genetic counselor (GC). We hypothesized such a restriction would reduce access and appropriate testing. METHODS: Test cancellation rates (ie, tests ordered that did not result in a reported test result), mutation-positive rates, and turnaround times for comprehensive BRCA1/2 testing for a study LNHP that implemented a GC-mandate policy were determined over the 12 months before and after policy implementation (excluding a 4-month transition period). Cancellation rates were evaluated based on the reason for cancellation, National Comprehensive Cancer Network testing criteria, and self-identified ancestry. A control LNHP was evaluated over the same period for comparison. RESULTS: The study LNHP cancellation rate increased from 13.3% to 42.1% ( P < .001) after policy implementation. This increase was also observed when only individuals who met National Comprehensive Cancer Network criteria for hereditary breast and ovarian cancer testing were considered (9.5% to 37.7%; P < .001). Cancellation rates increased after policy introduction for all ancestries; however, this was more pronounced among individuals of African or Latin American ancestry, for whom cancellation rates rose to 48.9% and 49.6%, respectively, compared with 33.9% for individuals of European ancestry. Over this same time period, control LNHP cancellation rates decreased or stayed the same for all subgroups. CONCLUSION: These findings demonstrate that a GC-mandate policy implemented by a LNHP substantially decreased access to appropriate genetic testing, disproportionately impacting minority populations without any evidence that inappropriate testing was decreased.

Insurance, risk, and magical thinking.

The possession of an insurance policy may not only affect the severity of a potential loss but also its perceived probability. Intuitively, people may feel that if they are insured nothing bad is likely to happen, but if they do not have insurance they are at greater peril. In Experiment 1, respondents who were reminded of their medical insurance felt they were less likely to suffer health problems in the future compared to people who were not reminded of their medical insurance. In Experiment 2a, participants who were unable to purchase travel insurance judged the probability of travel-related calamities higher compared to those who were insured. These results were replicated in Experiment 3a in a simulation of car accident insurance. The findings are explained in terms of intuitive magical thinking, specifically, the negative affective consequences of "tempting fate" and the sense of safety afforded by the notion of "being covered."