Implementation Of New Mexico's 'No Behavioral Health Cost Sharing' Law: A Qualitative Study.

Out-of-pocket spending is a long-standing challenge for privately insured people. New Mexico passed the first US law prohibiting private insurers from applying cost sharing to behavioral health treatment, effective January 1, 2022. We examined the perceptions of key informants, including clinicians, insurers, and state officials, about implementing the No Behavioral Health Cost Sharing law to explore how it might affect downstream outcomes such as spending and access. The law was viewed favorably and implemented without much difficulty. Clinicians noted widespread positive impacts, particularly for those needing intensive treatment. However, they worried about workforce capacity and the exclusion of people covered under self-insured employer plans, which are exempt from state regulation under the Employee Retirement Income Security Act (ERISA) of 1974. Insurers found the law to be in alignment with their organizational goals, but they expressed concern about the administrative burden caused by increased reviews of claims, and some were monitoring for unintended consequences (for example, waste and fraud) that could lead to increased premiums. Engagement strategies were needed to inform eligible members and facilitate enrollment in eligible plans. The law provides a potential model for states to improve access to behavioral health care, but impacts may be limited by factors such as workforce, awareness, and federal ERISA constraints.

Redefining the "Public Option": Lessons from Washington State and New Mexico.

Policy Points States are enacting a host of policy initiatives designed to reduce the number of Americans without health insurance. Policymakers and policy analysts need to examine whether this "laboratory of federalism" is producing ideas that can and should be replicated on a national scale. This article evaluates reform efforts in two states: Washington state, which enacted what its policymakers call a "public option" and New Mexico, which failed in its effort to enact a Medicaid buy-in. Some common themes emerge. First, without federal funding, state efforts to aid the uninsured remain limited. Second, the gap between commercial and public insurance reimbursement rates poses an additional significant obstacle. Washington state was able to overcome these obstacles by enacting a law (called Cascade Care) which imposes public sector reimbursement rates in a commercial insurance market (the state's ACA Marketplace). This quasi- or redefined public option could become a politically viable model for federal policymakers.

Why Health Reforms Fail: Lessons from the 2014 Chilean Attempt to Reform.

In 2014, Chile started a process to reform its private health insurance scheme. A commission was created and released a report with recommendations, but no changes have been introduced yet. This article analyzes that reform process. The analysis included document review and interviews with key stakeholders involved in the process. Results show that although the Commission failed in producing the intended changes, it contributed to opening the debate regarding the Chilean health system, making explicit the different positions on the issue. The analysis shows that the reform did not advance because of the lack of basic consensus on the Commission's role, scope, and main purpose among stakeholders. Previous reforms highlight the relevance of time and information in creating a successful reform process.

Responsabilidad civil médica y contrato de seguro: sobre las cláusulas de delimitación temporal / Medical liability and insurance contract: about claims made clause

Resumen: El presente artículo tiene por objeto dar a conocer un particular tipo de cláusula que puede encontrarse en las pólizas de seguro por actividades profesionales: la cláusula de delimitación temporal llamada claims made. Ésta presenta múltiples problemáticas desde el punto de vista jurídico, que tienen directa incidencia en el ámbito práctico de la responsabilidad médica. Una de ellas, se produce en aquellos casos en que los siniestros no reciben cobertura de la compañía, aun estando vigente y debidamente pagada la póliza por el asegurado, debiendo asumirse el pago de la indemnización por el propio médico frente a la víctima.

Abstract: The purpose of this paper is to present a particular type of clause that can be found in an insurance contract related to professional activities: the claims made clause. This clause presents multiple legal problems which have a direct impact on the practical application in the medical liability. One of these occurs in cases where the damage is not covered by the insurance company even if the policy has been properly paid by the insured, and the compensation must be paid by the doctor to the victim.

Regulating self-selection into private health insurance in Chile and the United States.

In the 1980s, Chile adopted a mixed (public and private) model for health insurance coverage similar to the one recently outlined by the Affordable Care Act in the United States (US). In such a system, a mix of public and private health plans offer nearly universal coverage using a combined approach of managed competition and subsidies for low-income individuals. This paper uses a "most different" case study design to compare policies implemented in Chile and the US to address self-selection into private insurance. We argue that the implementation of a mixed health insurance system in Chile without the appropriate regulations was complex, and it generated a series of inequities and perverse incentives. The comparison of Chile and the US healthcare reforms examines the different approaches that both countries have used to manage economic competition, address health insurance self-selection and promote solidarity. Copyright © 2015 John Wiley & Sons, Ltd.

Physician Attitudes Toward Adult Vaccines and Other Preventive Practices, United States, 2012.

OBJECTIVES: We described the following among U.S. primary care physicians: (1) perceived importance of vaccines recommended by the Advisory Committee on Immunization Practices relative to U.S. Preventive Services Task Force (USPSTF) preventive services, (2) attitudes toward the U.S. adult immunization schedule, and (3) awareness and use of Medicare preventive service visits. METHODS: We conducted an Internet and mail survey from March to June 2012 among national networks of general internists and family physicians. RESULTS: We received responses from 352 of 445 (79%) general internists and 255 of 409 (62%) family physicians. For a 67-year-old hypothetical patient, 540/606 (89%, 95% confidence interval [CI] 87, 92) of physicians ranked seasonal influenza vaccine and 487/607 (80%, 95% CI 77, 83) ranked pneumococcal vaccine as very important, whereas 381/604 (63%, 95% CI 59, 67) ranked Tdap/Td vaccine and 288/607 (47%, 95% CI 43, 51) ranked herpes zoster vaccine as very important (p<0.001). All Grade A USPSTF recommendations were considered more important than Tdap/Td and herpes zoster vaccines. For the hypothetical patient aged 30 years, the number and percentage of physicians who reported that the Tdap/Td vaccine (377/604; 62%, 95% CI 59, 66) is very important was greater than the number and percentage who reported that the seasonal influenza vaccine (263/605; 43%, 95% CI 40, 47) is very important (p<0.001), and all Grade A and Grade B USPSTF recommendations were more often reported as very important than was any vaccine. A total of 172 of 587 physicians (29%) found aspects of the adult immunization schedule confusing. Among physicians aware of "Welcome to Medicare" and annual wellness visits, 492/514 (96%, 95% CI 94, 97) and 329/496 (66%, 95% CI 62, 70), respectively, reported having conducted fewer than 10 such visits in the previous month. CONCLUSIONS: Despite lack of prioritization of vaccines by ACIP, physicians are prioritizing some vaccines over others and ranking some vaccines below other preventive services. These attitudes and confusion about the immunization schedule may result in missed opportunities for vaccination. Medicare preventive visits are not being used widely despite offering a venue for delivery of preventive services, including vaccinations.

[Genetic testing, prevention and health care insurance markets]. / Tests génétiques, prévention et marchés d'assurance santé

Since this special issue of medecine/sciences is devoted to personalized medicine, it seems unnecessary for two economists to summarize or discuss, from a medical perspective, recent advances in genetic research. We rather focus on the consequences of improved genetic testing on the health insurance market, on how this market may be affected and on the degree of coverage offered to consumers according to the regulations implemented. More precisely, we first study the value of the information conveyed by genetic tests and we then decompose this value into several components according to the regulations implemented in various health insurance markets.

Concept and measurement of pediatric value.

In the new health care marketplace, families will be making important decisions concerning choice of health plan, health provider, and even accountable care organizations. Ideally, they would make these decisions using information on health care value, which comprises the relationships between patient/family-centered outcomes (the outputs of health care services) and costs of providing care to achieve these outcomes. Providing information on pediatric value will require new investments in data collection systems that include outcomes that matter to children and families and costs measured at the level of the child. The analysis of these data must account for the perspective of the user of the information. In the case of families, direct standardization should be used to contrast care in one health care system with another according to the unique characteristics of each family and child.

[Complaints by private health insurance policy-holders to the Consumer Protection Bureau in Argentina, 2000-2008]. / Las denuncias de los afiliados de las empresas de medicina prepaga presentadas ante la Subsecretaría de Defensa del Consumidor en Argentina, 2000-2008.

This paper analyzes problems experienced by policy-holders of voluntary private health insurance plans in Argentina when insurance companies fail to comply with the Consumer Protection Code. The sample consisted of consumer complaints filed with the Consumer Protection Bureau and rulings by the Bureau from 2000 to 2008. One striking issue was recurrent non-compliance with services included in the Mandatory Medical Program and the companies' attempts to blame policy-holders. According to the study, the lack of an information system hinders scientific studies to adequately address the problem. Thus, a comparison with studies on health insurance in other Latin American countries highlighted the importance of such research, the relationship to health systems, constraints on use and denial of citizens' rights to healthcare, and the increasing judicialization of healthcare provision.

Las denuncias de los afiliados de las empresas de medicina prepaga presentadas ante la Subsecretaría de Defensa del Consumidor en Argentina, 2000-2008 / Complaints by private health insurance policy-holders to the Consumer Protection Bureau in Argentina, 2000-2008 / As denúncias de afiliados às empresas de planos e seguros privados de saúde encaminhadas à Subsecretaría de Defensa del Consumidor na Argentina, 2000-2008

El trabajo analiza los problemas de los afiliados a las empresas de medicina prepaga en Argentina cuando las mismas incumplen con la Ley de Defensa del Consumidor. El universo de estudio se conformó por las denuncias de los afiliados durante los años 2000-2008, ante la Subsecretaría de Defensa del Consumidor de la Nación, y por las disposiciones y laudos emitidos por la misma. Un aspecto conclusivo es la recurrencia de los incumplimientos en las prestaciones del Programa Médico Obligatorio y los argumentos expuestos por las empresas, centrados en la responsabilización de los afiliados. Se advierte que la falta de un sistema de información a nivel nacional impide la realización de estudios empíricos que reflejen adecuadamente el problema. La discusión se realiza a partir de estudios sobre los seguros privados de salud en otros países de la región. Sobre ello se observa la importancia de estudiar a las empresas de medicina prepaga, su articulación con el sistema de salud, y los procesos de limitación y negación de la ciudadanía, así como la creciente judicialización de la salud.

This paper analyzes problems experienced by policy-holders of voluntary private health insurance plans in Argentina when insurance companies fail to comply with the Consumer Protection Code. The sample consisted of consumer complaints filed with the Consumer Protection Bureau and rulings by the Bureau from 2000 to 2008. One striking issue was recurrent non-compliance with services included in the Mandatory Medical Program and the companies’ attempts to blame policy-holders. According to the study, the lack of an information system hinders scientific studies to adequately address the problem. Thus, a comparison with studies on health insurance in other Latin American countries highlighted the importance of such research, the relationship to health systems, constraints on use and denial of citizens’ rights to healthcare, and the increasing judicialization of healthcare provision.

O artigo analisa os problemas dos usuários das empresas de planos e seguros privados de saúde na Argentina quando as mesmas não cumprem com a Lei de Defesa do Consumidor. O universo de estudo foram as reclamações dos usuários durante os anos 2000-2008 encaminhadas à Subsecretaría de Defensa del Consumidor, e as disposições e os laudos emitidos pela Subsecretaría. Um aspecto conclusivo é a recorrência do não cumprimento dos serviços do Programa Médico Obrigatório e o argumento das empresas centrado na responsabilização dos usuários. Avalia-se que a falta de um sistema de informação dificulta estudos empíricos que reflitam adequadamente o problema. Assim, com base em estudos sobre empresas de planos e seguros de saúde em outros países da América Latina, observa-se a importância de realizar estudos sobre as mesmas, sua relação com os sistemas de saúde e os processos de limitação e negação da cidadania e da crescente judicialização da saúde.

[Private health insurance systems, constitution and the right to receive an equitable health care]. / Isapres, tribunal constitucional y distribución del derecho a cuidado sanitario.

This paper analyzes the constitutional problems that the private health system has faced as a result of the recent decisions of the Constitutional Court and the Supreme Court of Chile in defense of the right to health care and nondiscrimination. It also reviews the comparative literature on health systems that have been successful in the task of reconciling the demands of equity and efficiency in the delivery of health care in the private health sector, in accordance with the constitutional principles of equality and nondiscrimination.

Health reform and the US Virgin Islands: high-need-limited impact.

OBJECTIVES: There are 4.1 million residents living in the US territories, which is more than the combined population of many US states, yet the territories and their citizens are often overlooked from a policy perspective, because most individual territories are relatively small, geographically isolated, and have been treated differently than the states historically. This tendency to fall beneath the radar is clear in the realm of health policy, especially in the area of insurance coverage. This article provides an initial assessment of the potential impact of health reform on the US Virgin Islands (USVI) and, in light of this assessment, considers how the results of a USVI household survey conducted in 2003 and 2009 might be used as a baseline for future monitoring of the impact of national reform. METHODS: A study by the Virgin Island's Bureau of Economic Research, Office of the Governor, and the University of Minnesota, was conducted in 2003 and 2009. The Virgin Islands Health Insurance telephone Surveys were random digit dial landline telephone surveys of households in the USVI. A stratified sample was drawn to produce precise estimates of insurance coverage for the USVI as a whole and for the 3 islands separately. RESULTS: Almost one-third of the residents (28.7%) in the Virgin Islands were uninsured in 2009. This rate is twice the US average (15.4%) and significantly higher than the uninsured rate of 24.1% when a similar survey was last conducted the Virgin Islands in 2003. CONCLUSIONS: The Patient Protection and Affordable Care Act of 2010 provides special funding to the territories through a mix of increased Medicaid caps for each territory and the provision of premium subsidies through newly established health insurance exchanges to low-income populations. However, the Affordable Care Act's Medicaid expansions to newly eligible adults--primarily adults without children--are limited to current eligibility levels in the territories, which is $5,500 in annual income for adult coverage in the USVI. Within these abbreviated parameters, the Medicaid expansion can go so far only toward mitigating uninsurance among the lowest income groups in the territories. With certain low-income childless adults overlooked, the Affordable Care Act does not fully address the high need for affordable health insurance coverage in the territories.

Análisis del modelo de Salud de la Provincia de La Rioja, explorando la viabilidad de su extensión hacia un Seguro Universal de Salud / Analysis Model of Health of the Province of La Rioja, exploring the feasibility of its extension to a Universal Health Insurance

El Seguro Universal de Salud es una alternativa que puede implementar en el sistema salud, una región o país, en búsqueda de una estrategia para aumentar la cobertura de salud de sus habitantes. La Provincia de La Rioja funciona bajo parámetros de universalidad en su sistema público de salud. La presente investigación intenta realizar un análisis del modelo sanitario provincial, bajo aspectos básicos para el funcionamiento de un sistema universal de salud, como es el marco legal, el financiamiento y los aspectos organizativos, Para obtener los datos recolectados se utilizó bases de datos provinciales yt nacionales, censos provinciales y nacionales, y análisis descriptivos de investigación realizadas. Conclusión: en la presente investigación se concluyen que para poder aplicar el modelo sanitario de un seguro universal de salud en la Provincia de la Rioja, es necesario implementar previamente su marco legal, optimizar los resultados costo - efectividad del financiamiento del sistema público de salud, acercar el funcionamiento hacia la Atención Primaria de la Salud, su priorización de las cinco principales causas de muerte en la provincia.(AU)

SUMMARY: Universal Health Insurance is an alternative that can be implemented in the healthcare system, in a region or a contry as a strategy to increase health coverage of its inhabitants. The province of la Rioja functions under the setting of universal public Health system. The present research analyzes Mexico, Peru and Colombia´s health care systems, as benchmarks of health policies that came up their models toward universality; and then perform an analysis of provincial health model under basic aspects for running a universal health care system, such as legal, finance, and organizational issues. For the data collected, state and national databases, state and national censuses and descriptive analysis resarch were used.Conclusions: In the current investigation it is concluded that in order to implements the sanitary model of universal Health Insurance in the province of La Rioja, it is necessary to pre-deploy its legal framework, optimize funding cost-effectiveness of the public health system, approach to the primary health care, with prioritization of the five leading causes of death in the province.(AU)

Análisis del modelo de Salud de la Provincia de La Rioja, explorando la viabilidad de su extensión hacia un Seguro Universal de Salud / Analysis Model of Health of the Province of La Rioja, exploring the feasibility of its extension to a Universal Health Insurance

El Seguro Universal de Salud es una alternativa que puede implementar en el sistema salud, una región o país, en búsqueda de una estrategia para aumentar la cobertura de salud de sus habitantes. La Provincia de La Rioja funciona bajo parámetros de universalidad en su sistema público de salud. La presente investigación intenta realizar un análisis del modelo sanitario provincial, bajo aspectos básicos para el funcionamiento de un sistema universal de salud, como es el marco legal, el financiamiento y los aspectos organizativos, Para obtener los datos recolectados se utilizó bases de datos provinciales yt nacionales, censos provinciales y nacionales, y análisis descriptivos de investigación realizadas. Conclusión: en la presente investigación se concluyen que para poder aplicar el modelo sanitario de un seguro universal de salud en la Provincia de la Rioja, es necesario implementar previamente su marco legal, optimizar los resultados costo - efectividad del financiamiento del sistema público de salud, acercar el funcionamiento hacia la Atención Primaria de la Salud, su priorización de las cinco principales causas de muerte en la provincia.

SUMMARY: Universal Health Insurance is an alternative that can be implemented in the healthcare system, in a region or a contry as a strategy to increase health coverage of its inhabitants. The province of la Rioja functions under the setting of universal public Health system. The present research analyzes Mexico, Peru and Colombia´s health care systems, as benchmarks of health policies that came up their models toward universality; and then perform an analysis of provincial health model under basic aspects for running a universal health care system, such as legal, finance, and organizational issues. For the data collected, state and national databases, state and national censuses and descriptive analysis resarch were used.Conclusions: In the current investigation it is concluded that in order to implements the sanitary model of universal Health Insurance in the province of La Rioja, it is necessary to pre-deploy its legal framework, optimize funding cost-effectiveness of the public health system, approach to the primary health care, with prioritization of the five leading causes of death in the province.

[Characterization socio-occupational and health insurance of two groups of unemployed workers from Medellin-Colombia 2004 and 2007]. / Caracterización socio-laboral y de aseguramiento en salud de dos grupos de trabajadores cesantes de Medellín-Colombia 2004 y 2007.

OBJECTIVE: Analyzing the socio-occupational and health insurance for two groups of workers who lost their job in the city of Medellin, Colombia in two periods (2004 and 2007), in order to help design alternative public policies that effectively confront the problem of vulnerability in health of unemployed workers and their families. METHODOLOGY: Based on primary information, collected through the same instrument applied to two independent samples of workers who lost their job in the city of Medellin in 2004 (n = 267) and 2007 (n = 198), a descriptive cross-sectional study was made using quantitative research techniques of univariate and bivariate analysis. RESULTS: In both 2004 and 2007 studies the possibility that unemployed workers remain without health insurance was largely associated to variables of sex, age, education, socioeconomic status, occupational status, salary level and duration of unemployment. Their willingness to access to micro credit resources or a micro insurance, proposed to the municipal government as public policies to maintain their membership as contributors to the contributory regime, was highly favorable in both groups. CONCLUSIONS: The socio-occupational profile of unemployed workers keeps correspondence in both groups, although there are significant differences in the conditions of health insurance. We conclude that the vulnerability of unemployed workers excluded from the health insurance demands of society and State alternative public policies for their protection.

Caracterización socio-laboral y de aseguramiento en salud de dos grupos de trabajadores cesantes de Medellín-Colombia 2004 y 2007 / Characterization socio-occupational and health insurance of two groups of unemployed workers from Medellin-Colombia 2004 and 2007

Objetivo Analizar las condiciones socio-laborales y de aseguramiento en salud de dos grupos de trabajadores que perdieron su empleo en la ciudad de Medellín-Colombia en dos periodos (2004 y 2007), a fin de contribuir al diseño de políticas públicas alternativas que afronten eficazmente el problema de desprotección en salud del trabajador cesante y su grupo familiar. Metodología A partir de la información primaria, recolectada mediante el mismo instrumento aplicado a dos muestras independientes de trabajadores que perdieron su empleo en la ciudad de Medellín en 2004 (n=267) y en 2007 (n=198), se realizó un estudio descriptivo de corte transversal utilizando técnicas de investigación cuantitativa de análisis univariado y bivariado. Resultados Tanto en 2004 como en 2007 la eventualidad de que los trabajadores cesantes quedaran sin aseguramiento en salud estuvo asociada en buena medida a variables de sexo, edad, educación, estrato socioeconómico, posición ocupacional, nivel salarial y duración del desempleo. Su disposición de acceder a recursos del microcrédito o a un micro seguro, propuestos a la Administración Municipal como políticas públicas para mantener su afiliación como cotizantes en el régimen contributivo en salud, fue altamente favorable en ambos grupos. Conclusiones El perfil socio-laboral de los trabajadores cesantes guarda correspondencia en ambos grupos, aunque se presentan diferencias relevantes en las condiciones de aseguramiento en salud. Se concluye que la vulnerabilidad de los trabajadores cesantes que quedan excluidos del aseguramiento en salud demanda de la sociedad y del Estado políticas públicas alternativas para su protección.

Objective Analyzing the socio-occupational and health insurance for two groups of workers who lost their job in the city of Medellin, Colombia in two periods (2004 and 2007), in order to help design alternative public policies that effectively confront the problem of vulnerability in health of unemployed workers and their families. Methodology Based on primary information, collected through the same instrument applied to two independent samples of workers who lost their job in the city of Medellin in 2004 (n = 267) and 2007 (n = 198), a descriptive cross-sectional study was made using quantitative research techniques of univariate and bivariate analysis. Results In both 2004 and 2007 studies the possibility that unemployed workers remain without health insurance was largely associated to variables of sex, age, education, socioeconomic status, occupational status, salary level and duration of unemployment. Their willingness to access to micro credit resources or a micro insurance, proposed to the municipal government as public policies to maintain their membership as contributors to the contributory regime, was highly favorable in both groups. Conclusions The socio-occupational profile of unemployed workers keeps correspondence in both groups, although there are significant differences in the conditions of health insurance. We conclude that the vulnerability of unemployed workers excluded from the health insurance demands of society and State alternative public policies for their protection.