The relationship between claimed restorations and future restorations in children and adolescents: An observational follow-up study on risk categories for dental caries.

Various models are available to assess caries risk in individuals. In general past caries experience is considered as the best single predictor for future caries development in populations. Likewise, recent restorations have been used to predict future restorations. We aimed to evaluate a classification model for risk categories for dental caries in children based on claims data from Dutch healthcare insurance company Zilveren Kruis. The baseline caries risk categories were derived from the number of claimed restorations in two baseline years (2010 through 2011). These categories were defined as low (no new restorations), moderate (1 new restoration), and high (2 or more new restorations). First, we analyzed the relationship between baseline caries risk categories and the number of new restorations during 3 years of follow-up (2012 through 2014). Secondly, we used negative binominal two-level analyses to determine the accuracy of our classification model in predicting new restorations during follow-up. Thirdly, we reclassified the participants after 3 years and determined the changes in the categorization. We included insurance claims data for the oral healthcare services in 28,305 children and adolescents from 334 dental practices for the period 2010-2014. At baseline, 68% of the participants were in risk category low, 13% in moderate and 19% in high. The mean number of new restorations during follow-up was 0.81 (SD 1.72) in baseline risk category low, 1.61 (SD 2.35) in moderate, and 2.65 (SD 3.32) in high. The accuracy of the multivariate model for predicting 0/>0 restorations was 50%. After 3 years, 60% of the study participants were in the same risk category, 20% were in a lower, and 21% in a higher risk category. Risk categories based on claimed restorations were related to the number of new restorations in groups. As such, they could support planning and evaluation of oral healthcare services.

Competition and health plan quality in the Medicare Advantage market.

OBJECTIVE: To examine the relationship between insurer market structure, health plan quality, and health insurance premiums in the Medicare Advantage (MA) program. DATA SOURCES/STUDY SETTING: Administrative data files from the Centers for Medicare and Medicaid Services, along with other secondary data sources. STUDY DESIGN: Trends in MA market concentration from 2008 to 2017 are presented, alongside logistic and linear regression models examining MA plan quality and premiums as a function of insurer market structure for 2011. DATA COLLECTION/EXTRACTION METHODS: Data are publicly available. PRINCIPAL FINDINGS: MA plans that tend to operate in more concentrated MA markets have a higher predicted probability of receiving a high-quality health plan rating. Operating in more concentrated MA markets was also found to be associated with higher premiums. Among plans that tend to operate in very concentrated MA markets, high-quality MA plans were associated with premiums as much as two times higher than premiums associated with lower-quality plans. CONCLUSIONS: Any policies directed at enhancing insurer competition should consider implications for health plan quality, which may be very different than the implications for enrollee premiums.

Data transformations to improve the performance of health plan payment methods.

The conventional method for developing health care plan payment systems uses observed data to study alternative algorithms and set incentives for the health care system. In this paper, we take a different approach and transform the input data rather than the algorithm, so that the data used reflect the desired spending levels rather than the observed spending levels. We present a general economic model that incorporates the previously overlooked two-way relationship between health plan payment and insurer actions. We then demonstrate our systematic approach for data transformations in two Medicare applications: underprovision of care for individuals with chronic illnesses and health care disparities by geographic income levels. Empirically comparing our method to two other common approaches shows that the "side effects" of these approaches vary by context, and that data transformation is an effective tool for addressing misallocations in individual health insurance markets.

Quality insurance in head and neck cancer multidisciplinary team meetings: A watchful eye on real-life experience.

INTRODUCTION: Although Multidisciplinary Team Management (MDT) is integrated in most international head and neck cancer treatment guidelines, its applications and proceedings were rarely described. The present study explores a 6-year real-life experience in a French Comprehensive Cancer Care Center. METHODS: Patients, tumor and meeting characteristics of all consecutive cases discussed in head and neck MDT meetings between 2010 and 2015 were retrospectively reviewed. RESULTS: From 2010 to 2015, 1849 cases (accounting for 1786 patients) were discussed in 138 MDT meetings. Median age was 62 (range: 15-96). When reported (n = 310, 16.8%), performance status was ≥2 in 36.1% of patients. Tumors were mainly squamous cell carcinomas (n = 1664, 91.5%) of the larynx/hypo-pharynx (n = 630, 34.4%), oropharynx (n = 518; 28.3%) and oral cavity (n = 339; 18.5%). Tumors were diagnosed at a locally (n = 358, 25%), locally advanced (n = 946, 66%) or metastatic setting (n = 53, 3.7%). Mean number of discussed patients per MDT meeting was 16 (range: 3-32). Most patients were discussed once (n = 1663, 97%). Most patients (n = 969, 52%) underwent treatment before MDT meetings: mainly surgery (n = 709, 73.2%). The mean time between MDT meeting and first radiation course was 21 days (range: 1-116). DISCUSSION: Optimal multimodal treatment management is based on MDT meetings and results from the interaction and coordination of surgeons, medical and radiation oncologists. In the present series, most patients were discussed once despite the number of expected recurrences, suggesting that the management of tumor progression was not discussed in head and neck MDT meetings. Furthermore, most patients had surgery before MDT meeting, pointing out that MDT role and place still needs to be improved. Finally, the present population significantly differed from patients included in phase III clinical trials, with more advanced age and poorer condition. It calls for the necessity of a high-quality head and neck MDT meeting since evidence-based recommendations should be adapted to patient's frailties.

On Call at the Capitol: TMA's 2019 Legislative Agenda.

When the 86th Texas Legislature convenes on Jan. 8, TMA will build on its major successes of 2017, renew some of the biggest battles that stalled two years ago, and tackle relatively new ones. Physicians will make their case to a somewhat new makeup of lawmakers as they pursue better Medicaid coverage for postpartum women, insurer accountability for narrow networks, more funding for community mental health, and many other aims.

Provider-owned insurers in the individual market.

OBJECTIVES: To describe the number and availability of individual market plans sold by provider-owned insurers and compare differences in premiums between traditional and provider-owned insurers. STUDY DESIGN: Cross-sectional analysis. METHODS: Using the Robert Wood Johnson Foundation's HIX Compare data, we identified insurers selling Affordable Care Act (ACA)-compliant policies in the individual market and identified those insurers owned by health systems by using information on their websites. We determined the number of insurers selling policies in each market and the size of the population living in areas where provider-owned insurers sold plans in 2016 and 2017. We used least squares regression to compare premiums between traditional and provider-owned insurers within markets, and we adjusted standard errors for clustering at the market and insurer level. RESULTS: There were 149 insurers that sold ACA-compliant plans in 2017, of which 51 were provider owned. Provider-owned insurers operated in 208 of the 503 exchange markets. We estimate that about 62% of US residents (more than 170 million people) live in a market in which a provider-owned insurer sells plans. Premiums did not differ significantly between traditional and provider-owned plans in 2017. CONCLUSIONS: Provider-owned insurers play a prominent role in the individual insurance market. Although health systems that sell insurance have incentives to reduce costs, provider-owned insurers and traditional insurers have similar premiums.

Paying more for less? Insurer competition and health plan generosity in the Medicare Advantage program.

This paper explores the relationship between insurer competition and health plan benefit generosity by examining the impact of a regulatory change that caused the cancellation of 40% of the private plans in Medicare. I isolate cancellation's causal effect by using variation induced by insurers canceling all plans nationally. Results show that insurers in markets affected by cancellation reduced the benefit generosity of the plans remaining in the market. In the average market, out-of-pocket costs for a representative beneficiary enrolled in plans not directly affected by the policy increased by $91 annually. In the least competitive markets, out-of-pocket costs increased by roughly $64-$127 a year for enrollees in those plans. Meanwhile in the most competitive markets, benefit generosity barely changed. These findings have crucial implications for markets such as health insurance exchanges, as they suggest that plan generosity is degraded when competition declines.

Chondral Injuries and Irreparable Meniscal Tears Among Adolescents With Anterior Cruciate Ligament or Meniscal Tears Are More Common in Patients With Public Insurance.

BACKGROUND: Access to health care services is a critical component of health care reform and may differ among patients with different types of insurance. Hypothesis/Purpose: The purpose was to compare adolescents with private and public insurance undergoing surgery for anterior cruciate ligament (ACL) and/or meniscal tears. We hypothesized that patients with public insurance would have a delayed presentation from the time of injury and therefore would have a higher incidence of chondral injuries and irreparable meniscal tears and lower preoperative International Knee Documentation Committee (IKDC) scores than patients with private insurance. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This was a retrospective study of patients under 21 years of age undergoing ACL reconstruction and/or meniscal repair or debridement from January 2013 to March 2016 at a single pediatric sports medicine center. Patients were identified by a search of Current Procedural Terminology (CPT) codes. A chart review was performed for insurance type; preoperative diagnosis; date of injury, initial office visit, and surgery; preoperative IKDC score; intraoperative findings; and procedures. RESULTS: The study group consisted of 119 patients (mean age, 15.0 ± 1.7 years). Forty-one percent of patients had private insurance, while 59% had public insurance. There were 27 patients with isolated meniscal tears, 59 with combined meniscal and ACL tears, and 33 with isolated ACL tears. The mean time from injury to presentation was 56 days (range, 0-457 days) in patients with private insurance and 136 days (range, 0-1120 days) in patients with public insurance ( P = .02). Surgery occurred, on average, 35 days after the initial office visit in both groups. The mean preoperative IKDC score was 53 in both groups. Patients with meniscal tears with public insurance were more likely to require meniscal debridement than patients with private insurance (risk ratio [RR], 2.3; 95% CI, 1.7-3.1; P = .02). Patients with public insurance were more likely to have chondral injuries of grade 2 or higher (RR, 4.4; 95% CI, 3.9-5.0; P = .02). CONCLUSION: In adolescent patients with ACL or meniscal tears, patients with public insurance had a more delayed presentation than those with private insurance. They also tended to have more moderate-to-severe chondral injuries and meniscal tears, if present, that required debridement rather than repair. More rapid access to care might improve the prognosis of young patients with ACL and meniscal injuries with public insurance.

Efficacy of insurance for organisational disaster recovery: case study of the 2010 and 2011 Canterbury earthquakes.

Insurance is widely acknowledged to be an important component of an organisation's disaster preparedness and resilience. Yet, little analysis exists of how well current commercial insurance policies and practices support organisational recovery in the wake of a major disaster. This exploratory qualitative research, supported by some quantitative survey data, evaluated the efficacy of commercial insurance following the sequence of earthquakes in Canterbury, New Zealand, in 2010 and 2011. The study found that, generally, the commercial insurance sector performed adequately, given the complexity of the events. However, there are a number of ways in which insurers could improve their operations to increase the efficacy of commercial insurance cover and to assist organisational recovery following a disaster. The most notable of these are: (i) better wording of policies; (ii) the availability of sector-specific policies; (iii) the enhancement of claims assessment systems; and (iv) risk-based policy pricing to incentivise risk reduction measures.

State-based Marketplaces using 'clearinghouse' plan management models are associated with lower premiums.

The state-based and federally facilitated health insurance Marketplaces, or exchanges, enrolled more than eight million people during the first open enrollment period, which ended March 31, 2014. There is significant variation in how states have designed and implemented their Marketplaces. We examined how premiums varied with states' involvement in the Marketplaces through governance, plan management authority, and strategy during the first year that the exchanges have been open. State-based Marketplaces using "clearinghouse" plan management models had significantly lower adjusted average premiums for all plans within each metal level compared to state-based Marketplaces using "active purchaser" models and the federally facilitated and partnership Marketplaces. Clearinghouse management models are those in which all health plans that meet published criteria are accepted. Active purchaser models are those in which states negotiate premiums, provider networks, number of plans, and benefits. Our baseline estimates provide valuable benchmarks for evaluating future performance of states' involvement in governance, plan management, and regulatory authority of the insurance Marketplaces.

Time and distance to first accident and driving patterns of young drivers with pay-as-you-drive insurance.

We conducted a study of approximately 16,000 drivers under the age of 30 that had purchased a pay-as-you-drive insurance policy, where their risk of being involved in a crash was analyzed from vehicle tracking data using a global positioning system. The comparison of novice vs. experienced young drivers shows that vehicle usage differs significantly between these groups and that the time to the first crash is shorter for those drivers with less experience. Driving at night and a higher proportion of speed limit violations reduces the time to the first crash for both novice and experienced young drivers, while urban driving reduces the distance traveled to the first crash for both groups. Gender differences are also observed in relation to the influence of driving patterns on the risk of accident. Nighttime driving reduces the time to the first accident in the case of women, but not for men. The risk of an accident increases with excessive speed, but the effect of speed is significantly higher for men than it is for women among the more experienced drivers.

Plan-provider integration, premiums, and quality in the Medicare Advantage market.

OBJECTIVE: To investigate how integration between Medicare Advantage plans and health care providers is related to plan premiums and quality ratings. DATA SOURCE: We used public data from the Centers for Medicare and Medicaid Services (CMS) and the Area Resource File and private data from one large insurer. Premiums and quality ratings are from 2009 CMS administrative files and some control variables are historical. STUDY DESIGN: We estimated ordinary least-squares models for premiums and plan quality ratings, with state fixed effects and firm random effects. The key independent variable was an indicator of plan-provider integration. DATA COLLECTION: With the exception of Medigap premium data, all data were publicly available. We ascertained plan-provider integration through examination of plans' websites and governance documents. PRINCIPAL FINDINGS: We found that integrated plan-providers charge higher premiums, controlling for quality. Such plans also have higher quality ratings. We found no evidence that integration is associated with more generous benefits. CONCLUSIONS: Current policy encourages plan-provider integration, although potential effects on health insurance products and markets are uncertain. Policy makers and regulators may want to closely monitor changes in premiums and quality after integration and consider whether quality improvement (if any) justifies premium increases (if they occur).

Managing moral hazard in motor vehicle accident insurance claims.

Motor vehicle accident (MVA) insurance in Canada is based primarily on two different compensation systems: (i) no-fault, in which policyholders are unable to seek recovery for losses caused by other parties (unless they have specified dollar or verbal thresholds) and (ii) tort, in which policyholders may seek general damages. As insurance companies pay for MVA-related health care costs, excess use of health care services may occur as a result of consumers' (accident victims) and/or producers' (health care providers) behavior - often referred to as the moral hazard of insurance. In the United States, moral hazard is greater for low dollar threshold no-fault insurance compared with tort systems. In Canada, high dollar threshold or pure no-fault versus tort systems are associated with faster patient recovery and reduced MVA claims. These findings suggest that high threshold no-fault or pure no-fault compensation systems may be associated with improved outcomes for patients and reduced moral hazard.

Studies of transformational leadership in consumer service: market orientation behavior and alternative roles for the mediators and moderators of change commitment.

The present paper evaluates the relation between transformational leadership and market orientation along with the mediating and moderating effects of change commitment for employees in customer centers in Taiwan. 327 questionnaires were returned by personnel at several customer centers in four different insurance companies. Inter-rater agreement was acceptable based on the multiple raters (i.e., the consumer-related employees from the division groups) of one individual (i.e., a manager)--indicating the aggregated measures were acceptable. The multi-source sample comprised data taken from the four division centers: phone services, customer representatives, financial specialists, and front-line salespeople. The relations were assessed using a multiple mediation procedure incorporating bootstrap techniques and PRODCLIN2 with structural equation modeling analysis. The results reflect a mediating role for change commitment.

Psychosocial risks: acting upon the organisation by ergonomic intervention.

In this paper we discuss the possibilities of acting on psychosocial risk (PSR) factors by modifying the way in which an organisation operates. On the basis of an ergonomic intervention in an insurance company, we were able to show that the health problems observed by the operators were mainly the result of their inability to produce work of quality. Next, our analyses revealed the links between poor perceived quality, production difficulties and the rigidity of the organisational structure. After setting up working groups to deal with production difficulties, we were able to identify and test an organisational form that was better adapted to managing day-to-day production constraints and which was ultimately better able to be attentive to individual difficulties which had given rise, in the long term, to intrapsychic conflicts.