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1.
Plast Reconstr Surg ; 145(2): 545-554, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985657

RESUMO

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.


Assuntos
Abdominoplastia/economia , Cirurgia Bariátrica/economia , Contorno Corporal/economia , Cobertura do Seguro/economia , Seguro Saúde/estatística & dados numéricos , Abdominoplastia/estatística & dados numéricos , Dorso/cirurgia , Estudos Transversais , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Lipectomia/economia , Lipectomia/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Estados Unidos
2.
Med Care ; 57(10): 795-800, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31415344

RESUMO

BACKGROUND: A growing proportion of Medicare beneficiaries is covered by private insurers through Medicare Advantage, yet little is known about how these plans are structured in terms of relationships with physicians and implications for quality of care. OBJECTIVE: The objective of this study was to assess whether greater physician concentration of services across insurers was associated with higher quality in Medicare Advantage (MA), overall and particularly among MA insurers serving a high proportion of vulnerable enrollees. RESEARCH DESIGN: A retrospective cohort design with regression analysis. DATA SOURCES: The primary dataset was 2014 MA encounter records submitted by insurers to the Centers for Medicare and Medicaid Services, covering 600,329 physicians across 119 insurers. These data were merged with Centers for Medicare and Medicaid Services data on MA contract quality rating as well as physician characteristics in the Medicare Data on Provider Practice and Specialty file. MEASURES: Two measures were generated to capture the concentration of physician services across insurers: the percentage of a physician's Medicare services which was through MA (MA penetration); and the percentage of a physician's MA services with a specific insurer (insurer share of MA services). RESULTS: Greater MA penetration and insurer share of MA services were each associated with higher MA plan quality. The relationship between insurer share and quality was stronger in contracts with a relatively high percentage of disabled enrollees. CONCLUSION: Greater physician concentration of services across MA insurers was associated with a higher quality of care overall and especially among vulnerable enrollees.


Assuntos
Serviços de Saúde/provisão & distribução , Seguradoras/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Análise de Regressão , Estudos Retrospectivos , Estados Unidos
4.
Int J Health Serv ; 49(1): 142-164, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30428268

RESUMO

This scoping review identified what kinds of work disability policy issues are critiqued in articles published in countries with cause-based versus comprehensive welfare systems. Drawing on a review of work disability policy research, we identified 74 English-language, peer-reviewed articles that focused on program adequacy and design. Articles on cause-based systems dwelled on system fairness and policies of proof of entitlement, while those on comprehensive systems focused more on system design complexities relating to worker inclusion and scope of medical certificates. Overall, we observed a clear difference in the nature of problems examined in the different systems. Gaps in work disability policy literature are identified, and challenges for comparative policy research are discussed.


Assuntos
Políticas , Previdência Social/organização & administração , Previdência Social/estatística & dados numéricos , Indenização aos Trabalhadores/organização & administração , Indenização aos Trabalhadores/estatística & dados numéricos , Documentação/normas , Definição da Elegibilidade/normas , Órgãos Governamentais/organização & administração , Órgãos Governamentais/estatística & dados numéricos , Humanos , Indústrias/organização & administração , Indústrias/estatística & dados numéricos , Seguradoras/estatística & dados numéricos , Retorno ao Trabalho , Fatores de Risco , Previdência Social/normas , Avaliação da Capacidade de Trabalho , Indenização aos Trabalhadores/normas
5.
Am J Manag Care ; 24(12): e393-e398, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30586488

RESUMO

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.


Assuntos
Seguradoras/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Organizações Patrocinadas pelo Prestador/estatística & dados numéricos , Estudos Transversais , Humanos , Seguro/economia , Seguro/organização & administração , Seguro/estatística & dados numéricos , Seguradoras/economia , Seguro Saúde/economia , Seguro Saúde/organização & administração , Organizações Patrocinadas pelo Prestador/economia , Organizações Patrocinadas pelo Prestador/organização & administração , Estados Unidos
6.
BMC Health Serv Res ; 18(1): 797, 2018 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-30342542

RESUMO

BACKGROUND: Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer). METHODS: An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits. RESULTS: The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) cost-sharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents' characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care. CONCLUSIONS: The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volume-based to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.


Assuntos
Custo Compartilhado de Seguro , Gastos em Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Dedutíveis e Cosseguros/economia , Dedutíveis e Cosseguros/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/estatística & dados numéricos , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/economia , Padrões de Prática Médica/estatística & dados numéricos , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricos , Inquéritos e Questionários
7.
Health Aff (Millwood) ; 37(10): 1678-1684, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30273031

RESUMO

While the Affordable Care Act has expanded health insurance to millions of Americans through the expansion of eligibility for Medicaid and the health insurance Marketplaces, concerns about Marketplace stability persist-given increasing premiums and multiple insurers exiting selected markets. Yet there has been little investigation of what factors underlie this pattern. We assessed the county-level prevalence of limited insurer participation (defined as having two or fewer distinct participating insurers) in Marketplaces in the period 2014-18. Overall, in 2015 and 2016 rates of insurer participation were largely stable, and approximately 80 percent of counties (containing 93 percent of US residents) had at least three Marketplace insurers. However, these proportions declined sharply starting in 2017, falling to 36 percent of counties and 60 percent of the population in 2018. We also examined county-level factors associated with limited insurer competition and found that it occurred disproportionately in rural counties, those with higher mortality rates, and those where insurers had lower medical loss ratios (that is, potentially higher profit margins), as well as in states where Republicans controlled the executive and legislative branches of government. Decreased competition was less common in states with higher proportions of residents who were Hispanic or ages 45-64 and states that chose to expand Medicaid.


Assuntos
Competição Econômica , Trocas de Seguro de Saúde/estatística & dados numéricos , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/tendências , Estudos Transversais , Bases de Dados Factuais , Grupos Étnicos/estatística & dados numéricos , Trocas de Seguro de Saúde/tendências , Humanos , Seguradoras/tendências , Medicaid , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/legislação & jurisprudência , Política , Estados Unidos
8.
Rural Policy Brief ; 2018(3): 1-4, 2018 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30211515

RESUMO

Purpose: Since 2014, when the Health Insurance Marketplaces (HIMs) authorized by the Patient Protection and Affordable Care Act (PPACA) were implemented, considerable premium changes have been observed in the marketplaces across the 50 states and the District of Columbia. This policy brief assesses the changes in average HIM plan premiums from 2014 to 2018, before accounting for subsidies, with an emphasis on the widening variation across rural and urban places, providing information during Congressional debates on the future of the program. Key Findings: (1) Insurance issuers reduced HIM participation across both rural and urban places (with 1.7 and 2.2 issuers, respectively), both in states that expanded Medicaid under the PPACA and in non-expansion states. (2) The average adjusted premium (before premium subsidy) continues to rise across all of the above categories, and the gap has widened between the 32 Medicaid expansion and 19 non-expansion states. Average premiums in rural counties are higher than average premiums in urban counties in both expansion and non-expansion states (by $43 per month and $27 per month, respectively). (3) Prior trends of lower premium changes at greater population densities are no longer observed in the 2018 data. (4) In 2018, 1,581 counties (52 perent) have one participating insurance issuer. Nationwide, 42 percent of all urban counties and 55 percent of all rural counties only have one issuer.


Assuntos
Trocas de Seguro de Saúde/economia , Trocas de Seguro de Saúde/estatística & dados numéricos , Trocas de Seguro de Saúde/tendências , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Seguradoras/tendências , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Seguro Saúde/tendências , Serviços de Saúde Rural/provisão & distribução , Serviços de Saúde Rural/estatística & dados numéricos , Serviços de Saúde Rural/tendências , População Rural/estatística & dados numéricos , Previsões , Humanos , Medicaid , Patient Protection and Affordable Care Act , Densidade Demográfica , Estados Unidos
9.
J Safety Res ; 66: 141-150, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30121100

RESUMO

INTRODUCTION: Workers' compensation (WC) insurers offer services and programs for prospective client selection and insured client risk control (RC) purposes. Toward these aims, insurers collect employer data that may include information on types of hazards present in the workplace, safety and health programs and controls in place to prevent injury/illness, and return-to-work programs to reduce injury/illness severity. Despite the potential impact of RC systems on workplace safety and health and the use of RC data in guiding prevention efforts, few research studies on the types of RC services provided to employers or the RC data collected have been published in the peer-reviewed literature. METHODS: Researchers conducted voluntary interviews with nine private and state-fund WC insurers to collect qualitative information on RC data and systems. RESULTS: Insurers provided information describing their RC data, tools, and practices. Unique practices as well as similarities including those related to RC services, policyholder goals, and databases were identified. CONCLUSIONS: Insurers collect and store extensive RC data, which have utility for public health research for improving workplace safety and health. PRACTICAL APPLICATIONS: Increased public health understanding of RC data and systems and an identification of key collaboration opportunities between insurers and researchers will facilitate increased use of RC data for public health purposes.


Assuntos
Seguradoras/estatística & dados numéricos , Seguro de Acidentes/estatística & dados numéricos , Saúde Pública , Indenização aos Trabalhadores/estatística & dados numéricos , Humanos , Estados Unidos
10.
Am Econ Rev ; 108(8): 2048-87, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30091862

RESUMO

A central question in the debate over privatized Medicare is whether increased government payments to private Medicare Advantage (MA) plans generate lower premiums for consumers or higher profits for producers. Using difference­in­differences variation brought about by a sharp legislative change, we find that MA insurers pass through 45 percent of increased payments in lower premiums and an additional 9 percent in more generous benefits. We show that advantageous selection into MA cannot explain this incomplete pass­through. Instead, our evidence suggests that market power is important, with premium pass­through rates of 13 percent in the least competitive markets and 74 percent in the most competitive.


Assuntos
Custo Compartilhado de Seguro/economia , Medicare Part C/economia , Capitação , Custo Compartilhado de Seguro/estatística & dados numéricos , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/estatística & dados numéricos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Modelos Econométricos , Estados Unidos
11.
J Law Med ; 25(4): 1100-1105, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29978687

RESUMO

Risk mitigation practices are essential to protecting patients from harm and reducing medical practitioner exposure to unnecessary reputational damage and economic loss. Despite traditionally being perceived as a low-risk specialty, published data on medico-legal claims against dermatologists in Australia are currently lacking. This article reviews the sources of medico-legal claims against dermatologists in Australia from a single medical indemnity insurer over the most recent three years. The failure to meet patient expectations was the largest source of claims against dermatologists, followed by adverse outcomes. Improved communication from practitioner to patient remains the most effective step to preventing medico-legal claims. Medico-legal claims, when they occur, are more successfully defended when thorough documentation processes are in place.


Assuntos
Dermatologistas/legislação & jurisprudência , Seguradoras/estatística & dados numéricos , Imperícia , Austrália , Dermatologistas/normas , Documentação , Humanos , Responsabilidade Legal
12.
Health Aff (Millwood) ; 37(4): 619-626, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29608348

RESUMO

The administrative costs of providing health insurance in the US are very high, but their determinants are poorly understood. We advance the nascent literature in this field by developing new measures of billing complexity for physician care across insurers and over time, and by estimating them using a large sample of detailed insurance "remittance data" for the period 2013-15. We found dramatic variation across different types of insurance. Fee-for-service Medicaid is the most challenging type of insurer to bill, with a claim denial rate that is 17.8 percentage points higher than that for fee-for-service Medicare. The denial rate for Medicaid managed care was 6 percentage points higher than that for fee-for-service Medicare, while the rate for private insurance appeared similar to that of Medicare Advantage. Based on conservative assumptions, we estimated that the health care sector deals with $11 billion in challenged revenue annually, but this number could be as high as $54 billion. These costs have significant implications for analyses of health insurance reforms.


Assuntos
Custos e Análise de Custo , Serviços de Saúde/economia , Seguradoras/estatística & dados numéricos , Formulário de Reclamação de Seguro/economia , Seguro Saúde/estatística & dados numéricos , Organização e Administração/economia , Médicos/economia , Prática de Grupo/economia , Setor de Assistência à Saúde , Humanos , Seguro Saúde/economia , Medicaid , Medicare , Pacientes Ambulatoriais , Fatores de Tempo , Estados Unidos
13.
J Occup Environ Hyg ; 15(6): 502-509, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29580189

RESUMO

Despite substantial financial and personnel resources being devoted to occupational exposure monitoring (OEM) by employers, workers' compensation insurers, and other organizations, the United States (U.S.) lacks comprehensive occupational exposure databases to use for research and surveillance activities. OEM data are necessary for determining the levels of workers' exposures; compliance with regulations; developing control measures; establishing worker exposure profiles; and improving preventive and responsive exposure surveillance and policy efforts. Workers' compensation insurers as a group may have particular potential for understanding exposures in various industries, especially among small employers. This is the first study to determine how selected state-based and private workers' compensation insurers collect, store, and use OEM data related specifically to air and noise sampling. Of 50 insurers contacted to participate in this study, 28 completed an online survey. All of the responding private and the majority of state-based insurers offered industrial hygiene (IH) services to policyholders and employed 1 to 3 certified industrial hygienists on average. Many, but not all, insurers used standardized forms for data collection, but the data were not commonly stored in centralized databases. Data were most often used to provide recommendations for improvement to policyholders. Although not representative of all insurers, the survey was completed by insurers that cover a substantial number of employers and workers. The 20 participating state-based insurers on average provided 48% of the workers' compensation insurance benefits in their respective states or provinces. These results provide insight into potential next steps for improving the access to and usability of existing data as well as ways researchers can help organizations improve data collection strategies. This effort represents an opportunity for collaboration among insurers, researchers, and others that can help insurers and employers while advancing the exposure assessment field in the U.S.


Assuntos
Coleta de Dados/métodos , Seguradoras/estatística & dados numéricos , Exposição Ocupacional/estatística & dados numéricos , Indenização aos Trabalhadores/estatística & dados numéricos , Coleta de Dados/estatística & dados numéricos , Humanos , Saúde do Trabalhador , Estados Unidos
15.
Eur Spine J ; 27(6): 1255-1261, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29429037

RESUMO

PURPOSE: The long-term outcome of Whiplash-associated disorder (WADs) has been reported to be poor in populations from medical settings. However, no trials have investigated the long-term prognosis of patients from medico-legal environment. For this group, the "compensation hypothesis" suggests financial compensation being associated with worsened outcome. The aims of this study were to describe long-term (2-4 years) non-recovery rates in participants with WAD recruited from insurance companies and to investigate the association between self-reported non-recovery and financial compensation. METHODS: 144 participants, reporting neck pain after a motor vehicle accident, were recruited from two major insurance companies in Sweden. Self-reported recovery was measured at 6 months and 2-4 years. Those who received financial compensation from an insurance company were compared with those who received no compensation. RESULTS: The overall non-recovery rate after 2-4 years was 55.9% (66/118). In the non-compensated group, the non-recovery rate was 51.0% (25/49) and in the compensated group 73% (27/37) (p = 0.039). Adjusted OR was 4.33 (1.37-13.66). High level of pain at baseline was a strong predictor of non-recovery [OR 46 (4.7-446.0)]. However, no association was found between pain level at baseline and financial compensation. CONCLUSIONS: The non-recovery rate among patients making insurance claims is high, especially among those receiving financial compensation even if causal relationship cannot be determined based on this study. However, lack of association between baseline level of pain and compensation supports the compensation hypothesis.


Assuntos
Compensação e Reparação , Cervicalgia/etiologia , Traumatismos em Chicotada/complicações , Acidentes de Trânsito/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Seguimentos , Humanos , Seguradoras/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Cervicalgia/economia , Cervicalgia/epidemiologia , Medição da Dor , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Estudos Prospectivos , Recuperação de Função Fisiológica , Suécia , Traumatismos em Chicotada/economia
16.
Lakartidningen ; 1152018 01 26.
Artigo em Sueco | MEDLINE | ID: mdl-29381182

RESUMO

Puerpural fever still exist. A rare condition that must be kept in mind All 33 claims to the Swedish National Patient Insurance (LÖF) in 2010-2014 related to obstetric infections, of which 14 were due to endometritis, were examined. Nine women suffered from fulminant infections consistent with classical puerperal fever (childbed fever), 2 of which were life-threatening. They occurred unexpectedly, mainly after uncomplicated deliveries, and were usually caused by Group A streptococci. Five women suffered from endometritis with a mild or moderate clinical course. All occurred after early birth-related complications and were caused by low-virulent bacteria. In order for an infection to occur in a healthy woman who undergoes normal delivery, more virulent bacteria appear to be required. Since these bacteria may exist in the hospital environment, improved hygiene routines are a prerequisite for reducing the number of nosocomial infections.


Assuntos
Febre/epidemiologia , Infecção Puerperal/epidemiologia , Adolescente , Adulto , Estado Terminal , Endometrite/epidemiologia , Endometrite/microbiologia , Feminino , Febre/microbiologia , Humanos , Seguradoras/estatística & dados numéricos , Períneo/microbiologia , Gravidez , Infecção Puerperal/microbiologia , Infecções do Sistema Genital/epidemiologia , Infecções do Sistema Genital/microbiologia , Infecções Estreptocócicas/epidemiologia , Streptococcus pyogenes/isolamento & purificação , Suécia/epidemiologia , Vagina/microbiologia , Adulto Jovem
17.
Med Care Res Rev ; 75(3): 384-393, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29148331

RESUMO

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges.


Assuntos
Trocas de Seguro de Saúde/economia , Seguradoras/economia , National Health Insurance, United States/economia , National Health Insurance, United States/estatística & dados numéricos , Patient Protection and Affordable Care Act/economia , Planos Governamentais de Saúde/economia , Planos Governamentais de Saúde/estatística & dados numéricos , Trocas de Seguro de Saúde/estatística & dados numéricos , Humanos , Seguradoras/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estados Unidos
18.
Manag Care ; 27(12): 34-36, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30620327

RESUMO

PURPOSE: Using New York City as an example, this research explores reasons for the consistently poor financial performance of three start-up health plans (Health Republic, CareConnect, and Oscar) while other health plans have performed relatively well in the same market. DESIGN AND METHODS: This study compiles insurer data from financial years 2014 through 2016, submitted to the New York State Department of Financial Services as part of the rate-review process, including premium revenue, claims cost, risk adjustment, administrative costs, net income, and premium. The financial data were used to create a novel metric, adjusted net income, that evaluates the financial performance of an insurer excluding risk adjustment and assuming a market average administrative cost. Descriptive statistics were used to compare the performance of start-up plans, commercial plans, and Medicaid plans in the ACA exchange market. RESULTS: Premiums for start-up plans were within 9% of median silver premiums yet adjusted net income was negative (-$190 PMPM) for all three start-ups while it is positive (+$27 PMPM) for the non-start-ups. The difference in adjusted net incomes shows that poor financial performance of start-ups was due to claims costs, not high administrative costs and poor performance in risk adjustment. CONCLUSION: The consistent financial losses by New York City start-ups is driven by higher-cost provider contracts for the start-ups relative to competitors.


Assuntos
Seguradoras/economia , Seguro Saúde , Seguradoras/estatística & dados numéricos , Medicaid , Cidade de Nova Iorque , Risco Ajustado , Estados Unidos
19.
Health Aff (Millwood) ; 36(12): 2185-2194, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29200327

RESUMO

The five largest US commercial health insurance companies together enroll 125 million members, or 43 percent of the country's insured population. Over the past decade these insurers have become increasingly dependent for growth and profitability on public programs, according to an analysis of corporate reports. In 2016 Medicare and Medicaid accounted for nearly 60 percent of the companies' health care revenues and 20 percent of their comprehensive plan membership. Although headlines have focused on losses in the state Marketplaces created by the Affordable Care Act (ACA), the Marketplaces represent only a small fraction of insurers' members. Overall, the five largest insurers have remained profitable since passage of the ACA as a result of profits in other market segments. Notably, companies with significant Medicare or Medicaid enrollment have continued to insure beneficiaries in states where the insurers do not participate in Marketplaces. Given the insurers' dependence on public programs, there is potential to improve access if federal or state governments, or both, required insurers that participate in Medicare or Medicaid to also participate in the Marketplaces in the same geographic area. Such requirements could ensure more viable and less volatile insurance, benefiting people insured within each market as well as those who cycle on and off public and private insurance.


Assuntos
Comércio , Administração Financeira/estatística & dados numéricos , Política de Saúde , Seguradoras/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Trocas de Seguro de Saúde/economia , Humanos , Seguradoras/economia , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Governo Estadual , Estados Unidos
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