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6.
Schmerz ; 33(5): 443-448, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31478141

RESUMO

BACKGROUND: Since March 2017 the law amending narcotics and other legal regulations has made it possible for doctors to prescribe cannabis and cannabis-derived medicines. The introduction of § 31 para 6 of the Social Code Book V (SGB V) allows that patients can be treated with cannabis-derived medicines at the expense of the statutory health insurance if they have a severe illness. COURT DECISIONS: The law requires the approval of a prescription of cannabis for medical purposes by the health insurance before the granting of benefits. Due to denied permission, numerous cases are pending before the social tribunals. The article presents which legal issues are decided and why there is still no case law from the Federal Social Court on the essential questions. OUTLOOK: The possibility of prescribing cannabis as medicine at the expense of the health insurance is an important advance in social law. The § 31 para 6 SGB V should be evaluated as soon as possible. The provisions of SGB V for the reimbursement of off-label treatment should be harmonized with § 31 para 6 SGB V.


Assuntos
Cannabis , Seguro Saúde , Médicos , Prescrições , Assistência à Saúde/legislação & jurisprudência , Alemanha , Humanos , Seguro Saúde/economia , Seguro Saúde/legislação & jurisprudência , Médicos/legislação & jurisprudência , Prescrições/estatística & dados numéricos
7.
Plast Reconstr Surg ; 144(3): 560-568, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31461002

RESUMO

BACKGROUND: New York State passed the Breast Cancer Provider Discussion Law in 2010, mandating discussion of insurance coverage for reconstruction and expedient plastic surgical referral, two significant factors found to affect reconstruction rates. This study examines the impact of this law. METHODS: A retrospective cohort study of the New York State Planning and Research Cooperative System database to examine breast reconstruction rates 3 years before and 3 years after law enactment was performed. Difference-interrupted time series models were used to compare trends in the reconstruction rates by sociodemographic factors and provider types. RESULTS: The study included 32,452 patients. The number of mastectomies decreased from 6479 in 2008 to 5235 in 2013; the rate of reconstruction increased from 49 percent in 2008 to 62 percent in 2013. This rise was seen across all median income brackets, races, and age groups. When comparing before to after law enactment, the increase in risk-adjusted reconstruction rates was significantly higher for African Americans and elderly patients, but the disparity in reconstruction rates did not change for other races, different income levels, or insurance types. Reconstruction rates were also not significantly different between those treated in various hospital settings. CONCLUSIONS: The aim of the Breast Cancer Provider Discussion Law is to improve reconstruction rates through provider-driven patient education. The authors' data show significant change following law passage in African American and elderly populations, suggesting effectiveness of the law. The New York State Provider Discussion Law may provide a template for other states to model legislation geared toward patient-centered improvement of health outcomes.


Assuntos
Neoplasias da Mama/cirurgia , Disparidades em Assistência à Saúde , Cobertura do Seguro , Seguro Saúde , Mamoplastia , Mastectomia/estatística & dados numéricos , Adulto , Idoso , Feminino , Disparidades em Assistência à Saúde/legislação & jurisprudência , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Seguro Saúde/legislação & jurisprudência , Mamoplastia/legislação & jurisprudência , Mamoplastia/estatística & dados numéricos , Pessoa de Meia-Idade , New York , Assistência Centrada no Paciente/normas , Estudos Retrospectivos
8.
Tex Med ; 115(8): 18-19, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369142

RESUMO

TMA went into this session looking to attack insurer network inadequacy and health plans' use of care-impeding prior authorization demands. On both fronts, medicine scored solid legislative wins that will make it easier for patients and physicians to know who's in network, and provide needed transparency on preauthorization requirements. And on surprise billing, medicine turned what could've been a disastrous bill into something more palatable.


Assuntos
Acesso aos Serviços de Saúde/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Humanos , Autorização Prévia/legislação & jurisprudência , Texas
9.
Med Care ; 57(8): 567-573, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31299024

RESUMO

BACKGROUND: Every year, millions of Americans lose their health insurance and remain uninsured for various reasons, potentially impacting access to medical services. OBJECTIVE: To examine trends in health insurance loss in the periods shortly before and after implementation of Patient Protection and Affordable Care Act (ACA) and to assess the association of past-year health insurance loss with access to health services and medications. RESEARCH DESIGN AND SUBJECTS: Trends in health insurance loss were examined in 176,961 nonelderly adult participants of the National Health Interview Survey 2011-2017-a representative cross-sectional annual survey of US general population. Multivariable logistic regression models were used to examine access to health services and medications. MEASURES: Loss of private insurance or Medicaid in the past year; use of emergency room services and hospitalizations; contact with medical providers; affording medical care or medications; cost-related medication nonadherence. RESULTS: Private health insurance loss decreased from 3.9%-4.0% in 2011-2013 to 2.7% to 3.1% in 2014-2017 (P<0.001); Medicaid loss decreased from 8.5%-8.9% to 4.6%-6.4% in this period (P<0.001). Nevertheless, as late as 2017, ∼6 million uninsured adults reported having lost private insurance or Medicaid in the past year. Loss of either type of health insurance was associated with lower odds of accessing medical providers, but higher odds of not affording medical care and poor adherence to medication regimens to save costs. CONCLUSIONS: Implementation of ACA was associated with lower risk of health insurance loss. Nevertheless, health insurance loss remains a major barrier to accessing health services and prescribed medications.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/legislação & jurisprudência , Hospitalização/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/legislação & jurisprudência , Modelos Logísticos , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/legislação & jurisprudência , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
10.
S Afr Med J ; 109(7): 498-502, 2019 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-31266576

RESUMO

BACKGROUND: Prescribed Minimum Benefits (PMBs) in South Africa (SA) are a set of minimum health services that all members of medical aid schemes have access to regardless of their benefit options or depleted funds. Medical aid schemes are liable to pay for these services. However, ~40% of all complaints received by the Council for Medical Schemes (CMS) are in relation to PMBs. Individuals/stakeholders who are unsatisfied with judgments on their complaints are allowed to appeal. OBJECTIVES: To determine and describe the pattern of PMB appeals from 1 January 2006 to 31 December 2016. METHODS: This was a descriptive cross-sectional study that utilised the CMS Judgments on Appeals database. Data for PMBs, levels of appeal, judgments, appellants, respondents and medical scheme types were extracted. The CMS's lists of chronic conditions, PMBs and registered schemes were used to confirm PMBs and to categorise schemes as either open (i.e. to all South Africans) or restricted (i.e. only open to members of specific organisations). Data were extracted and frequencies were calculated using Stata software, version 14. RESULTS: All eligible appeal reports (N=340) were retrieved and 123 PMB appeals were included in the study (36.2%). The median number of PMB appeals per year was 11 (interquartile range 9 - 27). Open schemes accounted for 82.1% of all the PMB appeals. Half of the total appeals (50.4%, 62/123) were by medical aid schemes appealing their liability to pay for PMBs, and of these 69.4% (43/62) were found in favour of members. The remaining half (49.6%, 61/123) were appeals by members appealing that schemes were liable to pay, and of these 80.3% (49/61) were found in favour of the medical aid schemes. Treatment options that were scheme exclusions constituted 34.4% (21/61) of reasons why schemes were found not liable to pay. Various types of cancers and emergency conditions constituted one-quarter of all PMB appeals. CONCLUSIONS: While the pattern is unclear and the extent of the problem is masked, this study shows that a quarter of the conflict resulting in PMB appeals was due to various types of cancers and emergency conditions. Medical schemes should revise their guidelines, policies and criteria for payment of these two services and improve their communication with healthcare providers and members.


Assuntos
Seguro Saúde/legislação & jurisprudência , Estudos Transversais , Humanos , Seguro Saúde/economia , África do Sul
14.
Health Serv Res ; 54(4): 730-738, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31218670

RESUMO

OBJECTIVE: To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees. DATA SOURCES: 2014-2019 Qualified Health Plan Landscape Files augmented with supplementary insurer-level information. STUDY DESIGN: We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log-linear models for 15 222 county-years. PRINCIPAL FINDINGS: Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost-sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on-Marketplace silver plans. The latter approach also protects unsubsidized, off-Marketplace enrollees from experiencing premium shocks. CONCLUSIONS: Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment.


Assuntos
Trocas de Seguro de Saúde/organização & administração , Seguradoras/economia , Seguro Saúde/organização & administração , Custo Compartilhado de Seguro/economia , Custo Compartilhado de Seguro/legislação & jurisprudência , Trocas de Seguro de Saúde/economia , Trocas de Seguro de Saúde/legislação & jurisprudência , Humanos , Seguradoras/legislação & jurisprudência , Seguro Saúde/economia , Seguro Saúde/legislação & jurisprudência , Estados Unidos
15.
Pediatrics ; 143(6)2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31092588

RESUMO

OBJECTIVES: Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. METHODS: Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. RESULTS: Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. CONCLUSIONS: Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.


Assuntos
Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/terapia , Dedutíveis e Cosseguros/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/legislação & jurisprudência , Transtorno do Espectro Autista/economia , Criança , Dedutíveis e Cosseguros/economia , Feminino , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Masculino , Programas Obrigatórios/economia , Estados Unidos/epidemiologia
17.
PLoS One ; 14(5): e0217064, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31125366

RESUMO

The study of Autism Spectrum Disorder (ASD) in the United States has identified a growing prevalence of the disorder across the country, a high economic burden for necessary treatment, and important gaps in insurance for individuals with autism. Confronting these facts, states have moved quickly in recent years to introduce mandates that insurers provide coverage for autism care. This study analyzes these autism insurance mandates and demonstrates that while states have moved swiftly to introduce them, the generosity of the benefits they mandate insurers provide varies dramatically across states. Furthermore, our research finds that controlling for policy need, interest group activity, economic circumstances, the insurance environment, and other factors, the passage of these mandates and differences in their generosity are driven by the ideology of state residents and politicians-with more generous benefits in states with more liberal citizens and increased Democratic control of state government. We conclude by discussing the implications of these findings for the study of health policy, politics, and autism in America.


Assuntos
Transtorno do Espectro Autista/economia , Transtorno do Espectro Autista/terapia , Política de Saúde , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/economia , Política , Transtorno do Espectro Autista/epidemiologia , Necessidades e Demandas de Serviços de Saúde , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Estados Unidos
18.
J Law Med ; 26(3): 571-582, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30958650

RESUMO

In 2017/2018 the Australian Capital Territory held its first citizens' jury to deliberate changes to the Territory's Compulsory Third Party (CTP) insurance scheme, for injury compensation after motor vehicle accidents. Such citizens' juries were designed to aid the transition to next-generation parliamentary processes (such as liquid democracy - citizen direct electronic voting on laws or individual transfer of their vote to respected politicians) by enabling a variety of key stakeholders and interests to be actively represented in the process of statutory development. In effect such a process is a democratic alternative to the current model of corporate lobbyists covertly influencing the legislative process. This column investigates how the citizens' jury chose one from four proposed CTP models. It then critiques how, following the jury's recommendation, the Australian Capital Territory Government introduced the Motor Accidents Injuries Bill 2018 (ACT). Once enacted, this is designed to create a "no-fault" expedited scheme, but on our analysis, at the cost of certain adverse outcomes. These include greatly reducing an injured person's entitlements to fair compensation, a "whole person impairment threshold" that limits entitlements to treatment and care, wage loss and compensation for pain and suffering, removing the right to compensation for gratuitous care, and giving the insurance companies unfettered power over the provision of entitlements.


Assuntos
Acidentes de Trânsito/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Austrália , Território da Capital Australiana , Participação da Comunidade , Democracia , Humanos , Veículos Automotores
19.
Albany Law Rev ; 82(2): 533-54, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30990590

RESUMO

The Affordable Care Act (ACA) has been subject to considerable volatility, with perhaps the greatest blow being the rescission, as part of the 2017 Tax Cuts and Jobs Act, of the penalty for its individual mandate to have health insurance coverage. As a New Republic article noted, "we will now find out whether or not an individual mandate really is essential to health reform. And that will settle an old intra-Democratic fight that has been dormant for a decade." The author, Joel Dodge, noted that in the face of Republican efforts to repeal the ACA, "Obamacare defenders (myself included) rebutted these attacks by doubling down on the argument that the law's entire structure would collapse without a mandate." Yet, following the mandate's repeal, Dodge admitted: The mandate was also never much of a mandate to begin with. The Obama administration gave numerous exemptions from the mandate for hardship and other life circumstances. And at just $695 or 2.5 percent of household income, the mandate's penalty for going without insurance costs far less than the cost of actually buying insurance. In contrast, in Massachusetts, the state that pioneered health care reform, the penalty for going uninsured, when one is deemed to be able to afford coverage, is "50 per cent of the minimum insurance premium for creditable coverage available through the commonwealth health insurance connector for which the individual would have qualified during the previous year." As one national policy magazine noted, after the individual mandate was repealed, many Democratic legislators expressed support for enacting it in their states, but those efforts mostly faltered: "Health policy experts attribute the waning enthusiasm to the unpopularity of the individual mandate." This article traces the origin of the individual mandate, chronicles the efforts of some states to enact their own mandates, and concludes by questioning whether the mandate is either necessary or politic.


Assuntos
Reforma dos Serviços de Saúde/legislação & jurisprudência , Cobertura do Seguro/legislação & jurisprudência , Seguro Saúde/legislação & jurisprudência , Programas Obrigatórios/legislação & jurisprudência , Patient Protection and Affordable Care Act/legislação & jurisprudência , Governo Estadual , Humanos , Estados Unidos
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