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Insurance contracts

Frederik T Schut, Marco Varkevisser
In the Netherlands in 2006 a major health care reform was introduced, aimed at reinforcing regulated competition in the health care sector. Health insurers were provided with strong incentives to compete and more room to negotiate and selectively contract with health care providers. Nevertheless, the bargaining position of health insurers vis-à-vis both GPs and hospitals is still relatively weak. GPs are very well organized in a powerful national interest association (LHV) and effectively exploit the long-standing trust relationship with their patients...
November 14, 2016: Health Policy
Sergi Jiménez-Martín, José M Labeaga-Azcona, Cristina Vilaplana-Prieto
This paper analyzes the reasons for the scarce development of the private long-term care insurance market in Spain, and its relationship with health insurance. We are also interested in the effects the crisis has had both on the evolution of the demand for long-term care insurance and on the existence of regional disparities. We estimate bivariate probit models with endogenous variables using Spanish data from the Survey on Health and Retirement in Europe. Our results confirm that individuals wishing to purchase long-term care insurance are, in a sense, forced to subscribe a health insurance policy...
November 2016: Health Economics
Tiffany Shih, Craig Wakeford, Dennis Meletiche, Jesse Sussell, Adrienne Chung, Yanmei Liu, Jin Joo Shim, Darius Lakdawalla
OBJECTIVES: To illustrate a more comprehensive view of value associated with medicines treating a highly severe illness and to apply these insights to estimate the costs and benefits of 3 treatments for multiple sclerosis (MS): Avonex, Tysabri, and Tecfidera. STUDY DESIGN: Retrospective study spanning 2002 to 2013. We used economic theory to derive the value of therapy to patients with MS and to individuals who face the risk of contracting MS in the future, under the alternative assumptions that therapies were fully insured or paid for out of pocket...
November 1, 2016: American Journal of Managed Care
R Surender, R Van Niekerk, L Alfers
BACKGROUND: The launch of the National Health Insurance (NHI) White Paper in December 2015 heralded a new stage in South Africa's advancement towards universal health coverage. The 'contracting in' of private sector general practitioners (GPs), though only one component of the overall reformed system, is nevertheless crucial to address staff shortages and capacity, and also to realise the broader vision of a single unified, integrated system. OBJECTIVE: To report on the views and experiences of GP providers tasked with implementing the reforms at one pilot site, Tshwane District in Gauteng Province, providing an insight into the practical challenges the NHI scheme faces in implementation...
November 2, 2016: South African Medical Journal, Suid-Afrikaanse Tydskrif Vir Geneeskunde
David J Jacofsky, Paul Jawin, Geoff Walton, Lisa Fraser
Orthopedics, and especially total joint replacement (TJR), is growing in payer prominence due to large projected increases in volume. The unsustainability of the fee-for-service payment system has lead Centers for Medicare and Medicaid Services to employ new value and risk-based contracting strategies on a population health basis and on an episode of care basis, with programs such as the Bundled Payment for Care Improvement program and the Comprehensive Care for Joint Replacement program. These trends are forcing hospitals and physicians to align to improve quality and reduce costs through new structures such as Accountable Care Organizations, comanagement programs, and gainsharing...
November 4, 2016: Journal of Knee Surgery
Gabriele Gradl, Eva-Maria Krieg, Martin Schulz
BACKGROUND: Generic substitution can have unintended consequences. In Germany, brand name to generic or generic to generic switching is mainly driven by rebate contracts. Frequent switching may raise concerns about bio- and therapeutic equivalence. Expected patient confusion may result in compromised medication adherence or new onset of other drug-related problems. Since 2008, pharmacists are allowed to deviate from rebate contracts by denying substitution due to pharmaceutical concerns on an individual basis...
July 2016: Pharmacy Practice
Joanna P MacEwan, Felicia M Forma, Jason Shafrin, Ainslie Hatch, Darius N Lakdawalla, Jean-Pierre Lindenmayer
BACKGROUND: Poor medication adherence contributes to negative treatment response, symptom relapse, and hospitalizations in schizophrenia. Many health plans use claims-based measures like medication possession ratios or proportion of days covered (PDC) to measure patient adherence to antipsychotics. Classifying patients solely on the basis of a single average PDC measure, however, may mask clinically meaningful variations over time in how patients arrive at an average PDC level. OBJECTIVE: To model patterns of medication adherence evolving over time for patients with schizophrenia who initiated treatment with an oral atypical antipsychotic and, based on these patterns, to identify groups of patients with different adherence behaviors...
November 2016: Journal of Managed Care & Specialty Pharmacy
H Karimi, S A Motevalian, M Momeni, M Ghadarjani
Understanding the cost of burn treatment is very important for patients, their families, governmental authorities and insurance companies. It alleviates patient and familial stress, provides a framework for better use of resources, and facilitates better performance between burn centers. Hospital burn costs can provide a basis for authorities to budget for acute burn treatment, for further management of chronic complications, and for planning prevention and public educational programs in Iran. To identify costs we used data from our burn registry program...
December 31, 2015: Annals of Burns and Fire Disasters
Helmuth Cremer, Jean-Marie Lozachmeur, Pierre Pestieau
This paper studies the design of long term care (LTC) insurance contracts in the presence of ex post moral hazard. While this problem bears some similarity with the study of health insurance (Blomqvist, 1997) the significance of informal LTC affects the problem in several crucial ways. It introduces the potential crowding out of informal care by market care financed through insurance coverage. Furthermore, the information structure becomes more intricate. Informal care is not publicly observable and, unlike the insurer, caregivers know the true needs of their relatives...
September 27, 2016: Journal of Health Economics
P Kalbe
The reform of occupational insurance medical treatment in 2011 also resulted in many changes for occupational insurance consultants in private practice. The transformation of the physicians participating in treatment status (H-Arzt) to accident insurance consultant status (D-Arzt) has resulted in a significant increase in numbers in outpatient fields, which in some cases leads to increased competition. The tentative flexibilization of the conditions for participation of a D‑Arzt is welcomed but must be broadened to safeguard the future...
October 14, 2016: Der Unfallchirurg
Mauricio Avendano, Heta Moustgaard, Pekka Martikainen
This paper uses individual-level longitudinal data on working-age Finns to examine the health effects of economic fluctuations during a period of economic decline (1989-1996) and recovery (1997-2007) in Finland. We used a nationally representative, longitudinal sample formed by linking population, employment and mortality registers (n = 698,484; 7,719,870 person-years). We implemented a region fixed-effect model that exploits within-regional variations over time in the unemployment rate to identify the effect of economic fluctuations on mortality, controlling for individual employment transitions...
October 11, 2016: European Journal of Epidemiology
Alicia Atwood, Anthony T Lo Sasso
Network design is an often overlooked aspect of health insurance contracts. Recent policy factors have resulted in narrower provider networks. We provide plausibly causal evidence on the effect of narrow network plans offered by a large national health insurance carrier in a major metropolitan market. Our econometric design exploits the fact that some firms offer a narrow network plan to their employees and some do not. Our results show that narrow network health plans lead to reductions in health care utilization and spending...
September 21, 2016: Journal of Health Economics
Denise Menonna-Quinn
The focus of health care has moved toward prevention, and insurance companies are supporting preventive practices that enable their members to remain healthy. Many insurance companies have recorded healthy tips delivered by phone, employed case managers to assist patients in keeping physician appointments, created dedicated hot lines staffed by nurses, and developed resource centers. However, specific instances arise when insurance companies do not allow patients to have certain procedures because of contract language that was previously negotiated between the employer or individual and the insurance company...
October 1, 2016: Clinical Journal of Oncology Nursing
Robert D Lieberthal
Long-term health insurance provides consumers with protection against persistent, negative health shocks. While the stochastic rise in medical spending growth may make some health risks harder to insure, financial assets could act as a hedge for medical spending growth risk. The purpose of this research was to determine whether such hedges exist. The results of this study were two-fold. First, the asset classes with the strongest statistical evidence as hedges were bonds, not stocks. Second, any strategy to hedge medical spending growth involved shorting assets i...
August 2016: Applied Finance and Accounting
Julia K Ostermann, Anne Berghöfer, Frank Andersohn, Felix Fischer
BACKGROUND: Numerous drugs used in the treatment of psychiatric disorders are substrates of cytochrome P450 enzymes and are potential candidates for drug-drug interactions (DDIs). METHODS: Claims data of a German statutory health insurance company from severely mentally ill patients who registered in an integrated care contract from August 2004 to December 2009 were analysed. We measured time periods of concomitant prescription of drugs that have been reported to interact via cytochrome P450, with a focus on drugs acting as strong inhibitors...
2016: BMC Health Services Research
Lauren N Whiteman, Carlton Haywood, Sophie Lanzkron, John J Strouse, Adrian H Batchelor, Anthony Schwartz, Rosalyn W Stewart
OBJECTIVES: Poor oral health can have a negative impact on overall health. This is especially concerning for individuals with sickle cell disease (SCD), an inherited blood disorder that affects hemoglobin and can lead to an increased risk of infection and hyperalgesia. Because the majority of individuals with SCD have Medicaid insurance and no dental coverage, we provided free basic dental care to individuals with SCD to determine whether it decreased overall healthcare utilization. METHODS: Through a contract with a private dental office, we provided free basic dental care (eg, cleanings, fillings, x-rays) to individuals with SCD...
September 2016: Southern Medical Journal
William Riley, Les W Meredith, Rebecca Price, Kristi K Miller, James W Begun, Mac McCullough, Stanley Davis
OBJECTIVE: To evaluate the association of improved patient safety practices with medical malpractice claims and costs in the perinatal units of acute care hospitals. DATA SOURCES: Malpractice and harm data from participating hospitals; litigation records and medical malpractice claims data from American Excess Insurance Exchange, RRG, whose data are managed by Premier Insurance Management Services, Inc. (owned by Premier Inc., a health care improvement company)...
August 22, 2016: Health Services Research
Elizabeth A Stuart, Colleen L Barry, Julie M Donohue, Shelly F Greenfield, Kenneth Duckworth, Zirui Song, Elena M Kouri, Cyrus Ebnesajjad, Robert Mechanic, Michael E Chernew, Haiden A Huskamp
BACKGROUND AND AIMS: Global payment and accountable care reform efforts in the US may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an 'Alternative Quality Contract' (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD. DESIGN: Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC...
August 12, 2016: Addiction
Melody W Mulaik
It is important to remain current on the latest edit and modifier guidelines from the AMA, CMS, and your contracted payors. Failure to use modifiers correctly can result in under- or overpayments and can put a provider at risk of penalties. Also, since payors vary in how they adjudicate claims with modifiers, it is important to monitor payments for claims with modifiers to make certain you are being paid correctly.
May 2016: Radiology Management
Domino Determann, Mattijs S Lambooij, Esther W de Bekker-Grob, Arthur P Hayen, Marco Varkevisser, Frederik T Schut, G Ardine de Wit
Within a healthcare system with managed competition, health insurers are expected to act as prudent buyers of care on behalf of their customers. To fulfil this role adequately, understanding consumer preferences for health plan characteristics is of vital importance. Little is known, however, about these preferences and how they vary across consumers. Using a discrete choice experiment (DCE) we quantified trade-offs between basic health plan characteristics and analysed whether there are differences in preferences according to age, health status and income...
September 2016: Social Science & Medicine
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