Stop-loss insurance: are you tempting fate? (1/59)

Capitation is a gamble, but stop-loss insurance can keep physician groups from losing their shirts. Who needs it? That depends on the type of contract and many other factors.  (+info)

"Carving out" conditions from global capitation rates: protecting high-cost patients, physicians, and health plans in a managed care environment. (2/59)

The purposes of this study were (1) to develop a method for identifying individuals with high-cost medical conditions, (2) to determine the percentage of healthcare spending they represent, and (3) to explore policy implications of "carving out" their care from managed care capitation. Annual payments over a 2-year period to enrollees of three health plans--a traditional managed care organization, and a state Medicaid program--were determined by using a cross-sectional analysis of insurance claims data. The main outcome measures were the number of enrollees with total annual payments in excess of $25,000 and the contribution of these high-cost enrollees to each health plan's total costs. Forty-one groups of diagnosis and procedure codes representing a combination of acute and chronic conditions were included on the list of carve-out conditions. Pulmonary insufficiency and respiratory failure together accounted for the largest number of high-cost individuals in each health plan. Solid organ and bone marrow transplants, AIDS, and most malignancies that required high-dose chemotherapy were also important. The carve-out list identified more than one third of high-cost individuals enrolled in the Medicaid program, approximately 20% of high-cost managed care enrollees, and 10% of high-cost fee-for-service enrollees. These data confirm that it is possible to identify high-cost individuals in health plans by using a carve-out list. Carving out high-cost patients from capitation risk arrangements may protect patients, physicians, and managed care organizations.  (+info)

Catastrophic antiphospholipid antibody syndrome in systemic lupus erythematosus: an autopsy case report of a young woman. (3/59)

Catastrophic antiphospholipid syndrome (CAPS) is a severe variant of antiphospholipid syndrome (APS) characterized by disseminated microangiopathy that results in multiorgan failure. CAPS mainly occurs in association with systemic lupus erythematosus (SLE). Clinically, CAPS mimics disseminated SLE vasculitis, intravascular coagulation (DIC), and particularly thrombotic thrombocytopenic purpura (TTP). We describe an autopsy case of young woman with CAPS in SLE, which is difficult to differentiate from TTP secondary to SLE.  (+info)

A flexible benefits tax credit for health insurance and more. (4/59)

This essay outlines a concept for a "flexible benefits" tax credit for expanding health insurance coverage and other purposes such as retirement savings plans (with potential withdrawals for higher education, first-home ownership, and catastrophic medical expenses). Two examples are presented. The advantages of a flexible benefits tax credit are considered in terms of efficient use of the budget surplus to help meet the varied (and changing) needs of American families, to eliminate major national gaps in health insurance and pension coverage, and to advance other objectives. If the budget surplus is used wisely, political decisionmakers could achieve health insurance coverage for most uninsured workers and children and assure a future with real economic security for American families.  (+info)

Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: current experiences and challenges. (5/59)

OBJECTIVE: To assess the Self Employed Women's Association's Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use. METHODS: One thousand nine hundred and thirty claims submitted over six years were analysed. FINDINGS: Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (>10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22-37% of the estimated frequency of hospitalization). CONCLUSIONS: The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme's financial viability and protecting members against catastrophic expenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process - a system of monitoring and evaluation is vital.  (+info)

Abdominal catastrophe revisited: the risk and outcome of enteric peritoneal contamination. (6/59)

OBJECTIVE: Peritonitis from a visceral source is associated with striking morbidity and mortality in patients treated with peritoneal dialysis (PD). Surgical intervention for both diagnosis and repair is definitive. However, because the antecedents of enteric injury leading to peritonitis are unpredictable, no preventive strategy has been proposed or adopted. The goal of this study was to examine risk factors influencing the occurrence and outcome of anatomically documented peritonitis of enteric origin. DESIGN: Retrospective chart and database review. SETTING: Peritoneal dialysis unit in tertiary-care referral hospital. PATIENTS: 330 patients treated with PD for end-stage renal disease between 1988 and 2000. MAIN OUTCOME MEASURES: Prevalence of peritonitis of anatomically documented enteric origin over two consecutive time periods within the study interval: period 1, from 1 January 1988 through 30 June 1996; period 2, from 1 July 1996 through 30 June 2000. RESULTS: At least 1 episode of peritonitis occurred in 202 of 330 patients during the entire study period of 12.5 years (600.74 patient-years of care). There were 543 episodes of peritonitis. Anatomically documented visceral Injury caused bacterial peritonitis in 41 patients with a total of 63 discrete episodes, an incidence rate of 0.1048 per patient-year. Peritonitis-free survival was compared between the two periods using Kaplan-Meier analysis. The curve representing risk distribution for anatomically documented visceral peritonitis remained constant over the two periods, in contrast to improvements found in all other types of peritonitis, taken as a group (p= 0.044). Logistic regression modeling showed that the only risk factor associated with development of anatomically documented visceral peritonitis was older age. There was no influence of race, sex, time on PD, and underlying disease etiology. 31 deaths were attributed to peritonitis during the study period. The mortality rate from enteric peritonitis due to visceral injury was 46.3% (19/41 cases), compared to 7.5% for all other peritonitis taken as a group (12/161 cases, p < 0.0001). CONCLUSIONS: The experience at University Hospitals of Cleveland suggests that abdominal catastrophe occurs in approximately 10% of all patients treated with PD, and is associated with high mortality, which has not changed over time. Therefore, peritonitis due to spontaneous visceral injury presents a great diagnostic and therapeutic challenge. It is important to develop a research strategy to understand this devastating complication.  (+info)

How and why the health insurance system will collapse. (7/59)

The advocates of defined-contribution health plans extol the virtues of consumer-driven health care, consumer choice, and empowered consumers as solutions to the problems--particularly the rapidly growing costs--of employer-sponsored health benefits. This paper argues that the widespread use of defined-contribution plans, with more consumer choice and more knowledgeable consumers, will lead to the erosion of the social contract on which health insurance must be based, with healthier employees subsidizing the care of older and sicker ones, and a death spiral of adverse selection. If unchecked by government intervention, these trends will lead to the collapse of employer-sponsored health insurance.  (+info)

Wealth patterns among elderly Americans: implications for health care affordability. (8/59)

This paper estimates the ability of the elderly to pay for necessary health care services and emerging technologies. Projections from the Long Term Care Financing Model paint a promising picture of the income and assets that elders in the future will have available to support discretionary, uncovered health care and service costs. Nevertheless, policymakers should pay close attention to the finances of the "Tweeners"--people who are middle class with low levels of discretionary assets available for health and long-term care.  (+info)