Patients' rights after health care reform: who decides what is medically necessary?
(25/27)
President Clinton's Health Security Act entitles individuals not to unlimited health care, but to a package of defined insurance benefits with specific exclusions and limitations. Like virtually all reform proposals, it would limit covered benefits to services that are medically necessary. If health reform is to control costs, not all medically necessary care can be covered. In the absence of a generally accepted definition of medical necessity, many services will not be guaranteed to all patients unless they are explicitly covered in the federal legislation or regulations. Without a federal definition of medical necessity or regulations listing covered services, health insurance plans will retain the primary authority to decide what is medically necessary for their patient subscribers. (+info)
Who chooses prepaid medical care: Survey results from two marketings of three new prepayment plans.
(26/27)
Employees joining or not joining three newly marketed prepayment plans were surveyed during the first marketing period and during another open enrollment period 18 months later. In the 1973 survey the respondents were 149 subscribers (family contracts covering 568 persons) to the new plans and 224 nonjoiners (a total of 802 persons in their families)--all employees of Rochester's largest industry. In the 1975 survey the respondents were employees of several companies. They included 326 joiner families (1,101 persons) and 145 nonjoiner families (483 persons). There were no significant differences in previous out-of-pocket health expenditures between joiners and nonjoiners. Their self-reported health ratings did not differ; disability over the last 2 weeks was about the same. Physician utilization rates and inpatient rates were similar, except for the spouses of subscribers to one plan. However, the joiners were younger, had lived in Rochester for a shorter period, and had made less use of physicians in private practice. The three prepayment plans appealed to different population groups. The Network joiners were young, low-income families, mostly from the city. The Group Health joiners were young families with few children who especially valued availability, accessibility, and comprehensiveness. Health Watch joiners were older couples who preferred to use the traditional avenues to health care. (+info)
Impact of the Medicare Catastrophic Coverage Act on nursing homes.
(27/27)
The Medicare Catastrophic Coverage Act (MCCA) of 1988 altered eligibility and coverage for skilled nursing facility (SNF) care and changed Medicaid eligibility rules for nursing-home residents. Detailed data on the residents of a for-profit nursing-home chain and Medicare claims for a 1 percent sample of beneficiaries were used to examine the impact of the MCCA on nursing homes. The case mix of nursing-home admissions was scrutinized, specifically for length of stay, discharge disposition, rate of hospitalization, and changes in payer source. Findings revealed that, although the proportion of Medicare-financed nursing-home care increased, as did the case-mix severity of residents during the MCCA period, there was no corollary reduction in hospital use by nursing-home residents. (+info)