What physicians need to know about seniors and limited prescription benefits, and why.
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More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits, and they may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions. (+info)
Managing costs, managing benefits: employer decisions in local health care markets.
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OBJECTIVES: To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems. DATA SOURCES/STUDY SETTING: Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities. STUDY DESIGN: This is an observational study with data collection over a six-year period. DATA COLLECTION/EXTRACTION METHODS: The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions. PRINCIPAL FINDINGS: The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results. CONCLUSIONS: General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions. (+info)
An empty toolbox? Changes in health plans' approaches for managing costs and care.
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OBJECTIVE: To examine how health plans have changed their approaches for managing costs and utilization in the wake of the recent backlash against managed care. DATA SOURCES/STUDY SETTING: Semistructured interviews with health plan executives, employers, providers, and other health care decision makers in 12 metropolitan areas that were randomly selected to be nationally representative of communities with more than 200,000 residents. Longitudinal data were collected as part of the Community Tracking Study during three rounds of site visits in 1996-1997, 1998-1999, and 2000-2001. STUDY DESIGN: Interviews probed about changes in the design and operation of health insurance products--including provider contracting and network development, benefit packages, and utilization management processes--and about the rationale and perceived impact of these changes. DATA COLLECTION/EXTRACTION METHODS: Data from more than 850 interviews were coded, extracted, and analyzed using computerized text analysis software. PRINCIPAL FINDINGS: Health plans have begun to scale back or abandon their use of selected managed care tools in most communities, with selective contracting and risk contracting practices fading most rapidly and completely. In turn, plans increasingly have sought cost savings by shifting costs to consumers. Some plans have begun to experiment with new provider networks, payment systems, and referral practices designed to lower costs and improve service delivery. CONCLUSIONS: These changes promise to lighten administrative and financial burdens for physicians and hospitals, but they also threaten to increase consumers' financial burdens. (+info)
Self-insurance in times of growing and retreating managed care.
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This paper examines trends in self-insurance and in the content of self-insured plans from 1993 to 2001. The percentage of employees enrolled in self-insured plans fell during these years. Much of the decrease was attributable to the decline of indemnity insurance and the rise of HMO and point-of-service plan enrollment. If the product mix had remained constant throughout these years, self-insured enrollment would have grown between 1993 and 1996 and then declined to its current 50 percent level. As a result of the Health Insurance Portability and Accountability Act (HIPAA), the use of preexisting condition clauses declined dramatically in self-insured plans. Self-insured and purchased plans cost similar amounts and provide similar benefits. Cost sharing is somewhat lower in self-insured PPO plans. During periods of rapid inflation, premiums increase more slowly for self-insured than for fully insured plans. (+info)
Medicare program; improvement to the Medicare+Choice appeal and grievance procedures. Final rule with comment period.
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This final rule with comment period responds to comments on the January 24, 2001, proposed rule regarding improvements to the Medicare+Choice (M+C) appeal and grievance procedures. It establishes new notice and appeal procedures for enrollees when an M+C organization decides to terminate coverage of provider services. The January 24, 2001 proposed rule was published as a required element of an agreement entered into between the parties in Grijalva v. Shalala, civ. 93-711 (U.S.D.C. Az.), to settle a class action lawsuit. This rule also specifies a Medicare-participating hospital's responsibility for issuing discharge or termination notices under both the original Medicare and M+C programs, amends the Medicare provider agreement regulations with regard to beneficiary notification requirements, and amends M+C enrollee grievance procedures. (+info)
How low can you go? The impact of reduced benefits and increased cost sharing.
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Amid escalating health care costs and a managed care backlash, employers are considering traditional cost control methods from the pre-managed care era. We use an actuarial model to estimate the premium-reducing effects of two such methods: increasing employee cost sharing and reducing benefits. Starting from a baseline plan with rich benefits and low cost sharing, estimated premium savings as a result of eliminating five specific benefits were about 22 percent. The same level of savings was also achieved by increasing cost sharing from a 15 dollars copayment with no deductible to 20 percent coinsurance and a 250 dollars deductible. Further increases in cost sharing produced estimated savings of up to 50 percent. We discuss possible market- and individual-level effects of the proliferation of plans with high cost sharing and low benefits. (+info)
How much do kids count in corporate board rooms? Results from the first survey of Fortune 1000 companies.
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OBJECTIVE: The objective of this study was to characterize the extent of the business community's commitment to children, particularly with respect to understanding its role in assuring children's health and development, by conducting a survey of the largest US companies. METHODS: A survey of year 2001 Fortune 1000 companies was performed to determine whether their mission statements, vision statements, or guiding principles include a commitment to children; whether they employ people under the age of 18 years in the United States; whether they encourage their employees to mentor children under the age of 18 years; whether they have an affiliated philanthropic foundation; whether their company's philanthropy focuses specifically on children; and whether they participate in any activities that particularly help disadvantaged children. The survey consisted of 2 mailings followed by phone calls to companies to obtain answers to the questions listed above and answers to additional questions that asked specifically about the company's financial expenditures for parental leave, child care, and healthcare for children of employees and about the company's specific philanthropic giving aimed at helping children. Descriptive information about some of the ways that companies impact the lives of children was also obtained to provide context for the responses. RESULTS: Data were obtained from 333 year 2001 Fortune 1000 companies (33%) between March 20, 2002 and March 20, 2003, with a good representation of all industry sectors. These data suggest that approximately 33% of the companies that responded have mission statements, vision statements, or guiding principles that specifically include a commitment to children. Employment opportunities for children under the age of 18 years in the United States exist at approximately 41% of these companies. These companies clearly see mentoring as a major theme, with 77% of them encouraging their employees to mentor children under the age of 18 years. Approximately 60% of the companies that responded support affiliated, independent philanthropic foundations, and approximately 55% of companies indicated that they focus their philanthropy specifically (although not exclusively) on children. Approximately 80% of these companies indicated that they participate in at least one activity that helps disadvantaged children. Many companies faced challenges in estimating their overall investments in children, particularly given their large and decentralized nature, but they were able to provide an overall sense of their commitment and they indicated that they could provide quantitative data prospectively if they knew it would be requested. CONCLUSION: Many companies that responded play a major role in supporting children's health and development in the United States both directly and indirectly. Further efforts to better quantify the business community's aggregate commitments to improving children's health and development should be sought to allow better estimation of the amount of resources expended and the impact of these investments on children. (+info)
Elimination of sanctions for refusal of vocational rehabilitation services without good cause. Final rule.
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We are amending our regulations to remove provisions relating to the imposition of benefit sanctions on account of a beneficiary's refusal of rehabilitation services. We are making these changes to reflect the repeal of sections 222(b) and 1615(c) of the Social Security Act (the Act). Prior to their repeal, these sections of the Act authorized the Commissioner of Social Security to impose sanctions against the benefits of a disabled or blind beneficiary who refused, without good cause, to accept rehabilitation services made available by a State vocational rehabilitation (VR) agency. The Ticket to Work and Work Incentives Improvement Act of 1999 repealed these sections of the Act, effective January 1, 2001. We are amending our regulations by removing rules and related provisions that are obsolete as a result of the repeal of these sections of the Act to conform our regulations to the changes in the statute. (+info)