Industrial accident compensation insurance benefits on cerebrovascular and heart disease in Korea. (57/314)

The purpose of this study is to present the importance of work-related cerebrovascular and heart disease from the viewpoint of expenses. Using the insurance benefit paid for the 4,300 cases, this study estimated the burden of insurance benefits spent on work-related cerebrovascular and heart disease. The number of cases with work-related cerebrovascular and heart disease per 100,000 insured workers were 3.36 in 1995; they were increased to 13.16 in 2000. By the days of occurrence, the estimated number of cases were 1,336 in 2001 (95% CI: 1,211-1,460 cases) and 1,769 in 2005 (CI: 1,610-1,931 cases). The estimated average insurance benefits paid per person with work-related cerebrovascular and heart disease was 75-19 million won for medical care benefit and 56 million won for other benefits except medical care. By considering the increase in insurance payment and average pay, the predicted insurance benefits for work-related cerebrovascular and heart disease was 107.9 billion won for the 2001 cohort and 192.4 billion won for the 2005 cohort. From an economic perspective, the results will be used as important evidence for the prevention and management of work-related cerebrovascular and heart disease.  (+info)

Medicare program; modifications to managed care rules. Final rule. (58/314)

This final rule responds to comments that we received on a proposed rule that was published in the Federal Register on October 25, 2002. It implements certain provisions relating to the Medicare+Choice (M+C) program that were enacted in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection (BIPA) Act of 2000. It also addresses comments on, and makes revisions to, regulations that were discussed in the October 2002 proposed rule that were based on M+C program experience and feedback from M+C organizations.  (+info)

Clarification of rules involving residual functional capacity assessments; clarification of use of vocational experts and other sources at step 4 of the sequential evaluation process; incorporation of "special profile" into regulations. Final rules. (59/314)

For purposes of this document, "we," "our," and "SSA" refer to the Social Security Administration and State agencies that make disability determinations for the Social Security Administration. "You" and "your" refer to individuals who claim benefits from the Social Security Administration based on "disability." In this final rule we clarify our rules about the responsibility that you have to provide evidence and the responsibility that we have to develop evidence in connection with your claim of disability. This includes our rules about when we assess your residual functional capacity (RFC) and how we use this RFC assessment when we decide whether you can do your past relevant work or other work. These clarifications address issues of responsibility raised by some courts in recent cases; clarify that we may use vocational experts (VEs), vocational specialists (VSs), or other resources to obtain evidence we need to help us determine whether your impairment(s) prevents you from doing your past relevant work; add a special provision to our rules stating that, if you are at least 55 years old, and specific other circumstances are present, we will find that you are disabled; and make a number of minor editorial changes to clarify and update the language of our rules, and to use simpler language in keeping with our goal of using plain language in our regulations.  (+info)

Revised medical criteria for evaluating amyotrophic lateral sclerosis. Final rules. (60/314)

We are revising the criteria in the Listing of Impairments (the listings) that we use to evaluate Amyotrophic Lateral Sclerosis (ALS). We apply these criteria when you claim benefits based on disability under title II or title XVI of the Social Security Act (the Act). The revision provides that we will find you disabled if you have medical evidence showing that you have ALS. Because of this change, we are also adding guidance about ALS to our listings. We are also adding ALS to the list of specific impairment categories in our regulation that provides for presumptive disability payments under title XVI.  (+info)

Can managed care and competition control Medicare costs? (61/314)

Medicare+Choice (M+C) was conceived to bring managed care and competitive forces to bear on Medicare. Ultimately, M+C could not thrive under the conditions of the marketplace and the Balanced Budget Act of 1997. Here I review what went wrong and the lessons from the experience, concluding that M+C is a tool, not a strategy. While managed care in a multiple-choice environment may have the potential to generate limited savings, promoting managed care and competition alone will not preempt the need for a debate on Medicare's obligations and how to finance them.  (+info)

Expanding public health insurance to parents: effects on children's coverage under Medicaid. (62/314)

OBJECTIVE: To assess whether expanding public health insurance coverage to parents leads to increases in Medicaid participation among children. DATA SOURCES/STUDY SETTING: Study uses data from the 1997 and 1999 National Survey of America's Families. Insurance coverage of children eligible for Medicaid under the poverty-related expansions is analyzed. STUDY DESIGN: We conduct two analyses. In the first, we examine the cross-sectional difference regarding whether Medicaid participation is higher for children eligible for Medicaid under the poverty-related expansions when states expand public health insurance programs to cover their parents. In the second, we use a difference-in-difference approach to assess whether the expansion of the Medicaid program to cover parents in Massachusetts led to an increase in Medicaid coverage among children between 1997 and 1999 relative to changes that occurred in the rest of the nation. DATA COLLECTION/EXTRACTION METHODS: The analysis relies on a detailed Medicaid and SCHIP eligibility simulation model that identifies children surveyed on the NSAF who are eligible for Medicaid under the poverty-related expansions. PRINCIPAL FINDINGS: Children who reside in states that expanded public health insurance programs to parents participate in Medicaid at a rate that is 20 percentage points higher than of those who live in states with no expansions. The Massachusetts expansion in coverage to parents led to a 14 percentage point increase in Medicaid coverage among children due principally to reductions in uninsurance among already eligible children. CONCLUSIONS: Expanding public health insurance coverage to parents has benefits to children in the form of increased participation in Medicaid.  (+info)

Effects of a 3-tier pharmacy benefit design on the prescription purchasing behavior of individuals with chronic disease. (63/314)

OBJECTIVE: To evaluate the impact of 3-tier (copayment) pharmacy benefit structures on medication utilization behavior. METHODS: A pretest-posttest quasi-experimental design was employed. Chronic disease sufferers (N=8,132) from a health plan were classified into the following groups: (a) 2-tier copayment moving to a 3-tier structure, (.converting. group), (b) 2-tier staying in a 2-tier structure and, (c) 3-tier staying in a 3-tier structure. The latter 2 were.comparison. groups. Two 7-month time periods were determined: the.preperiod. (June through December 2000) and the.postperiod. (January through July 2001) for a change in pharmacy benefit structure. Pharmacy claims data were used for data collection. Statistical analyses included bivariate tests to evaluate predifferences and postdifferences across study groups. Maximum likelihood estimates from a repeated measures model were used to examine changes in formulary compliance and generic use rates. Discontinuation of nonformulary medications was evaluated using logistic regression. RESULTS: Controlling for demographics, number of comorbidities, disease state, and pharmacy benefit structure, the formulary compliance rate increased by 5.6% for the converting group. No significant increases were seen for the comparison groups. Generic use rates increased by 6 to 8 absolute percentage points for all groups (3.3% to 4.9 % adjusted rates). Converting group members were 1.76 times more likely to discontinue their nonformulary medication than those in the 2-tier comparison group and 1.49 times more likely than those in the 3-tier comparison group. CONCLUSIONS: These findings suggest that shifting individuals from a 2-tier to a 3-tier drug benefit copayment structure resulted in changes in medication utilization. Decision makers need to balance these changes with the potential dissatisfaction that members may express in paying higher copayments.  (+info)

Indicators of preventable drug-related morbidity in older adults 2. Use within a managed care organization. (64/314)

OBJECTIVE: To determine the incidence of preventable drug-related morbidity (PDRM) in older adults in a provider-sponsored network and identify risk factors for PDRM. METHODS: The study was based on a retrospective review of an integrated health care database, using 52 newly developed clinical indicators of PDRM. The incidence of PDRM was determined by identifying individuals in the database who matched an outcome and pattern of care associated with an indicator. Risk factors were determined through a forward inclusion logistic regression model. The subjects in this study were 3,365 older adults enrolled in a hospital-based health care system in Florida in 1997. The principal outcome measure was identification of individuals who matched a PDRM indicator and risk factors for PDRM. RESULTS: Ninety-seven enrollees who matched one or more of 52 PDRM indicators were found in 3,365 older adults, for an overall incidence rate of 28.8 per 1000. The top 5 indicators of PDRM were responsible for 46.8% of all PDRMs found. Regression analysis identified 5 risk factors: 4 or more recorded diagnoses, 4 or more prescribers, 6 or more prescription medications, antihypertensive drug use, and male gender. CONCLUSION: This study demonstrated that clinical indicators can be used in a managed care organization to identify seniors who have experienced a PDRM. The risk model should better prepare managed care organizations to proactively identify patients at risk for PDRM and to optimize medication use in older adults.  (+info)