The economic functions of carve outs in managed care.
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This paper considers the economic functions of contracting separately for a portion of the insurance risk, offering both the payer's (i.e., employer's) and the health plan's perspective. Four major forms of carve outs are discussed: (1) payer specialty carve outs from all health plans; (2) payer specialty carve outs from only indemnity and preferred provider organization arrangements; (3) individual health plan carve outs to specialty vendors; and (4) group practice carve outs to specialty organizations. The paper examines whether carving out care fosters the payer's goal of delivering reasonable healthcare efficiently, how adverse selection affects the provision of healthcare, and the costs of providing this specialized care. (+info)
Carve outs: definition, experience, and choice among candidate conditions.
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Despite increasing discussion of carve outs as a device for controlling costs and improving quality of care, little systematic information exists on the effects of carve outs on cost, quality, and access to healthcare services. In the absence of such information, a conceptual framework is useful for deciding which conditions and populations may benefit from carve-out strategies, and how such arrangements should be designed. After carefully defining carve outs, and distinguishing them from other similar arrangements, this paper identifies five characteristics of a healthcare condition that increase the likelihood that a carve out's benefits will outweigh its drawbacks. The paper also examines the advantages and disadvantages of alternative approaches to structuring and administering carve-out arrangements, including how to pay for services, how to integrate them with mainstream care, provisions for consumer choice and provisions for carve-out accountability. The piece concludes that population carve outs, in which all the healthcare problems of a group of patients are managed by the carve-out organization, have inherent advantages, and identifies candidate conditions for population carve outs. (+info)
The effect of a Medicaid managed care program on the adequacy of prenatal care utilization in Rhode Island.
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OBJECTIVES: The purpose of this study was to determine whether adequacy of prenatal care utilization improved after the implementation of a Medicaid managed care program in Rhode Island. METHODS: Rhode Island birth certificate data (1993-1995; n = 37021) were used to analyze pre- and post-program implementation changes in adequacy of prenatal care utilization. Logistic regression models were used to characterize the variation in prenatal care adequacy as a function of both time and the various covariates. RESULTS: Adequacy of prenatal care utilization for Medicaid patients improved significantly after implementation of the program, from 57.1% to 62.1% (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.1, 1.3). After the program was implemented, Medicaid patients who went to private physicians' offices for prenatal care were 1.4 times as likely as before to receive adequate prenatal care (OR = 1.4, 95% CI = 1.2, 1.7). CONCLUSIONS: Unlike many other Medicaid expansions for pregnant women, the RIte Care program in Rhode Island has resulted in significant improvement in adequacy of prenatal care utilization for its enrollees. This improvement was due to specific program interventions that addressed and changed organizational and delivery system barriers to care. (+info)
The impact of welfare reform on parents' ability to care for their children's health.
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OBJECTIVES: Most of the national policy debate regarding welfare assumed that if middle-income mothers could balance work while caring for their children's health and development, mothers leaving welfare for work should be able to do so as well. Yet, previous research has not examined the conditions faced by mothers leaving welfare for work. METHODS: Using data from the National Longitudinal Survey of Youth, this study examined the availability of benefits that working parents commonly use to meet the health and developmental needs of their children; paid sick leave, vacation leave, and flexible hours. RESULTS: In comparison with mothers who had never received welfare, mothers who had been on Aid to Families with Dependent Children were more likely to be caring for at least 1 child with a chronic condition (37% vs 21%, respectively). Yet, they were more likely to lack sick leave for the entire time they worked (36% vs 20%) and less likely to receive other paid leave or flexibility. CONCLUSIONS: If current welfare recipients face similar conditions when they return to work, many will face working conditions that make it difficult or impossible to succeed in the labor force at the same time as meeting their children's health and developmental needs. (+info)
Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration.
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OBJECTIVES: This study evaluated a joint initiative of the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) to improve access to Social Security disability benefits among homeless veterans with mental illness. METHODS: Social Security personnel were colocated with VA clinical staff at 4 of the VA's Health Care for Homeless Veterans (HCHV) programs. Intake assessment data were merged with SSA administrative data to determine the proportion of veterans who filed applications and who received disability awards at the 4 SSA-VA Joint Outreach Initiative sites (n = 6709) and at 34 comparison HCHV sites (n = 27 722) during the 2 years before and after implementation of the program. RESULTS: During the 2 years after the initiative began, higher proportions of veterans applied for disability (18.9% vs 11.1%; P < .001) and were awarded benefits (11.4% vs 7.2%, P < .001) at SSA-VA Joint Initiative sites. CONCLUSION: A colocation approach to service system integration can improve access to disability entitlements among homeless persons with mental illness. Almost twice as many veterans were eligible for this entitlement as received it through a standard outreach program. (+info)
Cost as a barrier to condom use: the evidence for condom subsidies in the United States.
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OBJECTIVES: This study sought to determine the impact of price on condom use. METHODS: A program based on distribution of condoms at no charge was replaced with one providing low-cost condoms (25 cents). Pretest and posttest surveys asked about condom use among persons reporting 2 or more sex partners. RESULTS: At pretest, 57% of respondents had obtained free condoms, and 77% had used a condom during their most recent sexual encounter. When the price was raised to 25 cents, the respective percentages decreased to 30% and 64%. CONCLUSIONS: Cost is a barrier to condom use. Free condoms should be distributed to encourage their use by persons at risk for HIV and other sexually transmitted diseases. (+info)
International developments in abortion law from 1988 to 1998.
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OBJECTIVES: In 2 successive decades since 1967, legal accommodation of abortion has grown in many countries. The objective of this study was to assess whether liberalizing trends have been maintained in the last decade and whether increased protection of women's human rights has influenced legal reform. METHODS: A worldwide review was conducted of legislation and judicial rulings affecting abortion, and legal reforms were measured against governmental commitments made under international human rights treaties and at United Nations conferences. RESULTS: Since 1987, 26 jurisdictions have extended grounds for lawful abortion, and 4 countries have restricted grounds. Additional limits on access to legal abortion services include restrictions on funding of services, mandatory counseling and reflection delay requirements, third-party authorizations, and blockades of abortion clinics. CONCLUSIONS: Progressive liberalization has moved abortion laws from a focus on punishment toward concern with women's health and welfare and with their human rights. However, widespread maternal mortality and morbidity show that reform must be accompanied by accessible abortion services and improved contraceptive care and information. (+info)
Health service accessibility and deaths from asthma.
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BACKGROUND: Good access to health services may be important for effective asthma management amongst patients, thus preventing unnecessary deaths. In a previous study, we found elevated levels of asthma mortality in English local authority districts with poor access to acute hospitals. Here, the relationship between asthma mortality and access to primary and secondary services within the rural region of East Anglia is examined. METHODS: A geographically based descriptive study, within 536 electoral wards in the region of East Anglia, England. Regression analysis was used to examine the relationship between health service accessibility, and mortality from asthma during the period January 1985 to December 1995. RESULTS: After controlling for confounding factors, there was a significant tendency for asthma mortality to increase with travel time to hospital, with a relative risk of 1.07 for each 10-minute increase in journey time (P = 0.04). There was no consistent trend for mortality to increase with travel time to general practitioner surgeries. CONCLUSIONS: The results of this study support the conclusions of earlier work that inaccessibility of acute hospital services may increase the risk of asthma mortality. The provision of good access to these facilities may be one factor in reducing the burden of avoidable deaths from asthma. (+info)