An insightful overview of health insurers and a guide to sustainability for provider organizations.Physicians experience ongoing frustrations in their relationships with health plans. Even as they ...struggle to keep up with accelerating clinical advances, they face daunting challenges from payers that are transitioning from traditional fee-for-service contracts to complex alternative payment models. In Health Plans Unmasked, Martin Lustick, MD, offers insights and guidance for those who face the herculean task of transforming their business practices to achieve financial stability while improving outcomes for their patients.By explaining both how and why insurance companies behave the way they do, Dr. Lustick helps providers avoid mistakes and take advantage of opportunities for success. He provides information on:• The evolution of health care financing in the United States• The nuts and bolts of health plan capabilities and the real motives of health plan administrators• Tips for successful contracting strategies • Alternative payment models and the promises of value-based careWith a career spanning five decades as a practicing pediatrician, chief operating officer of a medical group, chief medical officer of a hospital, and chief medical officer of a health plan, Dr. Lustick provides a straightforward guide to sustainability for provider organizations. Physicians, office managers, and anyone in a health-related field will benefit from his breaking down the role of health plans in our health care ecosystem.
Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and ...improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years.
We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status.
8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies).
Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.
After World War II, the United States and Canada, two countries that were very similar in many ways, struck out on radically divergent paths to public health insurance. Canada developed a universal ...single-payer system of national health care, while the United States opted for a dual system that combines public health insurance for low-income and senior residents with private, primarily employer-provided health insuranceùor no insuranceùfor everyone else. In National Health Insurance in the United States and Canada, Gerard W. Boychuk probes the historical development of health care in each country, honing in on the most distinctive social and political aspects of each countryùthe politics of race in the U.S. and territorial politics in Canada, especially the tensions between the national government and the province of Quebec.In addition to the politics of race and territory, Boychuk sifts through the numerous factors shaping health policy, including national values, political culture and institutions, the power of special interests, and the impact of strategic choices made at critical junctures. Drawing on historical archives, oral histories, and public opinion data, he presents a nuanced and thoughtful analysis of the evolution of the two systems, compares them as they exist today, and reflects on how each is poised to meet the challenges of the future.
Ensuring America's Health explains why the US health care system offers world-class medical services to some patients but is also exceedingly costly with fragmented care, poor distribution, and ...increasingly bureaucratized processes. Based on exhaustive historical research, this work traces how public and private power merged to favor a distinctive economic model that places insurance companies at the center of the system, where they both finance and oversee medical care. Although the insurance company model was created during the 1930s, it continues to drive health care cost and quality problems today. This wide-ranging work not only evaluates the overarching political and economic framework of the medical system but also provides rich narrative detail, examining the political dramas, corporate maneuverings, and forceful personalities that created American health care as we know it. This book breaks new ground in the fields of health care history, organizational studies, and American political economy.
Objective
To investigate how changes in insurer participation and composition as well as state policies affect health plan affordability for individual market enrollees.
Data Sources
2014‐2019 ...Qualified Health Plan Landscape Files augmented with supplementary insurer‐level information.
Study Design
We measured plan affordability for subsidized enrollees using premium spreads, the difference between the benchmark plan and the lowest cost plan, and premium levels for unsubsidized enrollees. We estimated how premium spreads and levels varied with insurer participation, insurer composition, and state policies using log‐linear models for 15 222 county‐years.
Principal Findings
Increased insurer participation reduces premium levels, which is beneficial for unsubsidized enrollees. However, it also reduces premium spreads, leading to lower plan affordability for subsidized enrollees. States responding to cost‐sharing reduction subsidy payment cuts by increasing only silver plans' premiums increase premium spreads, particularly when premium increases are restricted to on‐Marketplace silver plans. The latter approach also protects unsubsidized, off‐Marketplace enrollees from experiencing premium shocks.
Conclusions
Insurer participation and insurer composition affect subsidized and unsubsidized enrollees' health plan affordability in different ways. Decisions by state regulators regarding health plan pricing can significantly affect health plan affordability for each enrollee segment.
Can private health insurance fill gaps in publicly financed coverage? Does it enhance access to health care or improve efficiency in health service delivery? Will it provide fiscal relief for ...governments struggling to raise public revenue for health? This book examines the successes, failures and challenges of private health insurance globally through country case studies written by leading national experts. Each case study considers the role of history and politics in shaping private health insurance and determining its impact on health system performance. Despite great diversity in the size and functioning of markets for private health insurance, the book identifies clear patterns across countries, drawing out valuable lessons for policymakers while showing how history and politics have proved a persistent barrier to effective public policy. This title is also available as Open Access on Cambridge Core.
Summary Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and ...globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.
Since 1993, Colombia has had a mandatory social health insurance scheme that aims to provide universal health coverage to all citizens. However, some contributory regime participants purchase ...voluntary private health insurance (VPHI) to access better quality health services (i. e., physicians and hospitals), shorter waiting times, and a more extensive providers' network. This article aims to estimate the price elasticity of demand for the VPHI market in Colombia.
We use data from the 2016-2017 consumer expenditure national survey and apply a Heckman selection model to address the selection problem into purchasing private insurance. Using the estimation results to further estimate the price semi-elasticity for VPHI, we then calculate the price elasticity for the households' health expenditure and acquisition of VHPI.
Our main findings indicate that a 1% VPHI price increase reduces the proportion of households affiliated to a VPHI in the country by about 2.32% to 4.66%, with robust results across sample restrictions. There are relevant differences across age groups, with younger households' heads being less responsive to VPHI price changes.
We conclude that the VPHI demand in Colombia is noticeably elastic, and therefore tax policy changes can have a significant impact on public health insurance expenditures. The government should estimate the optimal VPHI purchase in order to reduce any welfare loss that the current arrangement might be generating.
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