Frequent-user patients: reducing costs while making appropriate discharges

Homeless patients who lack access to the health resources they need to maintain their health on their own pose a challenge for hospitals: Premature discharge of such patients can result in their being readmitted to the hospital in a short time, leading to higher costs for the hospital. Hospitals can address this problem by developing clear, effective homeless discharge policies and by developing ongoing relationships with appropriate medical respite care providers. A hospital also can benefit from spearheading an initiative to develop a medical respite program, enlisting the assistance of other community stakeholders.     

Medical savings accounts: why do they work?

This article analyzes and reviews the cost and design characteristics of medical savings accounts (MSAs). By placing premium savings from high-deductible health insurance in medical savings accounts, individuals have an incentive to shop for medical services. A more market-oriented health insurance and delivery system results, as individuals are now both users and buyers of health care. Data show that most families would accumulate balances in their MSAs that may be used for future medical expenses or savings. Through program design, the potential problems of adverse selection and cost to risk can be greatly reduced.     

Medicare on the critical list. Understanding the etiology of the disease will help in the search for a cure.

Medicare, and its companion program Medicaid, came into being as part of Lyndon Johnson's Great Society. Their purpose was to provide the elderly with equal access to high-quality medical care. Though the goals were laudable, the magnitude of the costs and of the effects was unforeseen. As the two programs made medical care available to a large segment of the population, the demand grew. At the same time, private industry became more generous with its health insurance plans. Because of their emphasis on hospital care, the governmental and private industry plans helped push hospital prices up. Now that both sectors are finding the cost of medical care unacceptably high, Congress is proposing remedial legislation and corporations are trying alternative health care plans. These authors explore how well the maladies of Medicare may respond to the various cures that are being proposed.     

医疗保险定额付费方式有效性的探讨

医疗保险中的定额付费方式指不论实际发生了多少医疗费用,均以事先确定的标准向医疗机构支付费用,这种支付方式的有效运作意味着可以在控制医疗费用的同时又确保医疗质量.本文认为可能对定额付费方式有效性产生影响的因素包括服务质量对患者诊疗需求的影响程度;医疗机构增加患者诊疗需求的意愿;医疗机构的拒诊和撇脂行为;经办机构在合同签订...     

Targeted population health management can help a hospital grow market share

In 2005, St. Luke's Hospital in Chesterfield, Mo., launched the "Passport to Wellness" program to help employers reduce preventable illnesses by providing access to screenings, health education, health coaching, disease management, and healthy lifestyle programs. The program was designed to influence consumer choice of hospitals and physicians and influence health insurance purchasing decisions. St. Luke's program also met goals created by local businesses, including identifying health risks of each employer's workforce and reducing health-related costs.     

Self-reported health: potential life underwriting tool?

Any approach that adds speed and efficiency to the underwriting process provides a competitive edge in today's fast changing financial services industry. The acquisition of data for medical underwriting has always been a challenge; with the traditional attending physician statement process adding time, real costs, and opportunity costs to manufacturing life products. Is there any potential for the use of self-reported medical and health history data in medical underwriting assessment? This article reviews published research on the uses and the validity of self-reported health data as it has been applied in current medical and public health practices. Whether self-reported medical history is valid data that can be applied in the underwriting context remains an open question.     

A THEORETICAL ANALYSIS OF DESIGN ISSUES IN MEDICAL SAVINGS ACCOUNTS: THE POLICY IMPLICATIONS

Abstract: Numerous methods for helping consumers deal with medical care costs have been suggested. One way that has been discussed is the use of Medical Saving Accounts. A pilot program introducing Medical Spending Accounts was passed by Congress as part of the Health Insurance Reform Act of 1996. The authors review the major points of this program and attempt to examine what impact this program could have on medical care cost.     

The employer's case for health management

Employers' past solutions to rising health benefit costs--adopting managed care strategies, cost shifting to employees and reducing benefits-are no longer effectively controlling costs and are depressing the value of health benefits for employee recruitment and retention. An alternative strategy is to implement health management approaches that improve the health status of employees. These programs reduce medical costs and have a documented positive impact on workers' compensation, disability costs, absenteeism and productivity. Further, this approach is complementary to health care consumerism as a strategy for health improvement and benefit cost reduction and results in improved employee health, outlook and satisfaction.     

从中国医药卫生体制改革看卫生教育的发展方向

新医改方案的出台,对卫生管理人才队伍建设和医学教育发展提出了更高的要求。新医改方案并不是最终的方案,需要不断地试点、摸索,加大对卫生管理人才队伍建设是当务之急。探讨我国卫生教育的发展方向,提出应大力培养医学创新人才和应用型卫生管理人才,加强人文素质教育,并使中医教育回归。     

The hospital: how will it survive?

The federal government is under pressure to implement and enforce a program to provide economic and social relief from the rapidly escalating health care costs which now consume 8.5% of the Gross National Product. Glick predicts that within the next twenty years, the character of health care institutions will be reshaped and only the most adaptable hospitals, health maintenance organizations and health-related governmental organizations will survive. He urges hospitals to develop appropriate strategies to deal with the problems of cost-containment, state-operated cost review and control agencies, and the competition for limited health care resources. The author warns the health care industry that if it does not adjust to these changes, it runs the risk of becoming heavily rgulated. It is suggested that health care institutions be integrated into comprehensive health care systems and the article includes a model for assigning patients to medical care facilities on a regional basis. Glick forecasts that hospitals will enter into a competition for survival, resulting in mergers of some and the closing of others. He believes that as the number of health care institutions decreases, the remaining ones will become more specialized and geographically dispersed.     

Medicare Secondary Payer--liability of alleged tortfeasors. Mason v. American tobacco company

The Medicare Secondary Payer (MSP) statute does not provide individuals whose medical costs have been paid for by Medicare with a right of recovery against alleged tortfeasors (wrongdoers). Tobacco companies are not self-insured primary plans under the MSP statute because they have no existing contractual obligation to pay the health care costs of those injured by smoking.     

Der Einfluss des demographischen Wandels auf die Ausgaben der Krankenversicherung

The analysis presented in this document investigates the question of whether the increase in life expectancy causes financial stress for health insurance systems or not. In particular, the authors focused on the financial impact of the ?costs of dying“ and how much these costs contribute to the total health costs. The article analyses an in-patient and an out-patient tariff of a large private health insurance company in Germany. It is based on health care costs of people who died in 1999 and of those who continued to live. The percentage of the costs of dying is often overestimated. However, the costs of those who continued to live increased overproportionately. In particular, this was true for the insured people over 80 years.The claim that the increase of life expectancy only postpones the high costs in the future and has no impact on the financial conditions of health insurance is doubtful. Older people live longer and have more opportunity to take medication and receive therapy for a longer period. Therefore we argue that longer life expectancy and other factors like progress in medical technology pose a severe threat on the financial stability of health insurance.     

微观经济个体参保行为对医疗费用支出的影响效应研究

本文根据2016年中国家庭追踪调查数据,运用面板数据回归方法和倾向得分匹配法(PSM)研究微观经济个体参保行为对医疗费用支出的影响。研究表明,城镇职工医疗保险参保行为显著提高了医疗总费用和自付费用,城乡居民医疗保险参保行为对降低医疗总费用和自付费用具有一定的积极作用,新农合参保行为显著降低了医疗总费用,对自付费用的降低具有一定的积极作用。运用PSM法解决内生性问题和消除选择性偏差后得到的净效应结果与上述发现基本一致。参保行为与医院等级的交互分析表明,选择社区诊所等基层诊疗机构就诊可显著降低医疗总费用和自付费用,选择综合医院就诊则显著提高医疗总费用和自付费用。此外,参保行为对医疗费用支出的影响具有个体和区域异质性。据此,建议增强基层医疗卫生服务能力,进一步提高统筹层次,推进公共卫生服务均等化。     

城镇职工退休人员缴纳医疗保险费的可行性及其相关问题探讨——社会保障学者专题讨论综述

2016年初有政府官员提出要建立合理分担、可持续的医保筹资机制,合理强化医保个人缴费责任,研究实行职工医保退休人员缴费政策。部分社会保障学者在微信平台上进行了"退休人员缴纳医疗保险费是否缓解医疗基金支付压力的良方"专题讨论。讨论从退休人员缴纳医保费问题的可行性开始,逐渐深入到医疗控费、公立医院改革、政府角色定位和长期护理保险等医疗领域重难点问题。     

Depression in the workplace: negative effects, perspective on drug costs and benefit solutions

Depression is a relatively common disease that has more impact on employers' health care costs and workplace productivity than many chronic medical conditions. This article describes the costs of depression, both direct and indirect, and discusses effective employer strategies for dealing with depression in the workplace.     

Health risk management: well-being for the employee and the bottom line

For most employers, a small percent of the employee/participant population accounts for a large percent of health care costs. However, the population of this high-cost group changes from year to year. The fundamental problem is keeping employees out of the high-risk/high-cost segment, something plan design changes cannot address but that integrated health risk management (IHRM) can help achieve. This article explains how employers can implement an IHRM program to significantly lower health care costs to a degree unattainable through traditional cost-control strategies, while simultaneously raising workers' productivity and well-being.     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

More preventive care, and fewer emergency room visits and prescription drugs--health care utilization in a consumer-driven health plan

Although consumer-driven health plans (CDHPs) have grown dramatically, the question of whether CDHPs have reduced health care costs has not been answered definitively. This article presents what the authors believe to be the first study to analyze a large sample of claims data and to look in detail at different types of utilization among enrollees in a CDHP and those in a traditional comprehensive major medical (CMM) plan. After adjusting for the finding that CDHP enrollees are both younger and healthier than those in CMM plans, the authors found that CDHP enrollees show no consistent or significant utilization differences for measures over which consumers have little control (e.g., inpatient stays); lower utilization for measures over which consumers have greater control (e.g., emergency room visits); and higher utilization of preventive services.     

新疆自治区农村医疗救助制度运行分析

本文在健康贫困的视角下,认为政府对贫困人口提供医疗救助是帮助贫困人口摆脱“贫困陷阱”的重要途径。本文分析了新疆农村地区的健康与贫困的概括,着重从制度的可及性、有效性、稳定性、运行成本四个维度评估了新疆农村医疗救助制度,并在评估结论的基础上,提出了改进新疆农村医疗救助事业的若干思考。