Setting a national minimum standard for health benefits: how do state benefit mandates compare with benefits in large-group plans?

Many proposed health insurance reforms would establish a federal minimum benefit standard--a baseline set of benefits to ensure that people have adequate coverage and financial protection when they purchase insurance. Currently, benefit mandates are set at the state level; these vary greatly across states and generally target specific areas rather than set an overall standard for what qualifies as health insurance. This issue brief considers what a broad federal minimum standard might look like by comparing existing state benefit mandates with the services and providers covered under the Federal Employees Health Benefits Program (FEHBP) Blue Cross and Blue Shield standard benefit package, an example of minimum creditable coverage that reflects current standard practice among employer-sponsored health plans. With few exceptions, benefits in the FEHBP standard option either meet or exceed those that state mandates require-indicating that a broad-based national benefit standard would include most existing state benefit mandates.

The Massachusetts Commonwealth Health Insurance Connector: structure and functions

The Commonwealth Health Insurance Connector Authority is the centerpiece of Massachusetts' ambitious health care reforms, which were implemented beginning in 2006. The Connector is an independent quasi-governmental agency created by the Massachusetts legislature to facilitate the purchase of affordable, high-quality health insurance by small businesses and individuals without access to employer-sponsored coverage. This issue brief describes the structure and functions of the Connector, providing a primer to policymakers interested in exploring similar reforms at the state and national level. The authors describe how the Connector works to promote administrative ease, eliminate paperwork, offer portability of coverage, and provide some standardization and choice of plans. National policymakers looking to achieve similar policy goals may find some of the structural components and functions of the Connector to be transferable to a national health reform model, say the authors.

[Discussing a "two-tiered medical system": a statement]

The criticism of a "two-tiered medical system" is a political slogan, which is also not exactly defined. However, for the public discussion this is not of further importance because talking about a "two-tiered medical system" has a priori a negative impact; in particular in times when people's fears surrounding medical care in Germany are great. Especially in a public health insurance system, insured people worry that in the future they will only receive the most essential medical services, rather than all services that are deemed reasonable and medically appropriate. One of the central themes in the discussion of a "two-tiered medical system" that causes disputes (or animosity) between privately and publicly insured persons arises when comparing differences in waiting periods to see a doctor and additional medical treatments made available to the privately insured. Critics of the "two-tiered medical system" envision a "one-tiered medical system"; one in which every person receives uniform healthcare, and in which the "purchase" of additional medical treatments is not permitted. However, the "one-tiered medical system" remains a theoretical construct. Service differences based on price differences are the reality. So the problem of the "two-tiered medical system" manifests itself only when those services that go beyond the basic care (privately offered services) negatively impact basic care, and/or displace basic care offerings. An example of this would be when a publicly insured patient has to wait longer to see a doctor because preference is given to privately insured patients. Economically speaking, negative external effects come into play. This causality has not been found or proven to be present in the German healthcare system. It exists neither in the inpatient nor in the outpatient healthcare sector. There is no basis to the claim that there is a difference in treatment favouring private patients with detrimental effects to non-privately insured patients. Therefore the claim that a "two tiered medical system" exists is negated. On the contrary: In the German health care system treatment differences above and beyond the basic services lead to an advantage for publicly insured patients. There are no negative, but rather positive external effects. This is mainly attributed to the increased doctors' revenue in the outpatient sector which amounted to Euro 4.4 billion in 2006 alone. Therefore, private patients subsidise the public insurance by funding a disproportionately high share of doctors' budgets.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit

OBJECTIVE

This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit.

METHOD

Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient.

RESULTS

A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems.

CONCLUSIONS

The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

The role of outcomes research in defining and measuring value in benefit decisions

OBJECTIVE

To identify ways that health care leaders at all levels can quantify the value proposition, thus influencing health care delivery and improving patient care.

SUMMARY

Payers and providers need to support, with rigorous research, the value proposition for customers. Outcomes research focusing on clinical and cost-effectiveness analysis can provide an understanding of successful, replicable interventions. Randomized controlled trials and observational studies can be used to reinforce and refine the business proposition in health care, and they can be integrated to target populations needing health care services. Evaluations using clinical and outcomes research can also predict what is likely to be successful in the future. To maximize the business value of projects, they must incorporate a prospective evaluation component that includes asking the right research questions, identifying an appropriate time period, including a targeted population, articulating a replicable intervention, and determining the correct statistical analysis.

CONCLUSION

Well-designed studies to analyze specific patient populations and their patterns of care can be used to determine a generalizable model to refine successful interventions that meet the critical value proposition for employers.

Crediting care or marriage? Reforming Social Security family benefits

OBJECTIVE

For more than 20 years policy advocates and policymakers have argued that Social Security should reward women for raising children. Current family benefits, which only benefit women who marry, are thought to be outdated and unable to protect the neediest women. Thus, would Black and poor women fare better if family benefits were linked to parenthood, as opposed to marriage? I examined three care credit proposals that reflect the most common proposals put forth in the United States and the most common designs in other countries.

METHODS

I used the 1992 Health and Retirement Study and the Current Population Survey to create a policy simulation that estimates how women reaching age 62 from 2020 to 2030 would be affected by care credits.

RESULT

Black and poor women fared best with benefits linked to parenthood. The specific proposal allowed parents, from the 35 earnings years used to calculate their benefit, to substitute $15,000 for up to 9 earnings' years that fell below this level.

DISCUSSION

The poorest women fare better with family benefits linked to parenthood instead of marital status. Moreover, they fare best when working women can benefit from care credits, but the care credit's value is not linked to earnings.

The effect of benefits, premiums, and health risk on health plan choice in the Medicare program

OBJECTIVE

To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan.

DATA SOURCE

Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare.

STUDY DESIGN

Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit.

PRINCIPAL FINDINGS

Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of -0.134 and an insurer-perspective elasticity of -4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage.

CONCLUSIONS

Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics.

A political history of medicare and prescription drug coverage

This article examines the history of efforts to add prescription drug coverage to the Medicare program. It identifies several important patterns in policymaking over four decades. First, prescription drug coverage has usually been tied to the fate of broader proposals for Medicare reform. Second, action has been hampered by divided government, federal budget deficits, and ideological conflict between those seeking to expand the traditional Medicare program and those preferring a greater role for private health care companies. Third, the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 reflect earlier missed opportunities. Policymakers concluded from past episodes that participation in the new program should be voluntary, with Medicare beneficiaries and taxpayers sharing the costs. They ignored lessons from past episodes, however, about the need to match expanded benefits with adequate mechanisms for cost containment. Based on several new circumstances in 2003, the article demonstrates why there was a historic opportunity to add a Medicare prescription drug benefit and identify challenges to implementing an effective policy.

Having it all: national benefit equity and local payment parity in Medicare

The Medicare Payment Advisory Commission (MedPAC) has identified two important problems with the Medicare+Choice (M+C) program: nationwide geographic inequity in government-financed benefits, and unequal government payments for M+C plans versus fee-for-service (FFS) Medicare in the same market area. MedPAC concludes that both problems cannot be solved simultaneously. We argue that both problems could be solved if Congress discontinued its policy of underwriting the cost of FFS Medicare. Instead, Congress should define a national entitlement benefit package and have all health plans submit bids on the package in each market area. The government's premium contribution should be equal to the lowest bid submitted by a qualified health plan in each market area. The contribution could be adjusted for health risk, the special obligations of FFS Medicare, and welfare enhancements associated with FFS Medicare that are valued by both beneficiaries and taxpayers but unrelated to beneficiaries' health status.

How does the purchasing staff of an accident insurance organization seek information about treatment effectiveness?

OBJECTIVES

The objective is to study how the staff who purchase health care services for a large national government accident-compensation system seek information on treatment effectiveness, how they assess the quality of that information, whether they question the information sources they choose, and how familiar they are with the key concepts of evidence-based health care (EBHC).

METHOD

Staff (22 out of 34) of the health purchasing division of the New Zealand Accident Compensation Corporation (NZ ACC) were interviewed using eight preformatted questions to which they could provide open and multiple answers. Responses were subsequently codified into typologies for quantitative analysis.

RESULTS

Most respondents report that they assess the effectiveness of a treatment by accessing published information (nonhuman sources), by consulting others (human sources), or by both means. They assess the quality of information mostly by consulting others, and the second-highest proportion of responses state that they do not know how to evaluate the quality of information. No clear preference emerges with respect to the types of information needed to determine the effectiveness of treatments. The majority of the staff believes they can access information needed to determine treatment effectiveness through the Internet or information databases such as MEDLINE. Although most said they understand the key concepts of EBHC, only five out of twenty-two were able to accurately describe them.

CONCLUSIONS

The findings suggest that there is a low level of awareness among the staff of the NZ ACC regarding the use of evidence and understanding of the key concepts of EBHC. Many surveyed staff members lack the skills or training to directly question information about effectiveness of a treatment. They have little idea of the information required to determine the effectiveness of a treatment, and the majority appears to lack the skills to evaluate the health care literature.

Commentary on Sommer et al. 'A randomized experiment of the effects of including alternative medicine in the mandatory benefit package of health insurance

The study by Sommer et al. recently reported in Complementary Therapies in Medicine has been heavily criticised in Switzerland since its original publication. Its major problems are an inadequate reflection of real practice, an inadequate study design relative to the central research objective, questionable value of the applied instrument and procedure for health assessment, methodological and statistical problems, and failure to consider literature relevant to the topic. For these reasons, this experimental study does not allow an answer to its central questions as to costs and effectiveness of complementary medicine made available within Switzerland's mandatory basic health insurance provisions. We propose more practice-related, non-experimental prospective study designs to realistically answer these questions.

Uses and abuses of prescription drug information in pharmacy benefits management programs

A 1998 incident in which patients' prescription information was used to advertise a new drug exemplifies the importance of confidentiality in the era of managed care and computers. The ethical concerns voiced about this incident can also apply to pharmacy benefits management programs. The use of personal health information in pharmacy benefits management is particularly important because of increased pressures to control rising drug costs. Specific confidentiality concerns include whether the goal of benefiting patients will be achieved and whether the means are appropriate. The means may be problematic because of financial conflicts of interest, lack of patient authorization, inappropriate access to information by third parties, and inadequate safeguards for confidentiality. Policies should be crafted that protect confidentiality while allowing appropriate use of personal health information in pharmacy benefits management. Sound policies should require clear evidence of benefit to patients, an oversight committee, patient authorization, disclosure or prohibition of conflicts of interest, additional safeguards for sensitive medical conditions, strong confidentiality protections, and restrictions on advertising.