Issue brief (Center for Studying Health System Change)最新文献

Rising premiums and a weak economy are generating questions about the potential erosion of health insurance coverage, particularly for the more than 46 million Americans who work for small firms. People working in small firms typically have less access to coverage than those in large firms. In 2000 and early 2001, the Center for Studying Health System Change (HSC) conducted its third round of site visits to 12 nationally representative metropolitan areas and found that while few small employers actually dropped coverage, many increased the employee share of premiums, raised copayments and deductibles, switched products and carriers and/or reduced benefits. With the U.S. economy now in rougher shape, small employers may pare back coverage even more, putting affordable health care further out of the reach of workers and their families.

Insurance brokers play an important role in helping small employers find affordable health coverage for their workers and dependents. While there are costs for using brokers, an examination of the role of brokers in 12 nationally representative communities by the Center for Studying Health System Change (HSC) indicated that brokers provide valuable services to small firms, such as obtaining prices for coverage, explaining benefits to employees and problem solving for employers. In some markets, brokers also helped educate employers and employees about state policy initiatives to expand coverage. In contrast to the notion that brokers merely make insurance more costly, these findings suggest brokers can provide important benefits to small employers, plans and policy makers.

Projected cuts in Medicare physician payments raise serious concerns that Medicare beneficiaries will lose access to needed physician services. A study by the Center for Studying Health System Change (HSC) shows growing physician access problems among Medicare and privately insured patients. Patients have the most difficulties obtaining care from specialists and in certain communities. Proposals to increase Medicare fees across the board may prevent deterioration of access for Medicare beneficiaries but are unlikely to address system-wide access problems that vary by specialty and market.

The percentage of low-income children who have health insurance has not changed over the last few years, despite expansions in public coverage through Medicaid and the State Children's Health Insurance Program (SCHIP). Data from 1996-1997 and 1998-1999 from the Center for Studying Health System Change (HSC) find that while the proportion of low-income children with public coverage has increased, the percentage with private insurance coverage has decreased sharply, resulting in no net change in the percentage who are uninsured. This Issue Brief describes these recent changes in public and private coverage. Possible factors that may explain these changes are discussed, including increases in private insurance premiums, substitution of public for private coverage and changes in the characteristics of low-income persons. The study did not determine conclusively the causes of the changes in coverage.

The growth of managed care has prompted questions about the effects of health maintenance organizations (HMOs) on consumers. This Issue Brief reports the results from a large national study of the privately insured population. No detectable difference was found between HMOs and other types of insurance in the use of three costly services--inpatient care, emergency room use and surgeries--and differences in reports of unmet need or delayed care are negligible. Differences for other measures pose a trade-off for consumers: HMOs provide more primary and preventive services and lower financial barriers to care, but they provide less specialist care and raise administrative barriers to care. In addition, patients in HMOs report less satisfaction, less trust in physicians and lower ratings of physician visits. These findings have implications for the current policy debate about managed care.

Risk contracting and capitation are two widely used financial mechanisms that give incentives to health care providers to control costs. Risk-bearing arrangements have failed in a number of communities, however. This has shaken local markets, disrupting consumers' access to health care services and triggering losses for physicians and hospitals. It also has raised questions about the adequacy of related regulatory oversight, which holds important implications for local and national policy makers. This Issue Brief provides case studies of failed risk-contracting arrangements in two of the 12 communities that the Center for Studying Health System Change (HSC) tracks intensively--Northern New Jersey and Orange County, Calif.--and examines implications for policy makers.

Policy makers are concerned that consumers have no voice in the changing health care system. They debate, however, whether the consumers' voice should be heard through regulation, such as patient protections, or the marketplace. For market forces to work in the consumers' interest, consumers must have a choice of plans and detailed information on which to base their choice. New survey data from the Center for Studying Health System Change (HSC) suggest that more consumers have a choice of plans than is generally believed, and that the proportion of consumers who have plan choice is increasing. According to HSC's 1998-1999 Household Survey, 64 percent of families have a choice of health plans--two percentage points higher than two years ago.

A number of communities in the United States are adopting a managed care approach to caring for low-income uninsured individuals. This Issue Brief focuses on such programs in five of the 12 communities that the Center for Studying Health System Change (HSC) is tracking intensively. It describes the local market factors that motivated the creation and varying design of these initiatives, all of which seek to increase access to primary and preventive care while managing the use of more costly inpatient and emergency care. The Issue Brief also discusses the long-term viability of these programs as they attempt to simultaneously expand access to services and contain costs for this growing population.

The United States has long relied on specialist physicians more heavily than other countries, and some policy experts have repeatedly recommended that the share and role of primary care physicians (PCPs) be increased as a way of providing cost-effective care. The growth of managed care, changing practice arrangements and new medical technology are forces that may be increasing the role of PCPs. This Issue Brief reports findings published in the New England Journal of Medicine showing that many physicians believe the scope of care provided by PCPs without referral to specialists is increasing. Moreover, almost a quarter of PCPs report that the scope of care they are expected to provide is greater than it should be. The likelihood of PCPs' concern is related to specific managed care techniques, practice size and specialty, among other factors.

After three years of anticipation, health care cost trends have taken an upward turn. In employment-based insurance, premium increases for 1999 were in the 5 percent range, up from 3 percent for 1998. The rate of increase in underlying costs of private insurance--lagged by one year--also rose by approximately 2 percentage points. Many had expected a sharper upturn in premium increases than underlying cost increases. This would have heralded a turn in the insurance underwriting cycle, which has not yet occurred. This Issue Brief tracks the rate of growth of health care costs and the experience with premiums for employment-based health insurance and discusses the impact of these trends on consumers.