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From page 347... ... group, enrollees, 168 n.1 premiums related to, 173 of uninsured workers, 93 Agency for Health Care Policy and Research, 226 Ambulatory care, definition of, 334 American Association for Labor Legislation, 58-59 Read the entire page →
From page 348... ... . Opposition to social insurance proposals by, 59-60, 63, 65 American Risk and Insurance Association, 41 n 6 Americans with Disabilities Act of 1990, 117-118, 148, 316-317 application to risk selection, 185 187 confidentiality provisions of, 246 legal uncertainties in, 186 medical records management in, 17 medical underwriting in, 182 B Benefit, definition of, 43, 335 Benefit design, 114-115 basic benefits, 19-20, 193, 249, 258 cost management in, 74-75 cost sharing in, 74, 103-106 diversity in, 10, 122-126, 237-238, 242 employee assistance programs in, 118-119 employee concerns about, 136-137, 145-149 ERISA on, 84, 302 evolution of, 101-102 flexible, 119, 218, 337 in health maintenance organizations, 102 health promotion programs in, 116 119 influence on risk selection of, 171 172, 173-174 innovation in, 10, 71-72, 238-239, 242 insurable events in, 44-45, 338 Medicare, 78-79 mental health care in, 104-106 planning, in case study, 130-133, 137-139 regulating, 19-20, 193-194, 249, 258 INDEX risk selection affecting, 184-185 in sample request for proposal, 156158, 162-165 in social insurance, 41-42, 56-57 state-mandated, 101, 249, 298 in workers' compensation programs, 115-116 Biased risk selection, see Risk selection Blue Cross plans costs of, 219 HMO sponsorship by, 126 origins of, 66-69, 71-72, 295 Blue Shield plans HMO sponsorship by, 126 in Medicare program, 78-79 origins of, 54 n.3, 68-69, 295 Bureau of the Census, Current Population Survey, 88, 93, 96 C Cafeteria plan, 335 California, 37, 108, 250 Canada, 22, 32, 33, 110, 151, 252 Capital expenditures, regulation of, 208-209 Capitation, 335 Carve-outs, for retirees, 94-95 n.6 Case management, 335 Case study contrasting cases, 142-145 employee advisory group in, 135 137 evaluating benefit plans in, 131 133 evaluating proposals in, 137-140 financial management in, 133 goal setting in, 130 implementing new benefit plan in, 140-142 legal issues in, 134 request for proposals in, 137, 155 166 small business concerns in, 143 Catastrophic expense protection, 335 Certificates of need, 209 Read the entire page →
From page 349... ... health care system, 11-12, 149-152, 240-241 Compulsory coverage in social insurance, 41-42, 56-57 recommendations, 251-254 Confidentiality in Americans with Disabilities Act, 185-186, 246 recommendations for, 16-17, 246 worker concerns about, 148 Consolidated Omnibus Budget Reconciliation Act of 1985, 85, 313-314 Consultants, in planning health benefits, 124-126 Continuity of care problems with, 10-11, 146, 239 research on, 259 Continuity of coverage, 10-11, 239, 259 349 under COBRA, 85, 313-314 termination benefits, ERISA on, 84 Cooperatives health-plan purchasing, 18, 127, 214-215, 247-248, 342 regulating competition through, 191192 Coordination of benefits, 94-95 n.6, 336 Copayment, 336 Cost management benefit designs for, 74-75 cost sharing strategies in, 217 early efforts in, 73-77 early federal initiatives, 82 flexible benefits and, 218 growth of government role in, 207211 health planning in, 75-76, 208-209 health promotion programs in, 218 issues in, 202-204 market-based strategies for, 220223, 240 in Medicare program, 208-209 in network plans, 217-218 obstacles to, 11, 239-240 private sector strategies for, 212-220 prospective payment system for, 211 rate-setting programs for, 208-210 risk pool management for, 74 role of, in health care reform, 20, 250-251 self-insurance and, 218 see also Costs of health care; Utilization management Cost sharing, 74, 103-106 definition of, 336 effect on cost of care, 217 income-adjusted, 181 n.7 Cost shifting definition of, 336 employer concerns about, 232 government role in, 211-212 recommendations for controlling, 248 uncompensated care and, 2 252 `, 184, Read the entire page →
From page 350... ... outpatient services in, 204 international comparisons of, 4-5, 29-30 market forces in, 220-223 medical care component of, 204-205 medical technology in, 203, 204 206, 224 as obstacle to small group benefit plans, 94 population growth as factor in, 204 premium costs in, 106-108 public program spending on, 5, 207, 274 public subsidy of, 18-19, 248 reform and, 20, 248, 250-251 risk selection and, 183-184 size of group and, 183 tax expenditures in, 110 trends in, 204-206 uncompensated care in, 184, 252 in workers' compensation programs, 115 see also Cost management Council of Smaller Enterprises, 127 Coverage continuity of, 10-11, 85, 239, 259, 313-314 INDEX direct employer, 90, 337 indirect employer, 90, 338 issues in legislative reform, 256 mandated continuity of, 313-314 state-mandated, 298 state regulation of, 296-297, 298 vs. access, 7, 234 see also Benefit design D Deductibles, 103-104, 336 Demographic risk adjustment, 196-197 Dental benefits, 102 Department of Health and Human Services, 88, 89 Department of Labor, Bureau of Labor Statistics, 88-89 Diagnosis-related groups, 197, 211, 336 Disability insurance, 43 n.8 in origins of medical insurance, 5154 Discrimination age, protection against, 316 health related, 117-118, 148, 185187, 236-237 in workplace health promotion programs, 118-119 E Economic Stabilization Program, 208 Elderly employment-based insurance for, 90 private insurance for, 77 Eligibility defining family members for, 89-90 n.5 state-mandated, 101 workplace rules, 93-94 Employee advisory groups, in case study, 135-137 Employee assistance programs, 24, 118-119, 258-259, 337 Employee Benefit Research Institute, 31, 88 survey, 148-149, 287-292 Read the entire page →
From page 351... ... l 6, 186 medical screening in hiring, 9, 117118 ERISA. See Employee Retirement Income Security Act of 1974 European experience, see International comparisons Experience rating, 47, 112-113, 133, 197, 337 F Families deductibles in coverage for, 103 of insured workers, benefits for, 8992 of uninsured workers, 92-94 Federal Employees Health Benefits Program features of, 170, 175 origins of, 73 risk selection in, 175-177 Federal regulation in development of employmentbased health plans, 70-71 early social insurance proposals, 6065 encouraging HMOs, 210 before ERISA, 82, 300 of mental health benefits, 106 n.ll need for, 19, 245-246, 248-250, 251-254 of pre-employment medical screening, 9 see also Employee Retirement Income Security Act of 1974 (ERISA) Read the entire page →
From page 352... ... 352 Financial Accounting Standards Board, 95 Financial management ERISA requirements, 84 evaluating benefit options, in case study, 133 retiree benefits as corporate liabilities, 95, 113-114 tax expenditures in health benefits, 110-111 Flexible benefits, 119, 218, 337 Foundations for medical care, 76 France, health care spending in, 30, 32 Fraud, 116 G Gatekeeper physician, 100, 338 Gender, premiums related to, 173 Geographic variations in coverage, 98, 101 Germany, 36-37 n.3 development of medical insurance in, 53 health care spending in, 30, 32t premium costs in, 106 risk segmentation in, 46 n.9, 168 n.2 role of employers in, 217 n.5 sickness funds of, 46 n.9, 56, 57 social insurance in, 41 n.6, 42, 57 Group Health Association, 69 Group practice origins of, 66, 69 prepaid, 341 H Hawaii, 37, 83, 108, 219, 307 Health Care Financing Administration, 88, 89 Health Insurance Association of America, 88, 89, 188 n.l3 Health Maintenance Organization Act of 1973, 82 Health maintenance organizations benefit coverage in, 102 definition of, 338 INDEX evaluating, in case study, 130, 132 135 evidence of cost savings in, 218 government encouragement of, 210 group model, 338 growth of, 100 Medicare-contracted, 197 numbers of, 126 open-ended, 340 relative restrictiveness of, 98 risk selection in, 174, 177-178, 179 staff model, 344 state regulation of, 298-299 Health planning, 75-76, 208-209 Health Planning and Resources Development Act of 1974, 209 Healthy People 2000, 116 Heritage Foundation, 37 High-risk individuals, 117-118, 171 172, 199-200 Historical developments, 3, 27 Blue Cross plan, 66-69 in cost management, 73-77 early social insurance proposals, 57 65 government efforts to control health care costs, 207-212 growth of cost of care, 78 key dates of, 52 origins of employment-based health plans, 69, 70-72 origins of medical insurance, 51-56 private insurance initiatives, 65-71 in regulation of insurance, 293-295 in social insurance, 56-57 in utilization review, 76-77 Hospice care, 102 Hospitals administrative expenses in, 110 cost of uncompensated care in, 184, 252 cost shifting in, 211-212 development of, 53 government cost control programs in, 208-210 prospective payment system in, 211 resource management of, 75-76 Read the entire page →
From page 353... ... . deilnlng employment-~ase~ systems in, 36 early medical insurance in, 51-56 in health care reform, 36-37 in health care spending, 4-5, 29-34, 239-240 universal coverage, 56-57, 236 see also specific country J Japan, health care spending in, 30, 33 Job "lock," 32, 239 K Kaiser plan origins of, 69 underwriting in, 127 n.2, 219 L Labor Management Relations Act of 1947, 300 Legal issues in authority of ERISA, 301 employer liability for managed care, 152-153 federal preemption of state laws by ERISA, 306-311 Read the entire page →
From page 354... ... insurance Marketing practices, risk selection through, 175 Maryland, 209 Massachusetts, 108 McCarran-Ferguson Act, 82, 295, 309 Medicaid, 2, 42, 79-80, 339 administrative expenses, 108, 110 cost shifting and, 212 Oregon plan for restructuring, 193 Medical organizations early opposition to health plans by, 69-70 see also American Medical Association Medical records, see Information management Medical services in cost of care, 204-206, 223-226 regulation of, 75-77, 208-211 Medical technology assessing value of, 225-226 INDEX cost of care and, 203, 205-206, 218, 224 development of, 51-53 innovation in benefit design and, 10, 31, 50 Medicare prospective payments and, 211 risk assessment methodologies and. 195-196 role in cost of health care, 205-206 Medicare, 2, 12, 78-79, 208-209, 339 administrative expenses, 108, 110 enrollment history, 79 HMOs in, 20 integrating retiree employment related coverage with, 94-95 n.6 pharmacy benefits in, 102 prospective payment system in, 211, 212 risk assessment in, 195-196 secondary payers in, 316 use of utilization measures in, 197 Mental health care cost of, as percentage of health expenditures, 104-106 coverage limits on, 104-106 employee assistance programs for, 118-119 Mississippi, 108 Moral hazard, 45-47, 339 Multiemployer plans, 85, 339 Multiple employer welfare associations, 84, 314-315, 339 N National Association of Insurance Commissioners, 82, 188 n.13, 295 National Conference on Medical Costs, 212 National Labor Relations Board, 70-71 National Medical (Care) Read the entire page →
From page 355... ... INDEX effect on cost of care by, 217-218 risk selection in, 174 state regulation of, 298-299 types of, 100-101 Norway, health care spending in, 30 o Oregon, 19, 193 n.15 p Part-time workers, 90, 337-338 Peer review, 76 Peer review organizations, 210-211 Pepper Commission, 37 Pharmacy benefits, 102, 147 n.4 Physician(s) early opposition to health insurance, 55 as gatekeepers, 100 impact of employment-based benefits on, 149-152 importance of, in consumer choice, 170 in Medicare program, 78-79 payment, 211 primary care, 341 risk selection in restricted network of, 174 role of, 53 types of, in state-mandated benefits, 101 Point-of-service plans definition of, 341 features of, 191 growth of, 100 relative restrictiveness of, 98 Preadmission review, 341 Preferred provider organizations, 218, 341 coinsurance in, 104 relative restrictiveness of, 98 risk selection in, 174 state regulation of, 298-299 Premiums age related to, 173 355 considerations in regulating, 255 cost of, 106-108 definition of, 341 effect of risk selection on, 175176 evaluating benefit plan options, in case study, 133 gender related to, 173 risk rating of individuals and cost of, 117 for self-insured groups, 112, 113 workers' compensation, 115 Private insurance, enrollment in, 90 Professional standards review organizations, 210 Prospective Payment Assessment Commission, 212 Prospective payment system cost shifting and, 211-212 definition of, 342 effect of, 211 origins of, 211 Public opinion on administration of health care system, 232 compulsory employment-related coverage in, 31 cost concerns in, 202 delivery of health care in, 1-2, 2223, 31 Employee Benefit Research Institute survey on, 148-149, 287-292 of health benefits system, 12-13 Public spending early social insurance proposals, 5765, 60-65 financing through reform, 20, 248 international comparisons, 4-5, 3233, 56-57 for Medicaid, 80 need for, 18-19, 248 public understanding of, 202 in risk-adjusted payment plans, 1718 statistics, 4, 27 Purchasing cooperatives, see Cooperatives Read the entire page →
From page 356... ... 356 Q Quality assurance, 342 Quality of care, 342 definition of, 184 effect of risk selection on, 184-185 health care spending and, 33 n.2 for the uninsured, 21, 252 R Redlining, 97-98 Reform of health care system administrative issues in, 151-152 alternatives proposed for, 37-38 amending ERISA in, 16, 19, 248 250 American Medical Association stance on, 59 n.8 basic benefit design in, 19-20, 193, 249, 258 confidentiality issues in, 16-17 continuity of care in, 259 cooperatives in, 18, 247-248 cost of, 250-251 employee assistance programs in, 258-259 employer size and, 219-220 high risk individuals in, 199-200 impact of private cost control strategies, 216-220 issues in, 1-3, 35-40, 48, 50, 254 256 managing competition in, 190-194 257 mandated universal coverage in, 21 23, 251-254 market-oriented approaches to, 7, 22, 207, 220-223, 240 mental health care in, 106 n.ll need for, 1, 14, 17, 47-48, 260 pace of, 227-228 proposals in other countries, 36-37 public subsidy of, 18-19, 248 to reduce risk selection, 14-17, 175 176, 187, 242 research needs for, 256-259 INDEX risk-adjusted payments in, 17-18, 194-196, 247, 257 risk sharing and, 261 role of employer in, 14, 22, 23-24, 31, 36, 216-220, 230-231, 242243, 260-261 role of private sector in, 227-228, 229-230, 260-261 state experimentation in, 249-250 underwriting practices in, 16, 47, 187-190, 245-246, 257 within voluntary system, 243 workers' compensation system in, 115-116 Reimbursement systems cost shifting and, 211-212 development of, 75 evaluation of, in case study, 133 in Medicare program, 79 in network plans, 100 physician, 211 prospective payment, 211 resource-based relative value scale, 211 Reinsurance, 199-200, 342 Request for proposals, in case study, 137-139, 155-166 Research needs basic benefit design, 19-20, 258 on continuity of care, 259 employee assistance programs, effects of, 258-259 for health care reform, 23, 256-259 methodologies for risk adjusting, 18, technology assessment, 226-227 underwriting reforms, consequences of, 257 Resource-based relative value scale, 68, 211 Responsible National Health Insurance plan, 37 Retirees, 94-95 benefits for, as corporate liability, 95, 113-114 Retrospective payment, 342 Risk, definition of, 43, 343 Read the entire page →
From page 357... ... INDEX Risk-adjusted payments, 17-18, 194 196, 247, 343 demographic approach to, 196-197 health status measures in, 198-199 methodologies for, 196-199, 257 prior use data for, 197-198 Risk pools, see Risk sharing Risk rating, 47, 117, 343 Risk segmentation arguments for, 13, 242 causes of, 47, 168 definition of, 46-47, 343 strategies for reducing, 187, 245 246 Risk selection, 167-169, 200-201 benefit design affecting, 171-174 biased, 46, 167, 335 causes of, 170-175, 178-179 definition of, 46, 168 discrimination and, 9, 236-237 in early insurance plans, 67, 69 effect of Americans with Disabilities Act, 185-187 effect on access, 182-183 effect on costs of care, 183-184 effect on premiums, 175-176 effect on quality of care, 184-185 employer factors contributing to, 170-172 equity issues in, 179-182 evidence of, 177-179 in Federal Employees Health Benefits Program, 175-177 high risk individuals and, 199-200 moral hazard and, 46 in network plans, 174 regulating competition to discourage, 190-194 risk-adjusted payments to reduce, 17-18, 194-196 size of group and, 168 strategies for reducing, 14-16, 187, 245 through administrative practices, 174-175 through individual medical records, 16-17 357 through marketing practices, 175 underwriting practices and, 173, 187-190, 245-246 universal coverage and, 22, 252 Risk sharing definition of, 343 importance of, 26 risk pools for, 43, 74-76, 199-200, 343 Rochester, New York, 113, 127, 181 n.8, 218-219 S Second opinion, 76, 343 Self-insured groups, 343 advantages of, 111-112 in case study, 133 cost savings by, 218 ERISA regulation of, 83-85, 310313 funding mechanisms for, 111 liability for managed care in, 153 medical underwriting within, 16 premiums for, 112, 113 related to employer size, 111 risk segmentation and, 47, 168 risk-sharing arrangements for, 112113 state regulation of, 101, 250, 310313 stop-loss insurance for, 113 taxing of, 248 trends in, 189 types of, 44 Size of employer administration of health plan and, 110, 121-122, 124-126 benefit design and, 5-6, 9-10, 99 cost containment strategies related to, 214 costs of health care and, 106, 183, 237 coverage availability related to, 5, 96-97, 232-233 employee assistance programs, 118 Read the entire page →
From page 358... ... , 60-61 consumer concerns about cost of care, 202 cost of mental health care, 104-106 coverage related to size of company, 96, 99 data sources for, 88-89 deductibles, 103 employment-based plans, enrollment in, 1, 27, 71, 236 flexible benefit plans, 119 health care in Rochester, New York, 219 health care spending, 3, 4, 27-28, 78, 204-206, 207 HMO enrollment, 210 industry type as variable in coverage availability, 97 insured populations, 3, 26, 27, 28, 236 insured workers, 89-92 Medicaid, 80 Medicare, 79, 236 network plan enrollments, 100 premium costs, 106-108 publicly funded health coverage, 4, 27 . Read the entire page →
From page 359... ... nonworking, in generating uncompensated care, 184 n.9 Unions in development of employmentbased health plans, 70-71 in development of medical insurance, 54, 55, 76 United Kingdom health care spending in, 30, 33 origins of medical insurance in, 51, 55-56 Universal coverage, 236 employment-based, 21-23, 251-254 lack of, 22-23, 254 need for, 21, 251-252 Utilization management definition of, 344 effect of, on cost of care, 217 employer liability for managed care and, 152-153 extent of, in employer benefit plans, 213-214 as measure in risk-adjusting, 197198 in Medicare, 208 origins of, 76-77 retrospective, 342 V Voluntary employee beneficiary association, 113 Read the entire page →
From page 360... ... 360 Voluntary system of coverage, 1, 8, 26, 235, 237 early history, 51-56 improving, 243-251 limitations of, 21, 251-252 marketplace effects of, 9-10 replacing, 251-254 INDEX W Welfare capitalism, 54 Well baby care, 102 Wellness programs, 116-119, 218 Workers' compensation, 114, 115-116, 345 Read the entire page →

From page 347...

... group, enrollees, 168 n.1 premiums related to, 173 of uninsured workers, 93 Agency for Health Care Policy and Research, 226 Ambulatory care, definition of, 334 American Association for Labor Legislation, 58-59

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From page 348...

... . Opposition to social insurance proposals by, 59-60, 63, 65 American Risk and Insurance Association, 41 n 6 Americans with Disabilities Act of 1990, 117-118, 148, 316-317 application to risk selection, 185 187 confidentiality provisions of, 246 legal uncertainties in, 186 medical records management in, 17 medical underwriting in, 182 B Benefit, definition of, 43, 335 Benefit design, 114-115 basic benefits, 19-20, 193, 249, 258 cost management in, 74-75 cost sharing in, 74, 103-106 diversity in, 10, 122-126, 237-238, 242 employee assistance programs in, 118-119 employee concerns about, 136-137, 145-149 ERISA on, 84, 302 evolution of, 101-102 flexible, 119, 218, 337 in health maintenance organizations, 102 health promotion programs in, 116 119 influence on risk selection of, 171 172, 173-174 innovation in, 10, 71-72, 238-239, 242 insurable events in, 44-45, 338 Medicare, 78-79 mental health care in, 104-106 planning, in case study, 130-133, 137-139 regulating, 19-20, 193-194, 249, 258 INDEX risk selection affecting, 184-185 in sample request for proposal, 156158, 162-165 in social insurance, 41-42, 56-57 state-mandated, 101, 249, 298 in workers' compensation programs, 115-116 Biased risk selection, see Risk selection Blue Cross plans costs of, 219 HMO sponsorship by, 126 origins of, 66-69, 71-72, 295 Blue Shield plans HMO sponsorship by, 126 in Medicare program, 78-79 origins of, 54 n.3, 68-69, 295 Bureau of the Census, Current Population Survey, 88, 93, 96 C Cafeteria plan, 335 California, 37, 108, 250 Canada, 22, 32, 33, 110, 151, 252 Capital expenditures, regulation of, 208-209 Capitation, 335 Carve-outs, for retirees, 94-95 n.6 Case management, 335 Case study contrasting cases, 142-145 employee advisory group in, 135 137 evaluating benefit plans in, 131 133 evaluating proposals in, 137-140 financial management in, 133 goal setting in, 130 implementing new benefit plan in, 140-142 legal issues in, 134 request for proposals in, 137, 155 166 small business concerns in, 143 Catastrophic expense protection, 335 Certificates of need, 209

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From page 349...

... health care system, 11-12, 149-152, 240-241 Compulsory coverage in social insurance, 41-42, 56-57 recommendations, 251-254 Confidentiality in Americans with Disabilities Act, 185-186, 246 recommendations for, 16-17, 246 worker concerns about, 148 Consolidated Omnibus Budget Reconciliation Act of 1985, 85, 313-314 Consultants, in planning health benefits, 124-126 Continuity of care problems with, 10-11, 146, 239 research on, 259 Continuity of coverage, 10-11, 239, 259 349 under COBRA, 85, 313-314 termination benefits, ERISA on, 84 Cooperatives health-plan purchasing, 18, 127, 214-215, 247-248, 342 regulating competition through, 191192 Coordination of benefits, 94-95 n.6, 336 Copayment, 336 Cost management benefit designs for, 74-75 cost sharing strategies in, 217 early efforts in, 73-77 early federal initiatives, 82 flexible benefits and, 218 growth of government role in, 207211 health planning in, 75-76, 208-209 health promotion programs in, 218 issues in, 202-204 market-based strategies for, 220223, 240 in Medicare program, 208-209 in network plans, 217-218 obstacles to, 11, 239-240 private sector strategies for, 212-220 prospective payment system for, 211 rate-setting programs for, 208-210 risk pool management for, 74 role of, in health care reform, 20, 250-251 self-insurance and, 218 see also Costs of health care; Utilization management Cost sharing, 74, 103-106 definition of, 336 effect on cost of care, 217 income-adjusted, 181 n.7 Cost shifting definition of, 336 employer concerns about, 232 government role in, 211-212 recommendations for controlling, 248 uncompensated care and, 2 252 `, 184,

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From page 350...

... outpatient services in, 204 international comparisons of, 4-5, 29-30 market forces in, 220-223 medical care component of, 204-205 medical technology in, 203, 204 206, 224 as obstacle to small group benefit plans, 94 population growth as factor in, 204 premium costs in, 106-108 public program spending on, 5, 207, 274 public subsidy of, 18-19, 248 reform and, 20, 248, 250-251 risk selection and, 183-184 size of group and, 183 tax expenditures in, 110 trends in, 204-206 uncompensated care in, 184, 252 in workers' compensation programs, 115 see also Cost management Council of Smaller Enterprises, 127 Coverage continuity of, 10-11, 85, 239, 259, 313-314 INDEX direct employer, 90, 337 indirect employer, 90, 338 issues in legislative reform, 256 mandated continuity of, 313-314 state-mandated, 298 state regulation of, 296-297, 298 vs. access, 7, 234 see also Benefit design D Deductibles, 103-104, 336 Demographic risk adjustment, 196-197 Dental benefits, 102 Department of Health and Human Services, 88, 89 Department of Labor, Bureau of Labor Statistics, 88-89 Diagnosis-related groups, 197, 211, 336 Disability insurance, 43 n.8 in origins of medical insurance, 5154 Discrimination age, protection against, 316 health related, 117-118, 148, 185187, 236-237 in workplace health promotion programs, 118-119 E Economic Stabilization Program, 208 Elderly employment-based insurance for, 90 private insurance for, 77 Eligibility defining family members for, 89-90 n.5 state-mandated, 101 workplace rules, 93-94 Employee advisory groups, in case study, 135-137 Employee assistance programs, 24, 118-119, 258-259, 337 Employee Benefit Research Institute, 31, 88 survey, 148-149, 287-292

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From page 351...

... l 6, 186 medical screening in hiring, 9, 117118 ERISA. See Employee Retirement Income Security Act of 1974 European experience, see International comparisons Experience rating, 47, 112-113, 133, 197, 337 F Families deductibles in coverage for, 103 of insured workers, benefits for, 8992 of uninsured workers, 92-94 Federal Employees Health Benefits Program features of, 170, 175 origins of, 73 risk selection in, 175-177 Federal regulation in development of employmentbased health plans, 70-71 early social insurance proposals, 6065 encouraging HMOs, 210 before ERISA, 82, 300 of mental health benefits, 106 n.ll need for, 19, 245-246, 248-250, 251-254 of pre-employment medical screening, 9 see also Employee Retirement Income Security Act of 1974 (ERISA)

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From page 352...

... 352 Financial Accounting Standards Board, 95 Financial management ERISA requirements, 84 evaluating benefit options, in case study, 133 retiree benefits as corporate liabilities, 95, 113-114 tax expenditures in health benefits, 110-111 Flexible benefits, 119, 218, 337 Foundations for medical care, 76 France, health care spending in, 30, 32 Fraud, 116 G Gatekeeper physician, 100, 338 Gender, premiums related to, 173 Geographic variations in coverage, 98, 101 Germany, 36-37 n.3 development of medical insurance in, 53 health care spending in, 30, 32t premium costs in, 106 risk segmentation in, 46 n.9, 168 n.2 role of employers in, 217 n.5 sickness funds of, 46 n.9, 56, 57 social insurance in, 41 n.6, 42, 57 Group Health Association, 69 Group practice origins of, 66, 69 prepaid, 341 H Hawaii, 37, 83, 108, 219, 307 Health Care Financing Administration, 88, 89 Health Insurance Association of America, 88, 89, 188 n.l3 Health Maintenance Organization Act of 1973, 82 Health maintenance organizations benefit coverage in, 102 definition of, 338 INDEX evaluating, in case study, 130, 132 135 evidence of cost savings in, 218 government encouragement of, 210 group model, 338 growth of, 100 Medicare-contracted, 197 numbers of, 126 open-ended, 340 relative restrictiveness of, 98 risk selection in, 174, 177-178, 179 staff model, 344 state regulation of, 298-299 Health planning, 75-76, 208-209 Health Planning and Resources Development Act of 1974, 209 Healthy People 2000, 116 Heritage Foundation, 37 High-risk individuals, 117-118, 171 172, 199-200 Historical developments, 3, 27 Blue Cross plan, 66-69 in cost management, 73-77 early social insurance proposals, 57 65 government efforts to control health care costs, 207-212 growth of cost of care, 78 key dates of, 52 origins of employment-based health plans, 69, 70-72 origins of medical insurance, 51-56 private insurance initiatives, 65-71 in regulation of insurance, 293-295 in social insurance, 56-57 in utilization review, 76-77 Hospice care, 102 Hospitals administrative expenses in, 110 cost of uncompensated care in, 184, 252 cost shifting in, 211-212 development of, 53 government cost control programs in, 208-210 prospective payment system in, 211 resource management of, 75-76

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From page 353...

... . deilnlng employment-~ase~ systems in, 36 early medical insurance in, 51-56 in health care reform, 36-37 in health care spending, 4-5, 29-34, 239-240 universal coverage, 56-57, 236 see also specific country J Japan, health care spending in, 30, 33 Job "lock," 32, 239 K Kaiser plan origins of, 69 underwriting in, 127 n.2, 219 L Labor Management Relations Act of 1947, 300 Legal issues in authority of ERISA, 301 employer liability for managed care, 152-153 federal preemption of state laws by ERISA, 306-311

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From page 354...

... insurance Marketing practices, risk selection through, 175 Maryland, 209 Massachusetts, 108 McCarran-Ferguson Act, 82, 295, 309 Medicaid, 2, 42, 79-80, 339 administrative expenses, 108, 110 cost shifting and, 212 Oregon plan for restructuring, 193 Medical organizations early opposition to health plans by, 69-70 see also American Medical Association Medical records, see Information management Medical services in cost of care, 204-206, 223-226 regulation of, 75-77, 208-211 Medical technology assessing value of, 225-226 INDEX cost of care and, 203, 205-206, 218, 224 development of, 51-53 innovation in benefit design and, 10, 31, 50 Medicare prospective payments and, 211 risk assessment methodologies and. 195-196 role in cost of health care, 205-206 Medicare, 2, 12, 78-79, 208-209, 339 administrative expenses, 108, 110 enrollment history, 79 HMOs in, 20 integrating retiree employment related coverage with, 94-95 n.6 pharmacy benefits in, 102 prospective payment system in, 211, 212 risk assessment in, 195-196 secondary payers in, 316 use of utilization measures in, 197 Mental health care cost of, as percentage of health expenditures, 104-106 coverage limits on, 104-106 employee assistance programs for, 118-119 Mississippi, 108 Moral hazard, 45-47, 339 Multiemployer plans, 85, 339 Multiple employer welfare associations, 84, 314-315, 339 N National Association of Insurance Commissioners, 82, 188 n.13, 295 National Conference on Medical Costs, 212 National Labor Relations Board, 70-71 National Medical (Care)

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From page 355...

... INDEX effect on cost of care by, 217-218 risk selection in, 174 state regulation of, 298-299 types of, 100-101 Norway, health care spending in, 30 o Oregon, 19, 193 n.15 p Part-time workers, 90, 337-338 Peer review, 76 Peer review organizations, 210-211 Pepper Commission, 37 Pharmacy benefits, 102, 147 n.4 Physician(s) early opposition to health insurance, 55 as gatekeepers, 100 impact of employment-based benefits on, 149-152 importance of, in consumer choice, 170 in Medicare program, 78-79 payment, 211 primary care, 341 risk selection in restricted network of, 174 role of, 53 types of, in state-mandated benefits, 101 Point-of-service plans definition of, 341 features of, 191 growth of, 100 relative restrictiveness of, 98 Preadmission review, 341 Preferred provider organizations, 218, 341 coinsurance in, 104 relative restrictiveness of, 98 risk selection in, 174 state regulation of, 298-299 Premiums age related to, 173 355 considerations in regulating, 255 cost of, 106-108 definition of, 341 effect of risk selection on, 175176 evaluating benefit plan options, in case study, 133 gender related to, 173 risk rating of individuals and cost of, 117 for self-insured groups, 112, 113 workers' compensation, 115 Private insurance, enrollment in, 90 Professional standards review organizations, 210 Prospective Payment Assessment Commission, 212 Prospective payment system cost shifting and, 211-212 definition of, 342 effect of, 211 origins of, 211 Public opinion on administration of health care system, 232 compulsory employment-related coverage in, 31 cost concerns in, 202 delivery of health care in, 1-2, 2223, 31 Employee Benefit Research Institute survey on, 148-149, 287-292 of health benefits system, 12-13 Public spending early social insurance proposals, 5765, 60-65 financing through reform, 20, 248 international comparisons, 4-5, 3233, 56-57 for Medicaid, 80 need for, 18-19, 248 public understanding of, 202 in risk-adjusted payment plans, 1718 statistics, 4, 27 Purchasing cooperatives, see Cooperatives

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From page 356...

... 356 Q Quality assurance, 342 Quality of care, 342 definition of, 184 effect of risk selection on, 184-185 health care spending and, 33 n.2 for the uninsured, 21, 252 R Redlining, 97-98 Reform of health care system administrative issues in, 151-152 alternatives proposed for, 37-38 amending ERISA in, 16, 19, 248 250 American Medical Association stance on, 59 n.8 basic benefit design in, 19-20, 193, 249, 258 confidentiality issues in, 16-17 continuity of care in, 259 cooperatives in, 18, 247-248 cost of, 250-251 employee assistance programs in, 258-259 employer size and, 219-220 high risk individuals in, 199-200 impact of private cost control strategies, 216-220 issues in, 1-3, 35-40, 48, 50, 254 256 managing competition in, 190-194 257 mandated universal coverage in, 21 23, 251-254 market-oriented approaches to, 7, 22, 207, 220-223, 240 mental health care in, 106 n.ll need for, 1, 14, 17, 47-48, 260 pace of, 227-228 proposals in other countries, 36-37 public subsidy of, 18-19, 248 to reduce risk selection, 14-17, 175 176, 187, 242 research needs for, 256-259 INDEX risk-adjusted payments in, 17-18, 194-196, 247, 257 risk sharing and, 261 role of employer in, 14, 22, 23-24, 31, 36, 216-220, 230-231, 242243, 260-261 role of private sector in, 227-228, 229-230, 260-261 state experimentation in, 249-250 underwriting practices in, 16, 47, 187-190, 245-246, 257 within voluntary system, 243 workers' compensation system in, 115-116 Reimbursement systems cost shifting and, 211-212 development of, 75 evaluation of, in case study, 133 in Medicare program, 79 in network plans, 100 physician, 211 prospective payment, 211 resource-based relative value scale, 211 Reinsurance, 199-200, 342 Request for proposals, in case study, 137-139, 155-166 Research needs basic benefit design, 19-20, 258 on continuity of care, 259 employee assistance programs, effects of, 258-259 for health care reform, 23, 256-259 methodologies for risk adjusting, 18, technology assessment, 226-227 underwriting reforms, consequences of, 257 Resource-based relative value scale, 68, 211 Responsible National Health Insurance plan, 37 Retirees, 94-95 benefits for, as corporate liability, 95, 113-114 Retrospective payment, 342 Risk, definition of, 43, 343

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From page 357...

... INDEX Risk-adjusted payments, 17-18, 194 196, 247, 343 demographic approach to, 196-197 health status measures in, 198-199 methodologies for, 196-199, 257 prior use data for, 197-198 Risk pools, see Risk sharing Risk rating, 47, 117, 343 Risk segmentation arguments for, 13, 242 causes of, 47, 168 definition of, 46-47, 343 strategies for reducing, 187, 245 246 Risk selection, 167-169, 200-201 benefit design affecting, 171-174 biased, 46, 167, 335 causes of, 170-175, 178-179 definition of, 46, 168 discrimination and, 9, 236-237 in early insurance plans, 67, 69 effect of Americans with Disabilities Act, 185-187 effect on access, 182-183 effect on costs of care, 183-184 effect on premiums, 175-176 effect on quality of care, 184-185 employer factors contributing to, 170-172 equity issues in, 179-182 evidence of, 177-179 in Federal Employees Health Benefits Program, 175-177 high risk individuals and, 199-200 moral hazard and, 46 in network plans, 174 regulating competition to discourage, 190-194 risk-adjusted payments to reduce, 17-18, 194-196 size of group and, 168 strategies for reducing, 14-16, 187, 245 through administrative practices, 174-175 through individual medical records, 16-17 357 through marketing practices, 175 underwriting practices and, 173, 187-190, 245-246 universal coverage and, 22, 252 Risk sharing definition of, 343 importance of, 26 risk pools for, 43, 74-76, 199-200, 343 Rochester, New York, 113, 127, 181 n.8, 218-219 S Second opinion, 76, 343 Self-insured groups, 343 advantages of, 111-112 in case study, 133 cost savings by, 218 ERISA regulation of, 83-85, 310313 funding mechanisms for, 111 liability for managed care in, 153 medical underwriting within, 16 premiums for, 112, 113 related to employer size, 111 risk segmentation and, 47, 168 risk-sharing arrangements for, 112113 state regulation of, 101, 250, 310313 stop-loss insurance for, 113 taxing of, 248 trends in, 189 types of, 44 Size of employer administration of health plan and, 110, 121-122, 124-126 benefit design and, 5-6, 9-10, 99 cost containment strategies related to, 214 costs of health care and, 106, 183, 237 coverage availability related to, 5, 96-97, 232-233 employee assistance programs, 118

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From page 358...

... , 60-61 consumer concerns about cost of care, 202 cost of mental health care, 104-106 coverage related to size of company, 96, 99 data sources for, 88-89 deductibles, 103 employment-based plans, enrollment in, 1, 27, 71, 236 flexible benefit plans, 119 health care in Rochester, New York, 219 health care spending, 3, 4, 27-28, 78, 204-206, 207 HMO enrollment, 210 industry type as variable in coverage availability, 97 insured populations, 3, 26, 27, 28, 236 insured workers, 89-92 Medicaid, 80 Medicare, 79, 236 network plan enrollments, 100 premium costs, 106-108 publicly funded health coverage, 4, 27 .

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From page 359...

... nonworking, in generating uncompensated care, 184 n.9 Unions in development of employmentbased health plans, 70-71 in development of medical insurance, 54, 55, 76 United Kingdom health care spending in, 30, 33 origins of medical insurance in, 51, 55-56 Universal coverage, 236 employment-based, 21-23, 251-254 lack of, 22-23, 254 need for, 21, 251-252 Utilization management definition of, 344 effect of, on cost of care, 217 employer liability for managed care and, 152-153 extent of, in employer benefit plans, 213-214 as measure in risk-adjusting, 197198 in Medicare, 208 origins of, 76-77 retrospective, 342 V Voluntary employee beneficiary association, 113

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From page 360...

... 360 Voluntary system of coverage, 1, 8, 26, 235, 237 early history, 51-56 improving, 243-251 limitations of, 21, 251-252 marketplace effects of, 9-10 replacing, 251-254 INDEX W Welfare capitalism, 54 Well baby care, 102 Wellness programs, 116-119, 218 Workers' compensation, 114, 115-116, 345

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INDEX Pages 347-360

INDEX
Pages 347-360