Despite the widely held belief that states lack power to alter insurance companies’ behavior, New Jersey’s individual health insurance market reform unearthed ways for states to expand coverage.
Health Affairs
Vol. 18, No. 4
July 1999
Swartz, K., and Garnick, D.W.
Despite the widely held belief that states lack power to alter insurance companies’ behavior, New Jersey’s individual health insurance market reform unearthed ways for states to expand coverage.
Adverse selection is a potentially significant problem in the individual (nongroup) health insurance markets if states use regulations to restrict insurance companies’ ability to select whom they will insure. In 1993, New Jersey implemented the Individual Health Coverage Program (IHCP), presenting an opportunity to test for adverse selection when insurers’ ability to select enrollees is severely restricted.
Medical Care Research and Review
Vol. 56, No. 3
September 1999
Swartz, K., and Garnick, D.W.
Adverse selection is a potentially significant problem in the individual (nongroup) health insurance markets if states use regulations to restrict insurance companies’ ability to select whom they will insure. In 1993, New Jersey implemented the Individual Health Coverage Program (IHCP), presenting an opportunity to test for adverse selection when insurers’ ability to select enrollees is severely restricted.
In this paper we use the reforms to the individual health insurance market in New Jersey to illustrate the intricate interaction between insurance agents and insurance reform initiatives.
Health Affairs
Vol. 17, No. 2
March 1998
Garnick, D.W., Swartz, K., Skwara, K.C.
In this paper we use the reforms to the individual health insurance market in New Jersey to illustrate the intricate interaction between insurance agents and insurance reform initiatives. Until recently, policymakers who designed reforms to the health insurance market largely ignored the role of agents in selling individual health insurance policies. These reforms have the potential to overturn the agent's traditional role, and agents can influence how the reforms are implemented.
Health plans, healthcare purchasers, and provider organizations throughout the United States are crafting pay-for-performance programs with the intent of improving the quality of care and with recognition of the need to restrain rapidly rising costs. Health plans and large, self-insured employers have typically led the movement toward using quality scorecards with which to gauge hospital and physician performance, coupled with the use of financial incentives directed at hospitals, physician group practices, and individual physicians and practice teams.
To determine the relative importance of enrollee, physician, medical group, and healthcare plan characteristics as determinants of healthcare use and expenditures in commercially insured children <18 years of age enrolled in managed care health plans. We focused on the effects of age and benefit level, the two most important predictors of cost and utilization in our study of adults.
Maternal and Child Health Journal
Vol. 4, No. 1
March 2000
Maynard, C., Ramsey, S., Wickizer, T., and Conrad, D.A.
Objective: To determine the relative importance of enrollee, physician, medical group, and healthcare plan characteristics as determinants of healthcare use and expenditures in commercially insured children <18 years of age enrolled in managed care health plans. We focused on the effects of age and benefit level, the two most important predictors of cost and utilization in our study of adults.
Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization.
JAMA
Vol. 279, No. 11
March 1998
Conrad, D.A., Maynard, C., Cheadle, A., Ramsey, S., et al.
CONTEXT: Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization.
OBJECTIVE: To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician.
This paper analyzes the emerging marketplace arrangements in health care that shift risk between different organizations and economic agents.
The Quarterly Review of Economics and Finance
Vol. 39, No. 4
Winter 1999
Conrad, D.A.
This paper analyzes the emerging marketplace arrangements in health care that shift risk between different organizations and economic agents. The linkages between these risk-bearing arrangements and the strategies used by health care organizations to finance their capital investments are discussed. A conceptual framework for predicting the success of different players in pursuing particular risk-bearing and capital financing strategies is presented and illustrated by reference to specific case examples from the professional and health services research literature.
Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children.
Pediatrics
Vol. 108, No. 2
August 2001
Ferris, T.G., Perrin, J.M., Manganello, J.A., Chang, Y., Causino, N., and Blumenthal, D.
BACKGROUND: Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children.
OBJECTIVE: To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions.
Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven.
JAMA
Vol. 278, No. 20
November 1997
Halm, E.A., Causino, N., and Blumenthal, D.
Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven.
Few studies have examined the provision of tertiary care services by managed care organizations (MCOs). Moreover, little is known about the role of quality assessment and quality assurance mechanisms in the contracting process. Site visits were conducted in 1995 in three geographic areas to describe and evaluate the contracting processes for tertiary care services, especially neonatal intensive care and coronary artery bypass graft surgery, of health maintenance organizations (HMOs). Three market areas in the United States, each with differing levels of maturity, as primarily defined in terms of managed care penetration, were selected for study.
RAND External Publication
Vol. 23, No. 2
February 1997
Schulman, K.A., Rubenstein, L.E., Seils, D.M, Harris, M., Hadley, J., and Escarce, J.J.
Few studies have examined the provision of tertiary care services by managed care organizations (MCOs). Moreover, little is known about the role of quality assessment and quality assurance mechanisms in the contracting process. Site visits were conducted in 1995 in three geographic areas to describe and evaluate the contracting processes for tertiary care services, especially neonatal intensive care and coronary artery bypass graft surgery, of health maintenance organizations (HMOs).
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