Outcome and cost of trauma among the elderly: a real-life model of a single-payer reimbursement system

BACKGROUND: As our population ages, the number of elderly trauma patients (age > or = 65 years) increases. Studies have demonstrated increased mortality and cost for a given injury severity in the elderly compared with younger patients. The financial viability of trauma centers in the United States has been an area of concern for many years. As reimbursement diminishes for privately insured patients, the ability to finance the care of the indigent is jeopardized. Medicare, the single-payer insurance plan for the elderly, reimburses at a lower rate than standard private insurance carriers. We examined the differences in outcome and cost between the elderly and younger patients and the financial burden imposed by care for elderly trauma. Our hypothesis was that elderly trauma patients would have poorer outcomes, higher cost, and generate greater financial losses than younger patients. METHODS: All patients admitted to the University of Virginia Trauma Service from July 1, 1994, to July 1, 1997 were included. Trauma registry and patients records were examined. Patients with incomplete financial data (cost, reimbursement, and payer source) were excluded. Patients were grouped by age (18-64 and > or =65 years), Injury Severity Score, and payer source. RESULTS: One thousand one hundred twenty-seven patients met the entry criteria. One hundred forty patients had incomplete financial or patient data and were excluded. Nine hundred eighty-seven patients were included in the study, of which 159 were elderly and 828 were 18 to 64 years of age. Injury Severity Scores were significantly higher in the elderly group. Only 2% of elderly patients were uninsured (76% were insured by Medicare), whereas 25% of younger patients were uninsured. Medicare reimbursement rates actually exceeded those of all other carriers (114% of costs). Elderly patients had a higher mortality rate, but the z score did not reach significance. The W score, however, indicated that there were more unexpected, negative outcomes among elderly patients. As injury severity increased, profit per case increased in the elderly and decreased in the younger group. CONCLUSION: Despite higher injury severity and lower survival probability for the elderly, the length of hospital and intensive care unit stays, as well as the percentage of admissions to the intensive care unit, were similar. The per capita cost of hospital care for the elderly was lower than for younger patients, whereas reimbursement was higher, primarily because 98% of elderly patients were insured. Medicare, the single-payer insurance plan for the elderly, adequately reimburses for elderly trauma care. This implies that universal insurance coverage for all trauma patients would be desirable, even if reimbursement rates decreased significantly. The increased mortality in the elderly requires continued study and diligence.     

Insurance matters for low-income adults: results from a five-state survey

Using survey data from 2,000 low-income adult respondents in each of five states, this DataWatch assesses how uninsured, low-income adults differ from low-income adults who have public or private insurance and how Medicaid expansions have affected insurance coverage patterns across states with different eligibility policies. Findings show that the proportion of low-income uninsured adults is two to three times higher in states that have not expanded Medicaid eligibility beyond relatively low welfare levels. Compared with persons who have either Medicaid or private insurance, uninsured persons report more difficulties getting needed care, are less likely to have a regular provider, and rate the care they do receive as lower quality.     

Lipid disorders in NIDDM: implications for treatment

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.     

Regulation of uterine immune function by progesterone--lessons from the sheep

Analyzing cross-sectional data from the National Medical Expenditure Survey (NMES), we find that the predicted probability of private insurance coverage for low-income individuals as a group fell dramatically from 1977 to 1987. The results of a decompositional technique show that the relationship between full-time employment and private insurance has weakened over the period for low-income females, but has strengthened for males in this group. While it appears that low-income females benefit from part-time employment relative to their unemployed cohorts, no discernible difference is found in the likelihood of being covered by private insurance for part-time and unemployed males. Finally, evidence suggesting a weakening over time in the relationship between part-time employment and private insurance coverage is found among middle-income females and high-income males. From a policy perspective, passage of the Health Insurance Portability and Accountability Act of 1996 has taken an important first step in attempting to lower the number of uninsured, especially among full-time workers. Our findings, however, suggest that this legislation may be too limited in scope to effectively reach part-time workers presently uninsured.     

Discrepancies in employer-sponsored health insurance among Hispanics, blacks, and whites: the effects of sociodemographic and employment factors

Using a nationally representative sample of employed adults from the 1987 National Medical Expenditure Survey (NMES), this research explores differences in the incidence and predictors of employer-sponsored health insurance among Hispanics, blacks, and whites. The data suggest that: 1) whites are most likely, and Hispanics are least likely, to have employer-sponsored medical insurance in their own name, or in the name of another individual; 2) Hispanics are most likely, and whites are least likely, to be completely uninsured; and 3) the factors which increase the odds of receiving employer-sponsored coverage in one's own name are relatively similar across racial groups, though they differ substantially in magnitude.