Medical
Insurance Trends
Insurance status and type are important
determinants of use patterns. Insurance greatly reduces
the marginal cost of obtaining physician services, and cost
sharing (deductibles, coinsurance) and plan restrictiveness
(managed indemnity versus closed network HMOs) can affect
access to certain physician specialties and practice settings.
The
PRM divides the United States population into four mutually
exclusive insurance groups: [12]
(1) Insured
under a fee-for-service arrangement;
(2) Insured
in an exclusive network HMO (e.g., group-, staff-, network-,
or mixed-model HMO);
(3) Insured
under a different type of managed care plan (e.g., preferred
provider organization [PPO], point of service [POS] organized
as open-ended HMO, non-HMO POS, and other HMO/managed care
plans); and
(4) Uninsured.
In the
baseline scenario, we assume a constant insurance probability
for each population group defined by age and sex using the
year 2000 insurance distribution.
Based
on use patterns determined through an analysis of the NIS,
NHAMCS, NAMCS, NNHS and other sources, we estimated how
per capita use of physician services compares under these
four insurance types after controlling for population age
and sex (Exhibit 23). For example, individuals in an exclusive
network HMO use 86 percent as many anesthesiology services
as individuals in a plan modeled after a traditional fee-for-service
arrangement (controlling for age and sex). Individuals insured
under other types of managed care plans and uninsured individuals
use 98 percent and 29 percent as many anesthesiologist services,
respectively, as individuals insured under the fee-for-service
type plan.
Exhibit
23. Per Capita Use of Physician Services
(as
a percentage of per capita use under an insured, fee-for-service
arrangement)
Specialty |
Exclusive Network HMO |
All Other Managed Care |
Uninsured |
Anesthesiology |
86 |
98 |
29 |
Cardiology |
92 |
100 |
18 |
Emergency
Medicine |
41 |
47 |
78 |
General/Family
Practice |
87 |
99 |
60 |
General
Internal Medicine |
103 |
118 |
25 |
General
Surgery |
86 |
98 |
33 |
Obstetrics/Gynecology |
83 |
95 |
30 |
Ophthalmology |
100 |
100 |
67 |
Orthopedic
Surgery |
78 |
90 |
22 |
Other
Internal Medicine Subspecialties |
90 |
100 |
24 |
Other
Specialties |
59 |
68 |
32 |
Other
Surgical Specialties |
86 |
98 |
33 |
Otolaryngology |
66 |
76 |
45 |
Pathology |
86 |
98 |
27 |
Pediatrics |
100 |
100 |
62 |
Psychiatry |
65 |
75 |
100 |
Radiology |
86 |
98 |
22 |
Urology |
94 |
100 |
21 |
|