scholarly journals Problems of providing medical care in excess of the amount established territorial compulsory health insurance program

2020 ◽  
Author(s):  
A.M. Moshin
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Medical Care ◽  
Legal Framework ◽  
Insurance Program ◽  
Health Insurance Program ◽  
Compulsory Health Insurance

The article deals with the legal framework and legislative problems of distribution of health care volumes for the territorial program of compulsory health insurance. The problem of conflicts of legislation in the field of compulsory health insurance in the area of distribution of the volumes of medical care.

Health

Getting By ◽  
2019 ◽  
pp. 329-428
Author(s):  
Helen Hershkoff ◽  
Stephen Loffredo
Keyword(s):  
United States ◽  
Health Care ◽  
Health Insurance ◽  
Low Income ◽  
The United States ◽  
Health Coverage ◽  
Eligibility Criteria ◽  
Insurance Program ◽  
Health Insurance Program ◽  
Child Health Insurance

This chapter addresses the issue of health care for low-income people. The United States, virtually alone among developed nations, does not offer universal access to health care, leaving many millions of individuals without health insurance or other means of obtaining necessary medical services. In 2010, Congress enacted the landmark Patient Protection and Affordable Care Act (ACA)—popularly known as “Obamacare”—marking an important but incomplete response to the nation’s health care crisis. This chapter examines the ACA in detail, including its impact on Medicaid and Medicare, the major government health programs in the United States, its creation of Health Insurance Exchanges and tax credits to help low-income households obtain private health coverage, and the reform of private health insurance markets through a patient’s bill of rights, which, among other measures, prohibits insurance companies from refusing coverage for preexisting medical conditions. Perhaps the most critical aspect of the ACA was its expansion of Medicaid to cover virtually all low-income citizens (and certain immigrants) who do not qualify for other health coverage. Although several states opted out of the ACA’s Medicaid expansion, the Medicaid program nevertheless remains the largest single provider of health coverage in the United States. This chapter also provides a detailed description of Medicaid, its eligibility criteria and scope of coverage; the Child Health Insurance Program (CHIP), a government-funded health insurance program for children in households with too much income to qualify for Medicaid; and Medicare, the federal health insurance program for aged, blind, and disabled individuals.

scholarly journals ANALYSIS OF MEDICAL SERVICE CONTROL PROCESS IN THE SCOPE OF COMPULSORY HEALTH INSURANCE PROGRAM

2015 ◽  
Vol 14 (3) ◽  
pp. 40-48
Author(s):  
M. A. Taranik ◽  
G. D. Kopanitsa
Keyword(s):  
Health Insurance ◽  
Medical Service ◽  
System Analysis ◽  
Clinical Service ◽  
Medical Documentation ◽  
Financial Resources ◽  
Insurance Program ◽  
Health Insurance Program ◽  
Compulsory Health Insurance ◽  
Clinical Records

The relevance of the presented paper deals with the necessity of determining problems and effective solutions for medical organizations on the stage of medical documentation reports control purposely for forecasting the average of financial resources that can be obtained in the scope of compulsory health insurance program.The aim of the study – for the purpose of further issues definition present formal model of the analyzed process using a set of system analysis methods.Material and methods. System analysis methods, especially IDEF0 diagrams and activity diagrams, for estimation of medical expert’s agreement Cohen’s kappa was used.The results. Based on the specification documents and expert’s experience the spread description on the process the control of volume, duration, quality and conditions of medical service assignment by medical organizations conducted by medical insurance organization was presented. Inputs, outputs, elements of management and executives were determined. As a result of decomposition, subprocesess were presented within activity diagrams.Conclusions. The obtained results of research allows to conclude that there is a set of problems which appear when medical organizations send reports for getting financial resources for clinical service realization in the scope of compulsory health insurance program. On the grounds of determined problems, we can conclude that it is necessary to develop an intellectual information system for estimating clinical records concerning getting financial resources for clinical service. In respect that human factor influence on the main stages of the analyzed process, we propose to use fuzzy logic as an inference engine. The self-learning function of the system will provide case-based reasoning.

scholarly journals Factors Affecting Enrollment in Government Health Insurance Program in Kailali District

2019 ◽  
Vol 17 (3) ◽  
pp. 388-393
Author(s):  
Deepak Raj Paudel
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Chronic Illness ◽  
Social Health Insurance ◽  
Social Health ◽  
Factors Affecting ◽  
Government Health ◽  
Insurance Program ◽  
Health Insurance Program ◽  
Insurance Enrollment

Background: Health care financial burden on households is high in Nepal. High health care expenditure is a major obstacle in achieving universal health coverage. The health insurance is expected to reduce healthcare expenditure. However, only small segments of the population are covered by health insurance in Nepal.This study assessed the factors affecting enrollment in government health insurance program in the first piloted district, Kailali, Nepal.Methods: A cross-sectional survey was conducted among 1048 households located in 26 wards of Kailali district after 21 months of the implementation of social health insurance program, Nepal. The sample was selected in two stages, first stage being the selection of wards and second, being the households.Results: The higher level of household economic status was associated with increased odds of enrollment in health insurance program (ORs=4.99, 5.04, 5.13, 8.05, for second, third, fourth, and the highest quintile of households, respectively). A higher level of head’s education was associated with increased odds of health insurance enrollment (ORs = 1.58, 1.78, 2.36, for primary, secondary, tertiary education, respectively). Presence of chronic illness in the household was positively associated with increased odds of health insurance enrollment (OR= 1.29). Conclusions: The poor and low educated groups were less benefited by social health insurance program in Kailali district, Nepal. Hence, policymakers should focus to implement income-based premium scheme for ensuring equal access to healthcare.Since household with chronic illness leads to high odds of being enrolled, a compulsory health insurance scheme can make the program financially sustainable.Keywords: Enrollment; health expenditure; health insurance; inequality; Nepal.

scholarly journals Medicaid/State Children's Health Insurance Program Patients and Infectious Diseases Treated in Emergency Departments: U.S., 2003

2007 ◽  
Vol 122 (4) ◽  
pp. 513-520 ◽  
Author(s):  
Nelson Adekoya
Keyword(s):  
Infectious Disease ◽  
Health Insurance ◽  
Infectious Diseases ◽  
Medical Care ◽  
Emergency Departments ◽  
Children's Health ◽  
Insurance Program ◽  
Health Insurance Program ◽  
Ed Visits ◽  
The U.S

Objective. Emergency departments (EDs) are a critical source of medical care in the U.S. Information is sparse concerning infectious disease visits among Medicaid entitlement enrollees nationwide. The objective of this study was to describe infectious diseases in terms of Medicaid/State Children's Health Insurance Program (SCHIP) as an expected source of payment. Methods. Data for 2003 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of nonfederal, short-stay, and general hospitals in the U.S. Data are collected annually and are weighted to generate national estimates. Results. Nationally in 2003, an estimated 21.6 million visits were made to hospital EDs for infectious diseases (rate = 76 visits/1,000 people). Medicaid/SCHIP was the expected source of payment for an estimated 6.7 million infectious disease-related visits (rate = 200 visits/1,000 people covered by Medicaid). Children aged <15 years made 39% of visits nationwide (nationwide rate = 139 visits/1,000 people). Of Medicaid visits, 63% were made by children <15 years of age (Medicaid enrollees rate = 255 visits/1,000 people). The rate of visits for Medicaid enrollees was comparable for females and males (198 visits vs. 201/1,000 people). The rate of visits for black Medicaid enrollees was 33% higher than for white Medicaid enrollees (255 vs. 192 visits/1,000 people). Upper respiratory tract infection (URTI) is the most frequent infectious condition recorded at ED visits. An estimated 47% of ED visits with an expected pay source of Medicaid relate to URTIs (93 visits/1,000 people), compared with 38% of ED visits in general (29 visits/1,000 people). Conclusion. Medicaid enrollee-specific ED visit rates for infectious diseases were higher by age group, gender, race, and region, compared with national rates. Because approximately half of visits relate to URTIs for a Medicaid payment group, URTIs should form the basis for development of appropriate control strategies.

scholarly journals Catastrophic Health Expenditure: An Experience from Health Insurance Program in Nepal

2019 ◽  
Vol 3 (5) ◽  
pp. 327-336 ◽  
Author(s):  
Deepak Raj Paudel
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Health Expenditure ◽  
Health Care Expenditure ◽  
Catastrophic Health Expenditure ◽  
Health Concern ◽  
Government Health ◽  
Insurance Program ◽  
Health Insurance Program ◽  
The Government

High expenditure due to health care is a noted public health concern in Nepal and such expenditure is expected to reduce through the access to health insurance. This study determines the factors affecting household’s catastrophic health care expenditure in Kailali district, where the government health insurance program was first piloted in Nepal. A cross-sectional survey was conducted from January to February 2018 among 1048 households (6480 individuals) after 21 months of the execution of the social health insurance program.  For the sample selection, wards were selected in the first stage followed by the selection of the households. Overall, 17.8% of the households reported catastrophic health expenditure using a threshold of more than 10% of out-of-pocket payment to total household expenditure. The study found that households without having health insurance, low economic status, and head with low level of education were more likely to face catastrophic spending. The findings suggest a policy guideline in the ongoing national health insurance debate in Nepal. The government health insurance program is currently at expansion stage, so, increase in insurance coverage, could financially help vulnerable households by reducing catastrophic health expenditure.

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