Health insurance in the United States

All public and private health insurers in the United States distinguish between inpatient, outpatient, and home health insurance benefits. So, whether or not an individual has insurance coverage for a prescription drug depends not only on whether he or she has health insurance but also on the setting in which the drug is prescribed and administered. Inpatient benefits cover services and products used in hospitals and sometimes in nursing homes. Outpatient benefits are for services or products obtained in clinics or offices of health professionals home health care benefits are for services or products provided by certified personnel to patients at home.2... 

However, herbs are not t5 ically prescribed in the United States for a number of reasons. Few pharmacy schools offer courses in botanical remedies and some nursing pharmaceutical courses focus more on misuse of herbal therapies than their proper use. Probably the most leading reason that herbs are not prescribed is that health insurance in the United States does not pay for these therapies. 

Medication adverse effects in general are more likely to develop in the elderly (Nolan et al., 1988). People who are elderly and people suffering from dementia are at extreme risk for many different adverse effects when exposed to neuroleptics. A recent study of administrative data from a health care insurer in the United States examined 959 cases of patients at least 45 years old who had been diagnosed with dementia,... 

These similarities are offset by contrasts in their health insurance arrangements, access of patients to the political process, the authority wielded by physicians, and social insurance systems. For example, health care in the United States is generally seen as a private good associated with individual choice and the availability of menus for insurance, thereby rationing care by price. In Germany, by contrast, health care is seen primarily as a right or entitlement. It serves as an instrument of broader social justice, and rationing, if at all, is controlled by providers on a local and individual level. 

Generic substitution has however been implemented by a number of reimbursement authorities, both insurance based schemes as in the United States and nationally run health care schemes, for example, Sweden (introduced October 2002) and Finland (introduced 1st April 2003) both countries health care schemes claim very considerable savings of the order of 5% of national expenditure on medicines. Sweden is considering extending the scheme to lead to compulsory generic prescribing. 

Price discrimination refers to the practice of selling identical products to different sets of customers at different prices. Expressed another way, different customers pay different markups over the identical incremental cost of producing an identical product. Price discrimination is widely practiced in the hotel and airline industries, by universities in the United States that can vary their tuition through scholarships, by electric power companies, and in the health care industry. Hospitals in the United States, for example, routinely charge different payers different prices for the same services. In the U.S. pharmaceutical market, different prices are charged to different insurance carriers and to self-paying patients. Worldwide, the same pharmaceutical firms sell the identical product to different countries at different prices. 

Economists have long emphasized that in health care, identification of the consumer is ambiguous. Is it the patient, the physician acting as a professional agent on behalf of the patient, or is it the third-party payer In most but not all countries, pharmaceutical manufacturer sales representatives, called detailers, are permitted to visit physicians in their offices and provide them with promotional material. Representatives from pharmaceutical manufacturers also interact with public-sector payers such as ministries of health, as well as with private-sector payers, such as insurers and self-insured employers in the United States. 

Even though advertising has long been controversial in many industries, commercial advertising in the context of health care goods and services has been particularly contentious, and even more so when it is directed at consumers rather than at health care providers or insurers. In this chapter I have summarized the accumulated empirical evidence on the size, composition, and impacts of DTCA in the United States. I have also briefly discussed New Zealand s experience with DTCA. 

The cost of health care became a hot public issue in the United States in the early 1990s. It swept an unknown, onetime university president named Harris Wofford into the Senate from Pennsylvania in 1991 and helped elect Bill Clinton president in 1992. Health insurance premiums were shooting up by double digits every year, some 37 million Americans didn t even have insurance, and if things kept on as they were, experts predicted, medical care would devour more than one-fourth of the gross national product by 2030. It was the rare case of an issue that seemed to unite both consumers, who couldn t afford to pay for health care, and business, which ended up being billed extra to pick up the unpaid charges of the uninsured. Some sort of national health care plan was a sure bet. 

It s no secret why AIDS gets attention and the neglected diseases don t It s the only one that also affects a large number of people in the United States with the money and health insurance to pay for prescriptions and the political clout to influence government and pharmaceutical officials. Now, is Big Pharma supposed to be working on those other diseases when it is unlikely to make any money ... 

What exactly is the market for a drug and a drug company At one level it is the number of patients who have adequate health insurance with the disease and in whom the disease is diagnosed properly at another level it is, in the United States, the 90,000 general practitioners, or the... 

Historically, a lack of public insurance programs created obstacles to health care services. For those who could not afford to pay for private insurance, the costs associated with health care were larger than most could afford. After lengthy debate, the U.S. Congress passed legislation in 1965 that established Medicare and Medicaid. Medicare covers over 95% of the elderly in the United States as well as many individuals who are disabled. Coverage for the disabled began in 1973 and is divided in two parts 1) hospital insurance and 2) supplementary medical insurance. The total disbursement for Medicare in 1997 was 213,575 billion, and there were 36,460,143 enrollees, of which 32,164,416 were elderly. 

In the United States, the 1996 HIPAA legislation (the Health Insurance Portability and Accountabflity Act) resulted in the designation of six required code sets for billing and reimbursement. These are fisted in Table 18-2. 

In the United States, federal legislation called the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to make patient information more strictly protected than before. Although most pharmaceutical companies have limited access to patient names and other health information, any patient information must be carefully guarded to avoid violation of HIPAA statutes, which address the use and disclosure of individuals medical information by covered entities , and set standards for individuals rights to control the use of their medical information. Violations can result in fines and/ or, in some instances, imprisonment. 

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