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This paper aimed to describe health insurance coverage in Brazil. Data from the 2013 and 2019 editions of the National Health Survey (PNS) were analyzed. The medical or dental health insurance coverage was analyzed according to demographic and socioeconomic characteristics, work status, urban/rural area, and Federation Unit. Coverage of medical or dental health insurance was 27.9% (95% CI: 27.1-28.8) for 2013 and 28.5% (95% CI: 27.8-29.2) for 2019. The results show coverage is still concentrated in large urban centers, in the Southeast and South, among those with better socioeconomic status and some formal employment. In 2019, only 30.7% of formal workers reported the monthly payment is made directly to the providers, while 72.7% of informal workers reported this information. About 92% of medical health insurance covers hospitalization, and almost 20% of women with health insurance are not covered for labor. Only 11.7% of women aged between 15 and 44 are covered for childbirth by health insurance. The results show the health insurance coverage is still quite unequal, reinforcing the Unified Health System (SUS) importance for the Brazilian population.

Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures. In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations. The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%. This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.).

Along with estimates suggesting that the admin- istrative expenses of private insurers in Canada are higher than those in the public sector, industry data also show that these amounts have increased over the past two decades. We compiled and adjusted for inflation the premium income col- lected and benefits paid for services that plan members received from for-profit health insurers from 1991 through 2011, using data from reports published by the Canadian Life and Health Insur- ance Association.10,11 The proportion of premium income spent on benefits is referred to as the \"medical loss ratio.\" The remainder consists of the amount spent on administration, the amount kept as profit and any other nonmedical spending (elements that are not separately reported by the Canadian Life and Health Insurance Association). Figures 1 to 3 show these numbers for the three major types of for-profit private health benefits plans in Canada: insured group plans (i.e., small and medium-sized employers; Figure 1), plans purchased by individuals (Figure 2) and self- insured group plans (i.e., those where large employers pay claims themselves, purchasing only processing services from the insurance com- pany; Figure 3). Figure 4 shows the same data for all plan types combined, along with policy divi- dends paid to some policyholders. Of note, these dividends never exceeded 3% of total premiums collected in any given year. As shown in Figures 1 and 2, medical loss ratios have dropped substantially for both group plans and individual plans over the past 20 years. For group plans, the percentage of premium rev- enue paid out as benefits dropped from 92% of premiums in 1991 to 74% in 2011. The differ- ence between premiums and benefits conse- quently tripled, reaching $4.4 billion in 2011. The Canadian Life and Health Insurance Associ- ation does not report dividend payments to policyholders by insurance type; however, even if one assumes that all policy dividends were paid out in the group insured market, the medical loss ratio was 77% in 2011 - notably lower than the 80% or 85% minimum now in place for private health insurance in the US. Premium rev- enue also increased much more rapidly than ben- efits paid in individual plans, with the medical loss ratio in these plans decreasing from 46% to 38% over the same period. Across all types of for-profit private insurance, industry data suggest that Canadians paid nearly $6.8 billion more in premiums than was paid out in benefits in 2011 (Figure 4). 12. Frakt A. JAMA forum: Are health insurers' administrative costs too high or too low? In: news@JAMA. Chicago (IL): American Med- ical Association; 2013 Apr. 24. Available: http://newsatjama.jama .com/2013/04/24/jama-forum-are-health-insurers-administrative -costs-too-high-or-too-low/ (accessed 2013 Apr. 24).

Background: Starting in 2011, the Affordable Care Act stipulates that insurers meet the minimum medical loss ratio (MLR) standards or issue rebates. An MLR is the proportion of premium revenues spent on clinical benefits, and must be at least 80% in the individual and small-group markets. Although some insurers have issued rebates, it is unclear whether they also adjusted MLRs and their components in ways to move toward compliance. Objective: To investigate early responses of individual and smallgroup insurers' MLR-related outcomes to the Affordable Care Act provisions. Research Design: Descriptive and multivariate analyses using 2010–2011 data from the National Association of Insurance Commissioners and other sources. Measures: Outcomes include MLRs, MLR components (claims incurred, premiums earned, quality improvement expenses, and fraud detection/recovery expenses), and administrative expenses. Results: In 2010, only 44.3% of individual market insurers reported MLRs of at least the stipulated level; by 2011, this percentage was 63.2%. Among small-group insurers, 74.9% had 2010 MLRs at or above the stipulated level, with little change in 2011. Individual insurers with 2010 MLRs >10 percentage points below the minimum exhibited the largest increases in MLRs, with changes occurring through increases in claims and indirectly through decreases in administrative expenses. Conclusions: Early responses to MLR regulation seem more pronounced in the individual versus small-group market, with insurers using both direct and indirect strategies for compliance. Because insurers learned of final MLR regulations only in late 2010, early responses may be limited and skewed more toward greater use of rebates than other adjustments.

The Affordable Care Act's regulation of medical loss ratios requires health insurers to use at least 80-85 percent of the premiums they collect for direct medical expenses (care delivery) or for efforts to improve the quality of care. To gauge this rule's effect on insurers' financial performance, we measured changes between 2010 and 2011 in key financial ratios reflecting insurers' operating profits, administrative costs, and medical claims. We found that the largest changes occurred in the individual market, where for-profit insurers reduced their median administrative cost ratio and operating margin by more than two percentage points each, resulting in a seven-percentage-point increase in their median medical loss ratio. Financial ratios changed much less for insurers in the small- and large-group markets. [PUBLICATION ABSTRACT]

Bleeding after percutaneous coronary intervention (PCI) is more common in women than in men. However, the relationship of sex and bleeding with outcomes is less well studied. We examined the sex-related differences in the incidence of bleeding and its association with in-hospital outcomes among 96,637 patients undergoing PCI enrolled in the BMC2 registry (2010-2012). Women had higher bleeding rate than did men (3.9% vs 1.8%) and thus received more blood transfusions (59% vs 41%). Both men (odds ratio [OR] 2.25, 95% CI 1.70-2.97) and women (OR 3.13, 95% CI 2.42-4.07) who bled had higher risk-adjusted death compared with their counterparts without bleeding. Although there was no difference in adjusted mortality between women and men without bleeding (OR 1.14, 95% CI 0.99-1.32), among patients who bled, adjusted death was higher in women (OR 1.28, 95% CI 1.11-1.47). Among patients with bleeding, transfusion was associated with similar increased risk of death in both men (OR 2.00, 95% CI 1.23-3.25) and women (OR 2.18, 95% CI 1.31-3.63) compared with their counterparts without transfusion(s). Post-PCI bleeding was more common and associated with higher-than-expected in-hospital death in women compared with men with bleeding. This trend for higher death in women with bleeding was independent of transfusion. Quality efforts geared toward reducing bleeding in general, with a special focus on women, need to be explored to help reduce post PCI-bleeding and mortality and decrease sex-related disparity in adverse events.

Currently, there are limited published data regarding resource use and spending on cancer care in the US. To characterize the most frequent medical services provided and the associated spending for privately insured patients with cancer in the US. This cohort study used data from the MarketScan database for the calendar year 2018 from a sample of 27.1 million privately insured individuals, including patients with a diagnosis of the 15 most prevalent cancers, predominantly from large insurers and self-insured employers. Overall societal health care spending was estimated for each cancer type by multiplying the mean total spending per patient (estimated from MarketScan) by the number of privately insured patients living with that cancer in 2018, as reported by the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Analyses were performed from February 1, 2018, to July 8, 2021. Evaluation and management as prescribed by treating care team. Current Procedural Terminology and Healthcare Common Procedure Coding System codes based on cancer diagnosis code. The estimated cost of cancer care in 2018 for 402 115 patients with the 15 most prevalent cancer types was approximately $156.2 billion for privately insured adults younger than 65 years in the US. There were a total of 38.4 million documented procedure codes for 15 cancers in the MarketScan database, totaling $10.8 billion. Patients with breast cancer contributed the greatest total number of services (10.9 million [28.4%]), followed by those with colorectal cancer (3.9 million [10.2%]) and prostate cancer (3.6 million [9.4%]). Pathology and laboratory tests contributed the highest number of services performed (11.7 million [30.5%]), followed by medical services (6.3 million [16.4%]) and medical supplies and nonphysician services (6.1 million [15.9%]). The costliest cancers were those of the breast ($3.4 billion [31.5%]), followed by lung ($1.1 billion [10.2%]) and colorectum ($1.1 billion [10.2%]). Medical supplies and nonphysician services contributed the highest total spent ($4.0 billion [37.0%]), followed by radiology ($2.1 billion [19.4%]) and surgery ($1.8 billion [16.7%]). This analysis suggests that patients with breast, colorectal, and prostate cancers had the greatest number of services performed, particularly for pathology and laboratory tests, whereas patients with breast, lung, lymphoma, and colorectal cancer incurred the greatest costs, particularly for medical supplies and nonphysician services. The cost of cancer care in 2018 for the 15 most prevalent cancer types was estimated to be approximately $156.2 billion for privately insured adults younger than 65 years in the US.

Federal subsidies available to enrollees in health insurance marketplaces are pegged to the premium of the second-lowest-cost silver plan available in each rating area (as defined by each state). People who qualify for the subsidy contribute a percentage of their income to purchase coverage, and the federal government covers the remaining cost up to the price of that premium. Because the number of plans offered and plan premiums vary substantially across rating areas, the effective value of the subsidy may vary geographically. The authors found that the availability of more plans in a rating area was associated with lower premiums but higher deductibles for enrollees in the second-lowest-cost silver plan. In rating areas with more than 20 plans, the average deductible in the second-lowest-cost silver plan was nearly $1,000 higher than it was in rating areas with fewer than thirteen plans. Because premium costs for second-lowest-cost silver plans are capped, deductibles may be a more salient measure of plan value for enrollees than premiums are.