Prospects of gatekeeping in German social health insurance

From 2004, German social health insurers are bound by law to offer their insured a gatekeeping option. In return for renouncing direct access to specialist care, the insured can be granted bonus payments by their social health insurer. So far, experience with gatekeeping is very limited in Germany. In social health insurance, sickness funds are very reluctant to offer gatekeeping, although this was already legally possible before 2004. In the private health insurance sector, cost savings in gatekeeping tariffs are probably the result of self-selection of the insured rather than more cost-efficient provision of health care services. International experience does not prove that gatekeeping results in cost savings or a better patient–physician relationship. Although in countries with a strong primary care system there is a higher life expectancy, gatekeeping is not the only factor to bring about this effect. It is not to be expected that the new legislation will result in a major proliferation of gatekeeping options in German social health insurance. Either the gatekeeping options will not be attractive for the insured or sickness funds will use gatekeeping options as an instrument for risk selection.     

Public insurance substituting for private insurance: new evidence regarding public hospitals, uncompensated care funds, and Medicaid

This paper examines the impact of public health insurance programs, whether structured as subsidies to health care providers (public hospitals and uncompensated care reimbursement funds) or as direct insurance (Medicaid), on the purchase of private health insurance. The presence of a public hospital is associated with a lower likelihood of private insurance for those with incomes between 100-200% and 200-400% of the poverty level. Uncompensated care reimbursement funds were associated with less purchase of private health insurance and a higher likelihood of being uninsured across all income groups. More generous Medicaid programs showed both safety-net and crowd out effects.     

Private health insurance plans in 1978 and 1979: a review of coverage, enrollment, and financial experience.

The private health insurance industry collected $55.9 billion in premiums in 1979 and returned $50.2 billion in benefits to its subscribers. Premiums rose 12.4 percent, slightly faster than in 1978 when premiums rose 11.4 percent, to $49.7 billion. Benefits rose 11.4 percent in 1979, down from the 12.6 rate in 1978. After operating expenses were deducted, the industry showed underwriting losses of $1.4 billion in 1979 and $1.5 billion in 1978. About 78 percent of the population was insured for hospital care, 76 percent for x-ray and laboratory examinations, and about 76 percent for surgical services in 1979. Smaller percentages had coverage for other types of care. An estimated 64 percent of the aged bought private hospital insurance, and about 43 percent bought surgical insurance, mostly to supplement Medicare benefits. An estimated 12 percent of persons under age 65 had no protection against the cost of hospital care either through private insurance or a public program such as Medicare or Medicaid.     

Providing therapy when managed care organizations deny reimbursement: are private practitioners and their clients taking the fall?

Sampled private practitioners from the Register of Clinical Social Workers, American Psychological and Psychiatric Associations were used to evaluate what percentage of these practitioners' caseloads are made up of clients who have been denied reimbursement by managed care organizations for ongoing therapy. The results indicate that 39% of the respondents' caseloads are of managed care insured clients, of whom nearly one-third have been denied reimbursement for ongoing therapy, and of whom 42% later reenter therapy with an acute exacerbation of symptoms. The results have potential ethical and legal complications for private practitioners treating clients insured by managed care organizations.     

Long‐term Care Insurance and Carers' Labor Supply – A Structural Model

In Germany, individuals in need of long‐term care receive support through benefits of the long‐term care insurance. A central goal of the insurance is to support informal care provided by family members. Care recipients can choose between benefits in kind (formal home care services) and benefits in cash. From a budgetary perspective, family care is often considered a cost‐saving alternative to formal home care and to stationary nursing care. However, the opportunity costs resulting from reduced labor supply of the carer are often overlooked. We focus on the labor supply decision of family carers and the incentives set by the long‐term care insurance. We estimate a structural model of labor supply and the choice of benefits of family carers. We find that benefits in kind have small positive effects on labor supply. Labor supply elasticities of cash benefits are larger and negative. If both types of benefits increase, negative labor supply effects are offset to a large extent. However, the average effect is significantly negative. Copyright © 2015 John Wiley & Sons, Ltd.     

Private payers of health care in Brazil: characteristics, costs and coverage

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.     

A Measure of the Welfare Cost of Health Insurance

A measure of the economic welfare cost due to excess usage of insured services is presented, illustrated by empirical estimations of the welfare cost of existing insurance in selected years and of the effect on marginal welfare cost if all 1963 physician care had been fully insured. It is argued that no a priori case can be made for either increasing or restricting insurance coverage as a means of reducing excess usage cost, but that empirical investigation, with refined estimates of critical parameters, will allow prediction of the effect of any health insurance package on economic welfare.     

Managing the behavior of the medically insured in Germany: the acceptance of cost-sharing and risk premiums by members of the statutory health insurance

In the course of the conflicts over the reform of statutory health insurance in Germany complaints about moral hazard-behavior on the part of the insured were repeatedly raised and linked to the demand for expanding managerial incentives aimed at reducing the consumption of health care benefits (copayments). However, critics and supporters of managerial incentives mostly neglect the perceptions and dispositions of the insured. In contrast, the article examines how members of the statutory health insurance scheme assess managerial intervention, namely cost-sharing and risk premiums.     

Optimal deductibles for outpatient services

This paper analyses the effect of absolute deductibles on the cost of insurance for outpatient services. Moreover, cost savings on retained losses are estimated. Sharing risks between the insured and the insurer reduces total expenditure for outpatient benefits by up to 35%. In particular, optimal deductibles are determined in their utilitarian sense: the maximum possible savings on medical expenses are computed from the ground up. As part of the study, the effect of age and gender on these savings is analysed. The analysis is based on data taken from the private medical insurance industry in Germany. Similarities and discrepancies with respect to results obtained in the RAND Health Insurance Experiment conducted in the United States from 1971 to 1982 are highlighted.     

我国农民工医疗保险制度：北京、深圳与上海三市比较

文章从参保对象、享受待遇、缴费安排和住院医疗报销等4个方面,对北京和深圳的专项农民工医疗保险制度和2011年7月1日前后的上海农民工医疗保险安排进行了比较研究,以形成对我国农民工医疗保险安排的具体认识,为各地区进一步建立和完善农民工医疗保险制度提供经验。     

Health sector reforms in Argentina and the performance of the health financing system

In Argentina, health sector reforms put particular emphasis on decentralization and self-management of the tax-funded health sector, and the restructuring of the social health insurance during the 1990s. Unlike other countries in the region, there was no comprehensive plan to reform and unify the sector. In order to assess the effects of the reforms on the performance of the health financing system, this study looks at impacts on the three inter-related functions of revenue collection, pooling, and purchasing/provision of health services. Data from various sources are used to illustrate the findings. It was found that the introduction of cost recovery by self-managed hospitals increased their budgets only marginally and competition among social health insurance funds did not reduce fragmentation as expected. Although reforming the Solidarity Redistribution Fund and implementing a single basic package for the insured was an important step towards equity and transparency, the extent of risk pooling is still very limited. This study also provides recommendations regarding strengthening reimbursement mechanisms for public hospitals, and regulating the private sector as approaches to improving the fairness of the health financing system and protecting people from financial hardship as a result of illness.     

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.     

Health insurance systems in five Sub-Saharan African countries: medicine benefits and data for decision making

Medicine benefits through health insurance programs have the potential to improve access to and promote more effective use of affordable, high quality medicines. Information is lacking about medicine benefits provided by health insurance programs in Sub-Saharan Africa. We describe the structure of medicine benefits and data routinely available for decision-making in 33 health insurance programs in Ghana, Kenya, Nigeria, Tanzania and Uganda. Most programs surveyed were private, for profit schemes covering voluntary enrollees, mostly in urban areas. Almost all provide both inpatient and outpatient medicine benefits, with members sharing the cost of medicines in all programs. Some programs use strategies that are common in high-income countries to manage the medicine benefits, such as formularies, generics policies, reimbursement limits, or price negotiation. Basic data to monitor performance in delivering medicine benefits are available in most programs, but key data elements and the resources needed to generate useful management information from the available data are typically missing. Many questions remain unanswered about the design, implementation, and effects of specific medicines policies in the emerging and expanding health insurance programs in Sub-Saharan Africa. These include questions about the most effective medicines policy choices, given different corporate and organizational structures and resources; impacts of specific benefit designs on quality and affordability of care and health outcomes; and ways to facilitate use of routine data for monitoring. Technical capacity building, strong government commitment, and international donor support will be needed to realize the benefits of medicines coverage in emerging and expanding health insurance programs in Sub-Saharan Africa.     

Mental health parity: what are the gaps in coverage?

BACKGROUND: Mental health benefits in private health insurance plans in the United States are typically less generous than benefits for physical health care services, driving reform efforts to achieve parity in coverage. While there is growing evidence about the effects such legislation would have on the utilization and cost of mental health services, less is known about the impact parity would have on reducing the risk of large out-of-pocket expenses that families would face in the event of mental illness. AIMS OF THE STUDY: We seek to understand the impact that mental health parity would have on the out-of-pocket burden that families would face in the event of mental illness. We focus in particular on variations in coverage across the privately insured population. METHODS: We compare out-of-pocket spending for hypothetical episodes of mental health treatment, first under current insurance coverage in the United States and then under a reform policy of full mental health parity. We exploit detailed informtion on actual health plan benefits using a nationally-representative sample of the privately insured population under age 65 from the 1987 National Medical Expenditure Survey (NMES) that has been carefully aged and reweighted to represent 1995 population and benefit characteristics. RESULTS: Our results show that existing benefits of the U.S. privately insured population under age 65 leave most people at risk of high out-of-pocket costs in the event of a serious mental illness. Moreover, the generosity of existing mental health benefits varies widely across subgroups, particularly across firm size. We find significantly lower out-of-pocket costs when simulating full parity coverage. However, our results show those with less generous mental health coverage tend to have less generous physical health coverage, as well. CONCLUSIONS: Parity would substantially increase generosity of mental health coverage for most of the privately insured population. The wide variation in the generosity of existing mental health benefits suggests that there are likely to be differential impacts from a parity mandate. Those with limited physical health coverage would still be at significant financial risk for catastrophic mental illness.     

Reconsidering the role of private health funds in Australia: a dynamic model

In recent years the private sector has played a more important role in the funding and provision of Australian hospital care as a consequence of federal government policies aimed at increasing participation in private health insurance (health funds). These policies include tax incentives, a 30% rebate on premiums and lifetime community rating (premiums set by age). While these policies have improved the short-term profitability of the private sector, its long-term success is not certain. This is because negotiations between health funds and private hospitals are often myopic, the nature of the insurance product may be inefficient, and there is a general lack of academic research on the private sector. This paper highlights the importance of the relationship between health funds and private hospitals in ensuring the long-term viability of the industry. It uses a simple overlapping generations model to demonstrate that it is not only the price that health funds pay that impacts on the capital value of hospitals, but also it is important how they structure their policies and attract individuals. The model demonstrates the potential benefits of implementing health insurance based on intertemporal transfers of funds rather than the current cross-subsidization. Such a policy would see health funds become an important store of capital. Also highlighted are the difficulties of discussing fundamental changes to the health care system. While recent health care reforms have been described as driven by ideology rather than evidence, in the Australian context there is little evidence on which to base policy. Researchers need to be more proactive in their consideration and evaluation of alternative health care policies. Through quality research on the private sector, academics can better guide policy makers at the national and institutional level.     

An "All-American" health reform proposal

Reforming the U.S. health care system is frequently thought of in absolutist terms: managed competition versus rate regulation; federal versus state administration; and business mandates versus individual insurance purchases. While these choices must be resolved over the long run, the transition to a new health care system will take several years and require more flexible solutions. The "All-American" Deal offers just that. It requires individual households to be insured and allows businesses to voluntarily offer health insurance; relies on the federal income tax system to collect income-based premiums and transfer funds to states through risk-adjusted payments; and lets states manage the disbursement of funds for uninsured residents.     

Private health insurance: implications for developing countries

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.     

Long-term care insurance demand limited by beliefs about needs, concerns about insurers, and care available from family

In spite of the high costs and major financial risks involved in long-term care, the majority of older Americans do not own long-term care insurance. We conducted a survey designed to learn more about the role of the following four broad factors in affecting the demand for long-term care insurance: preferences and beliefs, such as notions about the likelihood that one will become disabled; substitutes for insurance, such as savings that could be spent on long-term care; substitutes for formal care, such as care provided by family members; and features of the private market, such as concerns about the high costs of coverage. We found evidence that each of these factors was important in explaining low demand for long-term care insurance. For example, people who believed they might need long-term care were more likely to purchase long-term care coverage. People who had alternative ways to pay for care, such as through savings, or those who could use unpaid care from family members, were less likely to purchase insurance. Features of the private market, such as people's lack of trust in insurers and the high cost of coverage, made people less likely to buy long-term care insurance. We conclude that policy interventions designed to address only one factor limiting the purchase of long-term care insurance are unlikely to dramatically increase demand for long-term care insurance.     

Inpatient–Outpatient Cost Shifting in Washington Hospitals

This paper empirically investigates the phenomenon known as "cost shifting" across inpatient and outpatient hospital services. That is, we examine whether, when faced with lower government reimbursement for outpatient services, providers raise inpatient prices for non-government patients (and analogously for lower inpatient government reimbursement). Using a panel of hospitals from Washington State, we find that private, nonprofit hospitals do cost shift across types of services. We also find that a firm's cost shifting behavior differs based on the type government insurance program (i.e., Medicare versus Medicaid). Government owned hospitals do not cost shift with respect to any type of government insurance plan.     

Access to care for low-income women: the impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.