Consumer choice of social health insurance in managed competition

Objective To promote managed competition in Dutch health insurance, the insured are now able to change health insurers. They can choose a health insurer with a low flat‐rate premium, the best supplementary insurance and/or the best service. As we do not know why people prefer one health insurer to another, we investigated their reasons for selecting their health insurer and assessed the importance of the supplementary benefit package and the flat‐rate premium. Methods A self‐administered questionnaire was completed by 468 of a total of 884 (52.9%). Data were compared among three groups. The first group comprised those who left one health insurer for another (exit). The second group had joined the health insurer (entry) and the third group comprised those who did not switch (stayers). Results Those in the entry group were statistically significantly less satisfied with their former insurance organization than those in the other groups (exit and stayers) with the insurance organization under investigation. They were also less satisfied than the other groups in respect of the flat‐rate premium. Those in the exit group were younger and seemed to be in better health. In general, the insured were only aware of small differences between health insurance funds and the three groups did not differ from each other in this respect. About a quarter of the entry group reported the flat‐rate premium as a reason for selecting a particular health insurance fund. However, the most frequently reported reason, for both exit and entry, was the benefit package of the supplementary insurance. Conclusions In the absence of clear differences between insurance organizations, the advantages of managed competition maybe too difficult to achieve.     

Dynamics of social health insurance development: examining the determinants of Chinese basic health insurance coverage with panel data

Social health insurance (SHI) is gaining popularity in many developing countries, but there are few systematic empirical studies on the dynamics of SHI development. This study investigates the determinants of coverage of the Basic Healthcare Insurance for Urban Employees (BHI) in China. Using a panel database ranging from 1999 to 2007, the study finds that: (1) economic development plays a valuable role in BHI development; (2) strong financial capacity and administrative capacity in the government contributes to BHI progress; (3) higher trade union density is closely related to more rapid BHI expansion; and (4) taxation agencies are better at collecting SHI premiums. These findings provide evidence-based lessons for new and ongoing SHI programs. In addition, this article aims to make a more general contribution to the study of social policy development by expanding the scope of current theories on social policy development.     

Pricing behaviour of nonprofit insurers in a weakly competitive social health insurance market

In this paper we examine the pricing behaviour of nonprofit health insurers in the Dutch social health insurance market. Since for-profit insurers were not allowed in this market, potential spillover effects from the presence of for-profit insurers on the behaviour of nonprofit insurers were absent. Using a panel data set for all health insurers operating in the Dutch social health insurance market over the period 1996-2004, we estimate a premium model to determine which factors explain the price setting behaviour of nonprofit health insurers. We find that financial stability rather than profit maximisation offers the best explanation for health plan pricing behaviour. In the presence of weak price competition, health insurers did not set premiums to maximize profits. Nevertheless, our findings suggest that regulations on financial reserves are needed to restrict premiums.     

Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time.     

The adequacy of household survey data for evaluating the nongroup health insurance market

OBJECTIVE: To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance. DATA SOURCES/STUDY SETTING: Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording. STUDY DESIGN: To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population. DATA COLLECTION/EXTRACTION METHODS: Data for nonelderly New Jersey residents from the 2002 CPS (n=5,028) and the 1997 and 1999 NSAF (n=6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n=5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n=1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n=1,460 nonelderly). PRINCIPAL FINDINGS: General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage. CONCLUSIONS: Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined.     

The influence of supplementary health insurance on switching behaviour: evidence from Swiss data

This paper focuses on the switching behaviour of enrolees in the Swiss basic health insurance system. Even though the new Federal Law on Social Health Insurance (LAMal) was implemented in 1996 to promote competition among health insurers in basic insurance, there is limited evidence of premium convergence within cantons. This indicates that competition has not been effective so far, and reveals some inertia among consumers who seem reluctant to switch to less expensive funds. We investigate one possible barrier to switching behaviour, namely the influence of supplementary insurance. We use survey data on health plan choice (a sample of 1943 individuals whose switching behaviours were observed between 1997 and 2000) as well as administrative data relative to all insurance companies that operated in the 26 Swiss cantons between 1996 and 2005. The decision to switch and the decision to subscribe to a supplementary contract are jointly estimated. Our findings show that holding a supplementary insurance contract substantially decreases the propensity to switch. However, there is no negative impact of supplementary insurance on switching when the individual assesses his/her health as ‘very good’. Our results give empirical support to one possible mechanism through which supplementary insurance might influence switching decisions: given that subscribing to basic and supplementary contracts with two different insurers may induce some administrative costs for the subscriber, holding supplementary insurance acts as a barrier to switch if customers who consider themselves ‘bad risks’ also believe that insurers reject applications for supplementary insurance on these grounds. In comparison with previous research, our main contribution is to offer a possible explanation for consumer inertia. Our analysis illustrates how consumer choice for one's basic health plan interacts with the decision to subscribe to supplementary insurance. Copyright © 2009 John Wiley & Sons, Ltd.     

Managed competition and consumer price sensitivity in social health insurance

This paper examines whether the introduction of managed competition in Dutch social health insurance has resulted in effective price competition among insurance funds. We find evidence of limited price competition, which may be caused by low consumer price sensitivity. Using aggregate panel data from all insurance funds over the period 1996-1998, estimated premium elasticities of market share are -0.3 for compulsory coverage and -0.8 for supplementary coverage. These elasticities are much smaller than in managed competition settings in US group insurance. This may be explained by differences in switching experience and higher search costs associated with individual insurance.     

Optional deductibles in social health insurance systems

A fundamental aspect of the German health insurance system is the principle of solidarity. At the same time, it is possible for certain socio-economic groups to opt out of the otherwise compulsory system. To determine whether rates incorporating deductibles are compatible with the principles of solidarity and have the ability to heighten the appeal of statutory health insurance (SHI) funds compared with private health insurance companies, Germany's third largest SHI fund, Techniker Krankenkasse, implemented a pilot scheme involving the use of deductibles. Preliminary scientific evaluations of the pilot scheme indicate three main results for these deductibles: Firstly, they are compatible with the principles of solidarity in the statutory health insurance system; secondly, they provide an effective means of preventing defection to private health insurance companies and thirdly, they reduced the volume of insurance claims (moral hazard).     

商业健康保险对居民健康的影响——来自CGSS数据的经验证据

商业健康保险作为社会医疗保险的有益补充,是推动健康中国战略的重要抓手。本文基于中国综合社会调查(CGSS)数据,采用截面倍差法(DID)与倾向得分匹配法(PSM)估计了商业健康保险对参保居民健康的影响。研究发现:商业健康保险具有正向健康效应,即参加商业健康保险能够显著促进居民健康,提升居民健康水平。通过使用截面倍差法克服因果效应与倾向得分匹配法进行反事实估计发现,商业健康保险对居民健康的正向影响仍然成立。扩展性分析显示,商业健康保险对高收入群体的健康促进效应显著高于低收入群体,同时在40岁以上、中西部地区更显著。本文结论有助于认清商业健康保险对提升居民健康水平的价值与深层影响。     

德国医疗保障体系改革及启示

德国是世界上最早建立社会医疗保障制度的国家,其医疗保障体系以法定医疗保险为主,私人医疗保险为辅,基本实现了全民覆盖。本文在梳理德国医疗保障体系三次改革的基础上,阐述德国当前医保管理模式、医疗保险体系、医疗服务体系以及对弱势人群进行保障的现状特点,归纳德国医疗保障体系在发挥市场机制、医保福利包设计、提供均等医疗服务、实行家庭医生制度、注重质量和效率的具体经验,进而提出厘清政府和市场的关系、适时调整医保福利包、逐步建立分级诊疗模式、保障公平的医疗服务以及合理控制医药费用等建议。     

浅析我国商业健康保险对社会医疗保险的补充作用

社会医疗保险和商业健康保险共同构成了我国的医疗保障体系,其中社会医疗保险是基础,商业健康保险是必要补充。目前,我国商业健康保险业务量小,覆盖率低,对医疗费用的分担少,因此其对社会医疗保险补充作用的发挥程度较低,这是由医疗保险所针对风险的特殊性所决定的。为了充分发挥商业健康保险对社会医疗保险的补充作用,必须加强政商合作,实行专业化经营,加强人才培养,构建有吸引力的医保合作框架,针对特殊风险进行业务创新等。     

Individual behaviour and tobacco consumption: A panel data approach

This paper considers estimators of tobacco demand equations using Becker and Murphy's model of addiction with a complete panel of households for Spain. With these tools, we face two main problems: first, the endogeneity of past and future consumption and, second, the limited-dependent variable. To control these problems simultaneously is difficult and we proceed to confront them separately. We follow an instrumental variable approach (which also allows us to control for measurement errors in variables and non-independent effects) to tackle the first and we use a consistent within-group procedure to obtain the parameter vector of the structural form, once we have estimated T-Tobit models for the reduced form in order to deal with the limited-dependent variable problem.     

商业健康保险市场中医疗机构与保险公司关系的博弈分析

为促进我国健康保险市场的平稳发展,对医疗机构与健康保险公司之间的博弈关系进行了分析,结合当前实际,建议政府应当大力推进相关制度基础设施建设,这包括协助建立医疗机构—保险公司信息共享平台、推进医药分家制和费用预付制以及加大对违规医疗机构人员的执法力度等。     

Financing a national health insurance

Financing national health insurance is a topic that has been discussed for a long time in the United States. It is also of relevance for less developed countries, in particular in the Far East where some countries have just introduced or are on the brink of introducing national health insurance. Furthermore, there is an urgent need to consult those former socialist countries wishing to introduce a national health insurance system. The paper deals with basic principles of health insurance and specific elements of a (compulsory) social health insurance in detail.     

The effect of report cards on consumer choice in the health insurance market

We test the effect of report cards on consumer choice in the HMO market. Federal employees were provided with report cards on a limited basis in 1995 and then on a widespread basis in 1996. Exploiting this natural experiment, we find that subjective measures of quality and coverage influence plan choices, after controlling for plan premiums, expected out of pocket expenses and service coverages. The effect is stronger within a small sample of new hires compared to a larger sample of existing federal employees. We also find evidence that report cards increase the price elasticity of demand for health insurance.     

A structural econometric model of family valuation and choice of employer-sponsored health insurance in the United States

This paper estimates a fully structural unitary household model of employment and health insurance decisions for dual wage-earner families with children in the United States, using data from the 1987 National Medical Expenditure Survey. Families choose hours of work and the breakdown of compensation between cash wages and health insurance benefits for each wage earner in order to maximize expected utility under uncertain need for medical care. Heterogeneous demand for the employer-sponsored health insurance is thus generated directly from variations in health status and earning potential. The paper concludes by discussing the benefits of using structural models for simulating welfare effects of insurance reform relative to the costly assumptions that must be imposed for identification.     

社会医疗保险配套医药卫生政策存在的问题及对策探讨

目前我国医疗保险、医疗卫生和医药行业未能同步协调发展影响了我国社会医疗保险制度的顺利实施。文章分析了我国社会医疗保险制度的相关配套医药卫生政策方面存在的问题及改进对策。     

完善上海市基本医疗保险体系研究:基于商业健康保险视角

上海市基本医疗保险虽在覆盖面、筹资水平、保障水平等方面处于国内领先地位,但仍无法避免就医需求快速上升和基金管理效果不佳等问题带来的矛盾。商业健康保险在资金和人员管理方面有其独特的优势,可发挥其对基本医疗保险的补充作用,完善基本医疗保险体系。本文基于商业健康保险的视角,从经办模式、经办主体、保障对象、筹资方式和保障项目5个方面对上海市基本医疗保险体系进行探索和完善。     

我国社会医疗保险“逆向转移”现象研究

社会医疗保险是保证社会成员公平享有基本医疗服务,促进全民健康水平提高的重要工具,但部分微观制度设计的不当,造成社会医疗保险在收入再分配上呈现从低收入者向高收入者转移的逆向转移情况,是一种效率和公平的双损失。文章从微观制度设计角度分析我国社会医疗保险出现收入再分配逆向转移现象的原因,提出通过在医疗保险费用征收和医疗保险待遇给付两个环节对相应微观制度设计进行调整,并结合其他国家经验,提出扭转这种收入再分配上的逆向转移现象的建议。     

Plan choice,health insurance cost and premium sharing

We develop a model of premium sharing for firms that offer multiple insurance plans. We assume that firms offer one low quality plan and one high quality plan. Under the assumption of wage rigidities we found that the employee's contribution to each plan is an increasing function of that plan's premium. The effect of the other plan's premium is ambiguous. We test our hypothesis using data from the Employer Health Benefit Survey. Restricting the analysis to firms that offer both HMO and PPO plans, we measure the amount of the premium passed on to employees in response to a change in both premiums. We find evidence of large and positive effects of the increase in the plan's premium on the amount of the premium passed on to employees. The effect of the alternative plan's premium is negative but statistically significant only for the PPO plans.