Risk selection in the German public health insurance system

The German statutory health insurance market was exposed to competition in 1996. To limit direct risk selection the regulator required open enrollment. As the risk compensation scheme, introduced in 1994, is highly incomplete, substantial incentives for risk selection exist. Due to their low premiums, company-based sickness funds have been able to attract a lot of new members. We analyze, using data from the German Socio-Economic Panel, the determinants of switching behavior from 1995 to 2000. There is no evidence for selection by funds. The success of the company-based sickness funds originates in incomplete risk adjustment together with the negative correlation between health status and switching costs.     

On being new to an insurance plan: health care use associated with the first years in a health insurance plan

BACKGROUND We wanted to compare health care utilization and costs in the first year of being in a health insurance plan with those of subsequent years.     

Dynamic process of adverse selection: evidence from a subsidized community-based health insurance in rural China

This article examines the changes of adverse selection over time during a 3-year subsidized, voluntary-based Community Health Insurance (CHI) scheme in rural China. The data came from a 4-year longitudinal social experimental study (2002-2006) on the CHI in Fengsan Township, Guizhou Province of China. A panel of 8198 observations (average of 2730 individuals) was analyzed using random effect logit model. We found that the effect of health status on the enrollment choice of the CHI scheme was significant. People with chronic condition history, with fair health, and with poor health were more likely to enroll in the scheme than those without chronic condition and with good health status. In addition, we found that almost all of the interaction terms of the health status variables and CHI wave variable were not significant, which indicates that the effects of adverse selection have not significantly changed over time. Furthermore, people with medium income and high income were more likely to enroll in the scheme compared to those with low income. This shows that adverse selection persisted in the subsequent enrollments of the CHI scheme, even with the government subsidy to the premium. However, adverse selection did not become more or less severe over time and worked through to a steady state. In addition, inequity of enrollment still exists under the current premium subsidy policy. Based on the findings, relevant policy implications are put forward to further improve the CHI scheme.     

医疗保险资金管理模式研究:以A市为例

在全国几乎统一的管理模式下,A市经过多年探索和实践,建立了一套与全国其他地区不同的城镇医保资金管理模式。本文从A市医保资金管理模式形成、目前管理模式实施情况和各方对管理模式运行的评价与意见几方面对管理模式进行具体介绍。本文运用定性访谈方法重点对管理模式为什么形成,为什么能顺利运行,管理模式的优势和劣势进行了分析和讨论。本文认为应当挖掘A市的医疗保险资金管理模式的"精髓",切实建立一个多部门协调的平台。     

Gatekeepers in sickness insurance: a systematic review of the literature on practices of social insurance officers

Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by staff of private or public insurance organisations. The work performed by these professionals is debated, hence more knowledge is needed on this subject. The aim of the present study was to review scientific studies of the practices of social insurance officers (SIOs) published in English, Danish, Norwegian and Swedish. Studies were searched for in literature databases, in reference lists, and through personal contacts. Analyses were made of type of study, areas investigated, research questions, theories used, and the results. Sixteen studies were included. SIOs and several other actors are responsible for applying measures to minimise sick-leave and promote return to work (RTW). The studies focusing on coordination of such measures revealed that SIOs felt unsure about how to handle their contacts with clients and other actors. One study indicated that the SIOs, partly due to lack of time, accepted the recommendations of physicians instead of making their own judgments about granting sickness benefits. While all SIOs must make decisions concerning entitlement to sickness benefits on a daily basis, few of the reviewed studies scrutinised the actual granting of sickness compensation. The studies were also deficient in that they investigated the decision latitude of the SIOs from a very limited perspective, mainly on an individual level and often primarily in relation to colleagues and/or clients rather than to the laws and regulations of the sickness insurance. The concepts and framework in this area of research need to be developed to facilitate elucidation of the interaction between different actors in local spheres, professionals in different disciplines, and between welfare staff and individual citizens.     

Long-term care use and socio-economic status in Belgium: a survival analysis using health care insurance data

Background

The small but growing literature on socio-economic inequality in morbidity among older persons suggests that social inequalities in health persist into old age. A largely separate body of literature looks at the predictors of long-term care use, in particular of institutional care. Various measures of socio-economic status are often included as control variables in these studies. Review articles generally conclude that the evidence for such variables being a predictor for institutionalization is “inconclusive”. In this paper we look at the association among older persons in Belgium between one particular measure of socio-economic status – preferential status in public health care insurance – and first use of home long-term care and residential care. Preferential status entitles persons to higher reimbursement rates for health care from the public health care insurance system and is conditional on low income. We also study whether preferential status is related to the onset of five important chronic conditions and the time of death.

Methods

We use survival analysis; the source of the data is a large administrative panel of a sample representative for all older persons in Belgium (1,268,740 quarterly observations for 69,562 individuals).

Results

We find a strong association between preferential status and the likelihood of home care use, but for residential care it is small for men and non-existent for women. We also find that preferential status is significantly related to the chance of getting two out five chronic conditions – COPD and diabetes, but not dementia, hip fracture and Parkinson’s disease – and to the probability of dying (not for women). For home care use and death, the association with preferential status declines with increasing age from age 65 onwards, such that it is near zero for those aged around 90 and older.

Conclusion

We find clear associations between an indicator of low income and home care use, some chronic conditions and death. The associations are stronger among men than among women. We also find that the association declines with age for home care use and death, which might be explained by selective survival.     

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.     

Equity in health and health care in a decentralised context: evidence from Canada

The impact of administrative decentralisation on equity in health and health care is an important unresolved issue in the health policy debate. Predictions from the limited theoretical literature and the relevant empirical research are both insufficient to draw any firm conclusions. Many countries are nevertheless experimenting with decentralisation policies in the absence of research evidence. This paper presents an exploratory empirical analysis of decentralisation by investigating the spatial dimensions of health-related equity in Canada, a highly decentralised setting. Using data from the 2001 Canadian Community Health Survey, we apply a decomposition method of the Concentration Index to explore whether income-related inequalities in health and inequities in the use of health care are more likely to be due to gaps between rich and poor Canadian provinces rather than to differences between rich and poor individuals within them. The results show that within area variation is the most important source of income-related health inequality, while income-related inequities in health care use are mostly driven by differences between provinces.     

Offender health and social care: a review of the evidence on inter-agency collaboration

The involvement of health and social care agencies in crime reduction partnerships remains key to government strategy despite a growing awareness of the equivocal outcomes of inter-agency working in other settings. This paper reports findings from a literature review designed to assess the extent to which existing crime reduction partnerships have been able to overcome the barriers to joint working. The review focuses in particular on Drug (and Alcohol) Action Teams (D(A)ATs), Crime and Disorder Reduction Partnerships (CDRPs), Multi-Agency Public Protection-Arrangements (MAPPAs) and Youth Offending Teams (YOTs). A comprehensive review of published and unpublished literature suggests that these bodies have experienced similar difficulties to those highlighted in the broader partnership literature. The review further suggests that differences in ethical and professional outlook may be the most critical of these barriers as well as being the least explicitly addressed by recent government interventions. More work is required to build a consensus regarding the ethical underpinnings and fundamental objectives of partnerships across the care-control divide.     

One-year use and cost of inpatient and outpatient services among female and male patients with an eating disorder: evidence from a national database of health insurance claims

OBJECTIVE: This study examined rates and cost of inpatient and outpatient treatment among 1,932 patients with an eating disorder. METHOD: One-year (1995) data were available through MarketScan, a national insurance database containing claims for 1,902,041 male patients and 2,005,760 female patients. RESULTS: Female patients (n = 1,756, 0.14% of all females) were significantly more likely to have been treated for an eating disorder than male patients (n = 176, 0.016% of all males), and females received more days of treatment than males. Outpatient treatment was the norm, regardless of gender or type of eating disorder. Average number of days (inpatient or outpatient) was less than the minimum recommended by standards of care. Age-adjusted costs for the treatment of anorexia nervosa and bulimia nervosa were comparable to the cost of treatment for schizophrenia. DISCUSSION: The utilization data are discussed in terms of barriers to care and treatment guidelines for eating disorders.     

Testing for selection bias and moral hazard in private health insurance: Evidence from a mixed public-private health system

Separating selection bias from moral hazard in private health insurance (PHI) markets has been a challenging task. We estimate selection bias and moral hazard in Australia's mixed public-private health system, where PHI premiums are community-rated rather than risk-rated. Using longitudinal cohort data, with fine-grained measures for medical services predominantly funded by PHI providers, we find consistent and robust estimates of advantageous selection among hospitalized cardiovascular disease (CVD) patients. Specifically, we show that in addition to their risk-averse attributes, CVD patients who purchase PHI use fewer services that are not covered by PHI providers (e.g., general practitioners and emergency departments) and have fewer comorbidities. Finally, unlike previous studies, we show that ex-post moral hazard exists in the use of specific “in-hospital” medical services such as specialist and physician services, miscellaneous diagnostic procedures, and therapeutic treatments. From the perspective of PHI providers, the annual cost of moral hazard translates to a lower bound estimate of $707 per patient, equivalent to a 3.03% reduction in their annual profits.     

Risk selection and heterogeneous preferences in health insurance markets with a public option

Conventional wisdom suggests that if private health insurance plans compete alongside a public option, they may endanger the latter's financial stability by cream-skimming good risks. This paper argues that two factors may contribute to the extent of cream-skimming: (i) degree of horizontal differentiation between public and private options when preferences are heterogeneous; (ii) whether contract design encourages choice of private insurance before information about risk is revealed. I explore the role of these factors empirically within the unique institutional setting of the German health insurance system. Using a fuzzy regression discontinuity design to disentangle adverse selection and moral hazard, I find no compelling support for extensive cream-skimming of public option by private insurers despite their ability to fully underwrite risk. A model of demand for private insurance supports the idea that heterogeneity in non-pecuniary preferences and long-term structure of private insurance contracts may be muting cream-skimming in this setting.     

The impact of voluntary health insurance on health care utilization and out-of-pocket payments: new evidence for Vietnam

Vietnam aims to achieve full coverage of health insurance in 2015. An increasing type of health insurance in Vietnam is voluntary health insurance. Although there are many studies on the implementation of voluntary health insurance in Vietnam, little is known on the causal impact of voluntary health insurance. This paper measures the impact of voluntary health insurance on health care utilization and out-of-pocket payments using Vietnam Household Living Standard Surveys in 2004 and 2006. It was found out that voluntary health insurance helps the insured people increase the annual outpatient and inpatient visits by around 45% and 70%, respectively. However, the effect of voluntary health insurance on out-of-pocket expenses on health care services is not statistically significant.     

Consumer information surplus and adverse selection in competitive health insurance markets: an empirical study

If premiums for health insurance are not risk related, there exists a consumer information surplus that may result in adverse selection. Our results indicate that insurers can greatly reduce this surplus by risk-adjusting the premium. We conclude that there need not be any substantial unavoidable consumer information surplus if consumers can choose whether to take a deductible for a one- or two-year health insurance contract with otherwise identical benefits. Therefore, adverse selection need not be a problem in a competitive insurance market with risk-adjusted premiums or vouchers and with such a consumer choice of health plan.     

Assessment of systems for paying health care providers in Vietnam: Implications for equity,efficiency and expanding effective health coverage

Provider payment arrangements are currently a core concern for Vietnam's health sector and a key lever for expanding effective coverage and improving the efficiency and equity of the health system. This study describes how different provider payment systems are designed and implemented in practice across a sample of provinces and districts in Vietnam. Key informant interviews were conducted with over 100 health policy-makers, purchasers and providers using a structured interview guide. The results of the different payment methods were scored by respondents and assessed against a set of health system performance criteria. Overall, the public health insurance agency, Vietnam Social Security (VSS), is focused on managing expenditures through a complicated set of reimbursement policies and caps, but the incentives for providers are unclear and do not consistently support Vietnam's health system objectives. The results of this study are being used by the Ministry of Health and VSS to reform the provider payment systems to be more consistent with international definitions and good practices and to better support Vietnam's health system objectives.     

Willingness to pay for health insurance among rural and poor persons: field evidence from seven micro health insurance units in India

This study, conducted in India in 2005, provides evidence on Willingness to pay (WTP), gathered through a unidirectional (descending) bidding game among 3024 households (HH) in seven locations where micro health insurance units are in operation. Insured persons reported slightly higher WTP values than uninsured. About two-thirds of the sample agreed to pay at least 1%; about half the sample was willing to pay at least 1.35%; 30% was willing to pay about 2.0% of annual HH income as health insurance premium. Nominal WTP correlates positively with income but relative WTP (expressed as percent of HH income) correlates negatively. The correlation between WTP and education is secondary to that of WTP with HH income. Household composition did not affect WTP. However, HHs that experienced a high-cost health event and male respondents reported slightly higher WTP. The observed nominal levels of WTP are higher than has been estimated hitherto.