Insurance status and waiting times for hospital-based services in Ireland

In Ireland long waits for public hospital services are a feature of the healthcare system, with limited evidence that waits for private hospital services (delivered in both public and private hospitals) are shorter. In 2008, in an attempt to ensure more equitable access to hospital-based services, a ‘common waiting list’ for all patients within public hospitals was proposed. The aim of this paper is to analyse waiting times in Ireland for hospital services for patients with and without private health insurance (PHI) and to examine whether the 2008 reform reduced the differential in waiting. The analysis used data from the 2007 and 2010 health module of the Quarterly National Household survey (QNHS). The impact of insurance status on waiting times was analysed for the period before and after the reforms. A higher proportion of those without PHI were waiting more than three months for hospital services relative to those with PHI. There was no evidence that the 2008 reforms reduced the differential. Anecdotal evidence suggests that the proposals were not fully implemented, although expansion of capacity for private patients’ treatment in private hospitals is a possible confounding factor.     

Self-selection and moral hazard in Chilean health insurance

We study the existence of self-selection and moral hazard in the Chilean health insurance industry. Dependent workers must purchase health insurance either from one public or several private insurance providers. For them, we analyze the relationship between health care services utilization and the choice of either private or public insurance. In the case of independent workers, where there is no mandate, we analyze the relationship between utilization and the decision to voluntarily purchase health insurance. The results show self-selection against insurance companies for independent workers, and against public insurance for dependent workers. Moral hazard is negligible in the case of hospitalization, but for medical visits, it is quantitatively important.     

Waiting times for elective surgery and the decision to buy private health insurance

More than 45% of Australians buy health insurance for private treatment in hospital. This is despite having access to universal and free public hospital treatment. Anecdotal evidence suggests that avoidance of long waits for public treatment is one possible explanation for the high rate of insurance coverage. In this study, we investigate the effect of waiting on individual decisions to buy private health insurance. Individuals are assumed to form an expectation of their own waiting time as a function of their demographics and health status. We model waiting times using administrative data on the population hospitalised for elective procedures in public hospitals and use the parameter estimates to impute the expected waiting time and the probability of a long wait for a representative sample of the population. We find that expected waiting time does not increase the probability of buying insurance but a high probability of experiencing a long wait does. On average, waiting time has no significant impact on insurance. In addition, we find that favourable selection into private insurance, measured by self-assessed health, is no longer significant once waiting time variables are included. This result suggests that a source of favourable selection may be aversion to waiting among healthier people.     

The Australian health policy changes of 1999 and 2000

This article evaluates three measures introduced by the Australian Federal Government in 1999 and 2000 that were designed to encourage private health insurance and relieve financial pressure on the public healthcare sector. These policy changes were (i) a 30% premium rebate, (ii) health insurers offering lifetime enrolment on existing terms and the future relaxation of premium regulation by permitting premiums to increase with age, and (iii) a mandate for insurers to offer complementary coverage for bridging the gap between actual hospital billings and benefits paid. These measures were first evaluated in terms of expected benefits and costs at the individual level. In terms of the first criteria, the policy changes as a whole may have been efficiency-increasing. The Australian Government mandate to launch gap policies may well have created a spillover moral hazard effect to the extent that full insurance coverage encouraged policy holders to also use more public hospital services, thus undermining the government's stated objective to relieve public hospitals from demand pressure. Without this spillover moral hazard effect, there might have been a reduction in waiting times in the public sector. Secondly, the measures were evaluated in terms of additional benchmarks of the cost to the public purse, access and equity, and dynamic efficiency. Although public policy changes were found to be largely justifiable on the first set of criteria, they do not appear to be justifiable based on the second set. Uncertainties and doubts remain about the effect of the policy changes in terms of overall cost, access and equity, and dynamic efficiency. This is a common experience in countries that have considered shifts of their healthcare systems between the private and public sectors.     

Choices in health care: the European experience

This paper examines some policies to increase or restrict consumer choice in western European health systems as regards four decisions: choice between public and private insurance; choice of public insurance fund; choice of first contact care provider and choice of hospital. Choice between public and private insurance is limited and arose for historical reasons in Germany. Owing to significant constraints, few people choose the private option. Choice of public insurance fund tends to be exercised by younger and healthier people, the decision to change fund is mainly associated with price and, despite complex risk adjustment mechanisms, it has led to risk selection by funds. Choice of first contact care provider is widespread in Europe. In countries where choice has traditionally been restricted, reforms aim to make services more accessible and convenient to patients. Reforms to restrict direct access to specialists aim to reduce unnecessary and inappropriate care but have been unpopular with the public and professionals. Patients' take up of choice of hospital has been surprisingly low, given their stated willingness to travel. Only where choice is actively supported in the context of long waiting times is take up higher. The objectives, implementation and impact of policies about choice have varied across western Europe. Culture and embedded norms may be significant in determining the extent to which patients exercise choice.     

Estimating adverse selection and moral hazard effects with hospital invoices data in a government-controlled healthcare system

We use invoices for hospital services from a regional hospital in Croatia to test for adverse selection and moral hazard. There are three categories of patients: with no supplemental insurance, who bought it, and who are entitled to it for free. Our identification procedure relies on the premise that the difference in the observed medical care consumption between the patients who bought the insurance and those entitled to free insurance is caused by pure selection effect, whereas the difference in healthcare consumption between the group that received the free insurance and the group that has no insurance is due to moral hazard. Results show favorable selection for patients in 20- to 30-year-old cohort and significant moral hazard for all age cohorts. The selection effect reverses its sign in older cohorts explained by the differences in risk aversion across cohorts caused by the timing of transition from socialism to market economy.     

Optimal quality, waits and charges in health insurance

We examine the role of quality and waiting time in health insurance when there is ex post moral hazard. Quality and waiting time provide additional instruments to control demand and potentially can improve the trade-off between optimal risk bearing and optimal consumption of health care. We show that optimal quality is lower than it would be in the absence of ex post moral hazard. But it is never optimal to have a positive waiting time if the marginal cost of waiting is higher for patients with greater benefits from health care.     

Discrimination in waiting times by insurance type and financial soundness of German acute care hospitals

This paper shows that patients with private health insurance (PHI) are being offered significantly shorter waiting times than patients with statutory health insurance (SHI) in German acute hospital care. This behavior may be driven by the higher expected profitability of PHI relative to SHI holders. Further, we find that hospitals offering private insurees shorter waiting times when compared with SHI holders have a significantly better financial performance than those abstaining from or with less discrimination.     

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.     

Private medical insurance and saving: evidence from the British Household Panel Survey

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.     

Health technology assessment in Luxembourg

Luxembourg's public health insurance is a compulsory insurance for all employees, self-employed professionals, farmers, and pensioners. It is financed through contributions of the insured people, as well as by state taxes. Providers of health care are mainly private nonprofit institutions and self-employed professionals. All healthcare procedures are defined in fee schedules determined by a common decision of the Ministers of Social Security and Health according to proposals of a board of experts. The relative value of a service is also determined by the corresponding fee schedule. Hospitals are financed by individual budgets negotiated between each hospital and the health insurance. These hospital budgets do not cover services provided in hospitals by medical specialists, who are reimbursed on a fee-for-service basis. A low on hospital planning and organization allows the government to restrict the installation in hospitals of very expensive equipment or of equipment for which there is only a limited need in Luxembourg hospitals. Until recently there has been limited interest in or use of health technology assessment (HTA). However, large hospital investments have provoked some interest in the last few years. The Ministry of Health has asked for some HTA studies when a concrete decision had to be taken. Luxembourg decision makers have become more aware that HTA may help them to become more informed about the short- and long-term consequences of the application of health technology.     

THE DETERMINANTS OF HEALTH CARE EXPENDITURE TOWARD THE END OF LIFE: EVIDENCE FROM TAIWAN

This paper empirically investigates the relationship between the health care expenditure of end‐of‐life patients and hospital characteristics in Taiwan where (i) hospitals of different ownership differ in their financial incentives; (ii) patients are free to choose their providers; and (iii) health care services are paid for by a single public payer on a fee‐for‐services basis with a global budget cap. Utilizing insurance claims for 11 863 individuals who died during 2005–2007, we trace their hospital expenditures over the last 24 months of their lives. We find that end‐of‐life patients who are treated by private hospitals in general are associated with higher inpatient expenditures than those treated by public hospitals, while there is no significant difference in days of hospital stay. This finding is consistent with the difference in financial incentives between public and private hospitals in Taiwan. Nevertheless, we also find that the public–private differences vary across accreditation levels. Copyright © 2013 John Wiley & Sons, Ltd.     

Time spent on waiting lists for medical care: an insurance approach

In this paper, we develop a simple model of the benefits and costs of being on a waiting list. The model shows that complex factors are in operation, implying that a shorter waiting time need not necessarily be preferred to a longer waiting time. We also present an empirical study, where a sample of Swedes are offered the possibility of purchasing private insurance, thus reducing waiting time for surgery beyond the three-month guarantee offered by the public sector health care system. Respondents could choose between two insurance contracts. A 'spike' model, where the probability of a zero WTP is strictly positive, was developed and estimated to obtain demand functions for private insurance.     

Public health care and private insurance demand: The waiting time as a link

This paper analyzes the effect of waiting times in the Spanish public health system on the demand for private health insurance. Expected utility maximization determines whether or not individuals buy a private health insurance. The decision depends not only on consumer's covariates such as income, socio-demographic characteristics and health status, but also on the quality of the treatment by the public provider. We interpret waiting time as a qualitative attribute of the health care provision. The empirical analysis uses the Spanish Health Survey of 1993. We cope with the absence of income data by using the Spanish Family Budget Survey of 1990–91 as a complementary data set, following the Arellano–Meghir method [4]. Results indicate that a reduction in the waiting time lowers the probability of buying private health insurance. This suggests the existence of a crowd-out in the health care provision market. This revised version was published online in July 2006 with corrections to the Cover Date.     

The influence of insurance status on waiting times in German acute care hospitals: an empirical analysis of new data

Background

There is an ongoing debate in Germany about the assumption that patients with private health insurance (PHI) benefit from better access to medical care, including shorter waiting times (Lüngen et al. 2008), compared to patients with statutory health insurance (SHI).

Problem

Existing analyses of the determinants for waiting times in Germany are a) based on patient self-reports and b) do not cover the inpatient sector. This paper aims to fill both gaps by (i) generating new primary data and (ii) analyzing waiting times in German hospitals.

Methods

We requested individual appointments from 485 hospitals within an experimental study design, allowing us to analyze the impact of PHI versus SHI on waiting times (Asplin et al. 2005).

Results

In German acute care hospitals patients with PHI have significantly shorter waiting times than patients with SHI.

Conclusion

Discrimination in waiting times by insurance status does occur in the German acute hospital sector. Since there is very little transparency in treatment quality in Germany, we do not know whether discrimination in waiting times leads to discrimination in the quality of treatment. This is an important issue for future research.     

Ten years of structural reforms in Danish healthcare

A major structural reform of the Danish public sector took place in 2007 when the number of administrative units at the regional and municipal levels was reduced. The larger administrative units allowed for a new hospital structure with a reduced number of acute hospitals covering a population of between 200,000 and 400,000 inhabitants. The restructuring involves creation of acute hospitals with a 24-h acute service by a range of specialists. The idea was to weight quality higher than geographical closeness to the nearest hospital. Concurrently, the pre-hospital service will be expanded. The National Board of Health was given authority to approve regional plans for specialties rather than provide guidelines. The use of private hospitals was increased as a means to fulfil a waiting time guarantee of between 2 and 1 month. Increased use of private insurance also increased use of private hospitals. A new way of financing health care was intended to give municipalities incentives to invest in health prevention and health promotion. Concurrent reforms included economic incentives to increase hospital production as measured by DRGs; quality programmes to secure high quality and patient safety; and electronic patient records and increased use of IT systems.     

Health insurance and health services utilization in Ireland

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.     

患者选择公立或民营医院就诊的影响因素分析——以中老年患者为例

本文采用二项Logistic回归模型,利用2011年"中国健康与养老追踪调查"(CHALRS)数据,对中老年就诊患者选择公立或民营医院的影响因素进行分析。研究发现自评健康、就诊咨询、使用基本医疗保险报销等因素影响显著。健康存量越小、有就诊咨询需求、使用基本医疗保险报销的患者选择公立医院的概率相对较高。说明中老年就诊患者在处理疾病风险时更信赖公立医院,医保定点医院主要集中在公立医院,进一步推动了患者选择公立医院就诊。建议加强对老年性疾病的预防和控制;提高医院的咨询服务水平;加强对民营医院的扶持,放开民营医院的价格限制,调整医保定点医院的准入机制;加强行业监管和信息公开。     

Waiting times for hospital admissions: the impact of GP fundholding

Waiting times for hospital care are a significant issue in the UK National Health Service (NHS). The reforms of the health service in 1990 gave a subset of family doctors (GP fundholders) both the ability to choose the hospital where their patients were treated and the means to pay for some services. One of the key factors influencing family doctors' choice of hospital was patient waiting time. However, without cash inducements, hospitals would get no direct reward from giving shorter waiting times to a subset of patients. Using a unique dataset, we investigate whether GP fundholders were able to secure shorter waiting times for their patients, whether they were able to do so in cases where they had no financial rewards to offer hospitals, and whether the impact of fundholding spilled over into shorter waiting times for all patients.     

Patient hospital choice for hip replacement: empirical evidence from the Netherlands

In the Dutch health care system, hospitals are expected to compete. A necessary condition for competition among hospitals is that patients do not automatically choose the nearest hospital, but are—at least to some extent—sensitive to differences in hospital quality. In this study, an analysis is performed on the underlying features of patient hospital choice in a setting where prices do not matter for patients as a result of health insurance coverage. Using claims data from all Dutch hospitals over the years 2008–2010, a conditional logit model examines the relationship between patient characteristics (age, gender and reoperations) and hospital attributes (hospital quality information, waiting times on treatments and travel time for patients to the hospitals) in the market for general non-emergency hip replacement treatments. The results show that travel time is the most important determinant in patient hospital choice. From our analysis, however, it follows that publicly available hospital quality ratings and waiting times also have a significant impact on patient hospital choice. The panel data used for this study (2008–2010) is rather short, which may explain why no coherent and persistent changes in patient hospital choice behaviour over time are found.