Trends in the golden state: small-group premiums rise sharply while actuarial values for individual coverage plummet

Using multiple databases, this paper examines recent trends in the affordability and comprehensiveness of small-group and individual health insurance markets in California. Both became less affordable over the study period. In 2006, a single person age 32-52 earning the median income who purchased individual insurance spent on average 16 percent of income on premiums and out-of-pocket medical expenses. For individual insurance, the share of medical expenses paid by insurance as opposed to patients declined from 2002 to 2006. In the small-group market, premiums rose more than 50 percent from 2003 to 2006, but the proportion of claims paid by insurers for a standardized population remained constant.     

State-sponsored price transparency programs for ophthalmic services

ObjectivesTo characterize the information provided by state-sponsored price transparency programs and describe price variation for ophthalmic services.MethodsWe searched for state-sponsored price transparency programs and reviewed all available information on ophthalmic services.ResultsIn total, 55% (6/11) of state-sponsored price transparency programs included ophthalmic services. Three provided nonfinancial value metrics, five provided prices by clinician organization, and none reported out-of-pocket costs, insurance costs, or prices by insurers for ophthalmic services. The median within-state price ratio was 3.65 (interquartile ratio [IQR]: 2.04–7.91). Mean prices for cataract surgery ranged from $2575 to $5097 and from $873 and $27,801.66 for retinal detachment repair.DiscussionMost of the eleven state-sponsored price transparency programs included pricing information for ophthalmic services. No programs provided specific out-of-pocket costs, insurance costs, or prices by insurers for ophthalmic services. There was substantial variation in prices for all included ophthalmic services within and between states.     

Injury and Illness Costs in the Certified Safe Farm Study

CONTEXT: The Certified Safe Farm (CSF) intervention program aims to reduce occupational injuries and illnesses, and promote wellness to reduce health care and related costs to farmers, insurers, and other stakeholders. PURPOSE: To evaluate the cost effectiveness of CSF. METHODS: Farms (316) located in a 9-county area of northwestern Iowa were recruited and randomized into intervention and control cohorts. Intervention farms received occupational health screenings, health and wellness screening, education, on-farm safety reviews, and performance incentives. For both cohorts, quarterly calls over 3 years were used to collect self-reported occupational injury and illness information, including costs to the farmers and their insurers. FINDINGS: Annual occupational injury and illness costs per farmer paid by insurers were 45% lower in the intervention cohort ($183) than in the control cohort ($332). Although out-of-pocket expenses were similar for both cohorts, combined costs of insurance and out-of-pocket expenses were 27% lower in the intervention cohort ($374/year per farmer) compared to the control cohort ($512/year per farmer). Within the cohort of intervention farmers, annual occupational injury and illness cost savings were directly associated with on-farm safety review scores. Reported health care costs were $237 per farmer in the safest farms (those farms scoring in the highest tertile) versus $485 per farmer in the least safe farms (lowest tertile). CONCLUSIONS: Results suggest that farmers receiving the intervention had lower health care costs for occupational injuries and illnesses than control farmers. These cost savings more than cover the cost of providing CSF services (about $100 per farm per year).     

IGeL oder Nicht-IGeL

Background

Cancer screening tests such as ultrasound scans, extensive skin cancer screening, or the prostate-specific antigen (PSA) test are among the most commonly used individual out-of-pocket health services (in German: Individuelle Gesundheitsleistungen, or IGeL) among people who have statutory health insurance in Germany. They are usually offered as an add-on to the services that are covered by statutory insurers.

Questions and methods

There are a number of reasons why cancer screening tests might not be covered by insurers. The main reasons are because the test does not have any clear benefits, and because the harms outweigh the benefits. This article describes the fundamental difficulties of, and the requirements imposed on, benefit assessments of cancer screening tests.

Results

Cancer screening tests that are available as individual out-of-pocket health services are always potentially harmful, while their benefit is either not clear or contested, or there is clearly no benefit.

Discussion

Health-care providers who offer cancer screening tests are required to provide interested people with relevant information on the related benefits, harms, and uncertainties of the tests, so as to enable an informed decision. This is especially important when it comes to “IGeL” services.     

The impact of price transparency on consumers and providers: A scoping review

Escalating levels of healthcare spending and price variation in the healthcare market have driven government and insurer interest in price transparency tools that are intended to help consumers shop for services and reduce overall healthcare spending. However, it is unclear whether the objectives of price transparency are being achieved. We conducted a scoping review to synthesize the impact of price transparency on consumer, provider, and purchaser behaviours and outcomes.Price transparency tools had weak impact overall on consumers due to low uptake, and mixed effects on providers. Price-aware patients chose less costly services that led to out-of-pocket cost savings and savings for health insurers; however, these savings did not translate into reductions in aggregate healthcare spending. Disclosure of list prices had no effect, however disclosure of negotiated prices prompted supply-side competition which led to decreases in prices for shoppable services.     

Does risk equalization reduce the viability of voluntary deductibles?

Theoretically, a risk avers consumer takes a deductible if the premium rebate (far) exceeds his/her expected out-of-pocket expenditures. In the absence of risk equalization, insurers are able to offer high rebates because those who select into a deductible plan have below-average expenses. This paper shows that, for high deductibles, such rebates cannot be offered if risk equalization would “perfectly” adjust for the effect of self selection. Since the main goal of user charges is to reduce moral hazard, some effect of self selection on the premium rebate can be justified to increase the viability of voluntary deductibles.      

Does the financial protection of health insurance vary across providers? Vietnam’s experience

Using household panel data from Vietnam, this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers. In the random effects model, the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24% for those with the compulsory and voluntary coverage and by about 15% for those with the health insurance for the poor coverage. However, the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model. Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers. Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers. Compared to the uninsured patients using district hospitals, compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32%, respectively. However, for contacts at the commune health centers, both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15%.     

Reductions in out-of-pocket prices and forward-looking moral hazard in health care demand

Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.     

Do Insurance Mandates Affect Racial Disparities in Outcomes for Children with Autism?

Objective The study investigated whether state mandates for private insurers to provide services for children with autism influence racial disparities in outcomes. Methods The study used 2005/2006 and 2009/2010 waves of the National Survey of Children with Special Health Care Needs. Children with a current diagnosis of autism were included in the sample. Children residing in 14 states and the District of Columbia that were not covered by the mandate in the 2005/2006 survey, but were covered in the 2009/2010 survey, served as the mandate group. Children residing in 32 states that were not covered by a mandate in either wave served as the comparison group. Outcome measures assessed included care quality, family economics, and child health. A difference-in-difference-in-differences (DDD) approach was used to assess the impact of the mandates on racial disparities in outcomes. Results Non-white children had less access to family-centered care compared to white children in both waves of data, but this difference was not apparent across mandate and comparison states as only the comparison states had significant differences. Parents of non-white children reported paying less in annual out-of-pocket expenses compared to parents of white children across waves and groups. DDD estimates did not provide evidence that the mandates had statistically significant effects on improving or worsening racial disparities for any outcome measure. Conclusions This study did not find evidence that state mandates on private insurers affected racial disparities in outcomes for children with autism.     

Trust in times of health reform

Trust is seen as an important condition for the smooth functioning of institutions, such as the health care system. In this article we describe the trust relationships between the three main actors in the Dutch health care system: patients/insured, healthcare providers and insurers. We used data from different surveys between 2006 and 2016. 2006 was the year of the introduction of an insurance reform in the Netherlands towards regulated competition.In the triangle of trust relationships between the three actors we found strong and mutual trust relationships between patients and healthcare providers and weak trust relationships between healthcare providers and insurers as well as between insured and insurance organisations. This hampers the intended role of insurers as selective purchasers of health care on the basis of quality and price.     

So much to do,so little time: physician capacity constraints, 1997-2001

Signs of tightened physician capacity--or physicians' ability to provide services relative to demand--appeared between 1997 and 2001, according to a study by the Center for Studying Health System Change (HSC). Patients waited longer for appointments, and more physicians reported having inadequate time with patients. Despite signs of tightened physician capacity, the supply of physicians grew modestly, the proportion of physicians working with nurse practitioners and other caregivers increased and doctors spent more time in direct patient care. This seeming contradiction emerged as the retreat from tightly managed care gave patients freedom to seek more care without substantial out-of-pocket cost increases. Current physician capacity constraints may ease if higher out-of-pocket costs prompt patients to seek less care.     

The 2018 risk-adjustment reform in the Czech Republic: Introducing Pharmacy-based Cost Groups and strengthening reinsurance

BackgroundRisk-adjustment in resource allocation is commonly used for regional redistribution or for eliminating risk selection motives of multiple statutory health insurers. In the Czech Republic, revenue redistribution between health insurers takes place since the 1990′s. Since 2018, the risk-adjustment mechanism includes an adjustment for insured with chronic diseases using Pharmacy-based Cost Group (PCG) classification. In addition, retrospective compensation for very high cost patients has been strengthened.AimTo provide an internationally relevant overview of the Czech risk-adjustment system. To assess the implication of the 2018 reform for health insurers and for the development of chronic care.MethodThe framework of the Health Reform Monitor is used to analyse the policy process. Data from Czech health insurers and Czech Ministry of Health are used to assess likely impact of the reform.ResultsThe reform increases coverage of predictable individual health risks and combines prospective risk-rating with strengthened retrospective risk-sharing among insurers. The reform results in moderate changes in risk-adjusted allocations of individual insurers.ConclusionThe Czech experience with risk-adjustment reforms is relevant for countries with multiple health insurers as well as for countries with risk-adjusted regional redistribution mechanisms. Combining prospective risk factors of age, sex, and PCGs with retrospective compensation of expensive cases limits potential losses to a manageable level, also for small risk-pools. It reduces incentives for cream skimming based on health status, enables higher use of risk-sharing contracts, and incentivizes the development of disease management programs in the Czech Republic.     

不同医保类型老年人脑血管病住院患者自付费用研究

目的 分析不同医保类型老年人脑血管病的保障水平,为降低患者经济负担和优化医保支付方式提供依据。方法 收集河南省2018年3月1日—2018年6月30日主要诊断为脑血管病患者共35 711例,运用描述统计、独立样本t检验、单因素方差分析方法进行统计分析。结果 住院患者总体自付比例为18.37%,整体效果较好,但不同医保类型自付比例差距大;不同医保类型自付费用构成中药费占比最高（39.5%）,其次为诊断费（29.46%）;城乡居民医保颅内出血、脑梗死和其他脑血管病自付比例分别为20.2%、20.36%、21.3%,均高于城镇职工,差异具有统计学意义（P＜0.001）;两种医保自付比例在不同住院费用分组间的差异具有统计学意义（P＜0.001）,当住院费用大于1.5万元时,城镇职工医保自付比例随住院费用的增高而增高,城乡居民医保自付比例随住院费用费用升高而降低。结论 政府可以通过提高医保统筹层次,优化医保费用结构,构建多元化医保监管体系,健全城乡居民医保保障体系等措施控制患者自付费用,优化医保支付方式。     

Outpatient encounter data for risk adjustment--a view from Europe: comments on Welch

This article comments from a European perspective on W. Pete Welch's article, which examines the use of outpatient encounter data for risk adjustment. Although diverse, Western European health care systems all seek to provide a comprehensive package of care, financed by premiums unrelated to health status. Some form of risk adjustment is therefore required as a basis for funding insurers in all systems. Two objectives have dominated: to secure equity between patients covered by different insurers and to ensure that (where implemented) competitive insurer markets operate efficiently. The commentary concludes that, although risk adjustment research of this type is important, the most fundamental requirement is to develop a more active purchasing function on the part of insurers.     

Competition policy for health care provision in the Netherlands

In the Netherlands in 2006 a major health care reform was introduced, aimed at reinforcing regulated competition in the health care sector. Health insurers were provided with strong incentives to compete and more room to negotiate and selectively contract with health care providers. Nevertheless, the bargaining position of health insurers vis-à-vis both GPs and hospitals is still relatively weak. GPs are very well organized in a powerful national interest association (LHV) and effectively exploit the long-standing trust relationship with their patients. They have been very successful in mobilizing public support against unfavorable contracting practices of health insurers and enforcement of the competition act. The rapid establishment of multidisciplinary care groups to coordinate care for patients with chronic diseases further strengthened their position. Due to ongoing horizontal consolidation, hospital markets in the Netherlands have become highly concentrated. Only recently the Dutch competition authority prohibited the first hospital merger. Despite the highly concentrated health insurance market, it is unclear whether insurers will have sufficient countervailing buyer power vis-à-vis GPs and hospitals to effectively fulfill their role as prudent buyer of care, as envisioned in the reform. To prevent further consolidation and anticompetitive coordination, strict enforcement of competition policy is crucially important for safeguarding the potential for effective insurer–provider negotiations about quality and price.     

Do health insurers use target marketing as a tool for risk selection? Evidence from the Netherlands

In health care systems based on managed competition, enrolees can choose between insurers who are positioned as prudent buyers of care on their behalf. To avoid risk selection, insurers are compensated through a system of risk equalisation. The Dutch system of risk equalisation is generally considered to be one of the most sophisticated in the world. Empirical evidence, however, shows there are still consumer segments that are profitable for insurers. To examine whether insurers use target marketing for attracting these segments, we assessed promotional material used by Dutch insurers during the switching season of 2019. Our findings provide preliminary evidence that large insurers with different brands primarily use their sub brands as strategic vehicles to improve their competitive positions by targeting these brands at financially favourable groups and price sensitive buyers. By contrast, the more visible main brands are targeted at a much broader spectrum of consumer groups to display the insurer's social character. Only a minority of insurers’ marketing expressions are targeted at actual users of care. Despite continuous improvements in the risk equalisation system, on average this group is still unprofitable for insurers. From a health policy perspective, further improvements are key to motivate health insurers to target their efforts at improving care for the chronically ill and to eliminate incentives for risk selection.