Potential determinants of deductible uptake in health insurance: How to increase uptake in The Netherlands?

Factors associated with the enrollment of commercial medical insurance in China: Results from China General Social Survey

BACKGROUND

The Chinese government has been promoting commercial medical insurance (CMI) in recent decades as it plays an increasingly important role in addressing disease burden, health inequities, and other healthcare challenges. However, compared with developed countries, the CMI is still less fledged with low coverage.

OBJECTIVE

This study aims to explore the factors associated with enrollment in CMI, with regards to explicit characteristics (including sociodemographic characteristics and family economic status), latent characteristics (including social security status), and the global incentive compatibility index (including health status), to inform the design of CMI to improve its coverage in China.

METHODS

Based on the principal-agent model, we summarized and classified the factors associated with the enrollment in CMI, and then analyzed the data generated from the Chinese General Social Survey in 2015,2018 and 2021 respectively. A comparison of factors regarding sociodemographic characteristics, family economic status, social security status, and health status was conducted between individuals enrolled and unenrolled in CMI using Mann-Whitney U test and Chi-square test. Binary logistic regression analysis was used to explore factors influencing the enrollment status of CMI.

RESULTS

Of all individuals, the proportion of enrolled individuals shows an increasing trend year by year, with 8.7%,11.8% and 14.1% enrolled in CMI in 2015,2018 and 2021, respectively. The binary regression analysis further suggested that the factors associated with the enrollment in CMI were consistent in 2015,2018 and 2021.We found that individuals divorced, obese, who had a higher level of education, had non-agricultural household registration, perceived themselves as the upper social status, conducted daily exercise, had more family houses, had a car, had investment activities, or did not have basic health insurance were more likely to be enrolled in CMI.

CONCLUSIONS

We identified multidimensional factors associated with the enrollment of CMI, which help inform the government and insurance industry to improve the coverage of CMI.

Financial burden of medicines in five Northern European countries: A decommodification perspective

Affordable access to healthcare including medicines is a key social policy goal in Europe. However, it has rarely been addressed in comparative social policy research. Although the concept of decommodification has already been used in the context of healthcare and sickness benefits, we argue that the scope of such studies should be expanded to medicines to understand how welfare states protect their citizens from market forces in case of illness. We examine and compare the relationship between income, other characteristics, and subjective financial burden of medicines (FBM) across five countries with universal health systems pursuing egalitarian aims (Denmark, Finland, the Netherlands, Norway and Sweden). Analyses using 2017 EU-SILC microdata and linear probability models showed large differences in the level of FBM across countries, with the highest income quintile in Finland reporting FBM more frequently than the lowest income quintile in Denmark. Finland differed from the rest by increasing probability of FBM with age. In other countries, middle-aged adults tended to be the most affected, and older adults were well-protected. The association between income and FBM was strongest in the Netherlands; however, the higher probability of FBM was skewed towards the lower quintiles in all countries. FBM and financial burden of medical care were strongly associated although FBM tended to be more common. Unmet needs for medical examination were rare and lacked sensitivity in capturing manifestations of market risk. Decommodification literature has focused healthcare services as proxy of access; nevertheless, our study shows that further functions, and broader outcomes should be examined to capture market risk. Our evidence further highlights that important differences can be found even in countries with relatively similar health policy aims. The cost of medicines should be considered in comparative studies of health and welfare states.

Does the framing of patient cost-sharing incentives matter? the effects of deductibles vs. no-claim refunds

Understanding how health care utilization responds to cost-sharing is of central importance for providing high quality care and limiting the growth of costs. We study whether the framing of cost-sharing incentives has an effect on health care utilization. For this we make use of a policy change in the Netherlands. Until 2007, patients received a refund if they consumed little or no health care; the refund was the lower the more care they had consumed. From 2008 onward, there was a deductible. This means that very similar economic incentives were first framed in terms of smaller gains and later as losses. We find that patients react to incentives much more strongly when they are framed in terms of losses. The effect on yearly spending is 8.6 percent. This suggests that discussions on the optimal design of cost-sharing incentives should also revolve around the question how these are presented to patients.

Can risk rating increase the ability of voluntary deductibles to reduce moral hazard?

Several regulated health insurance markets include the option for consumers to choose a voluntary deductible. An important motive for this option is to reduce moral hazard. In return for a voluntary deductible, consumers receive a premium rebate, which is typically community rated. Under community rating, voluntary deductibles are particularly attractive for low-risk consumers. Since these people use relatively little medical care, the total moral hazard reduction might be relatively small compared to the total healthcare spending. This paper examines the potential moral hazard reduction under risk-rated premiums. We use Chile as a case study due to institutional features that make it a valid benchmark for other countries. Our simulations show that in the presence of self-selection and under a uniform percentage moral hazard reduction across risk types, the absolute moral hazard reduction from a voluntary deductible is indeed expected to be larger in a system with risk-rated premiums than in a system with community-rated premiums. Nevertheless, sensitivity checks show that this conclusion might no longer hold as the percentage moral hazard reduction is lower for high-risk individuals compared to low-risk individuals.

Private Health Insurance in Malaysia: Who Is Left Behind?

Despite various efforts introduced, private health insurance coverage is still low in Malaysia. The objective of this article is to find the factors associated with not having a private health insurance in Malaysia. We analyze data involving 19 959 respondents from the 2015 National Health Morbidity Survey. In this article, we describe the prevalence of not having health insurance and conducted binary logistic regression to identify determinants of uninsured status. A total of 56.6% of the study population was uninsured. After adjusting for other variables, the likelihood of being uninsured was higher among those aged 50 years and above, females, Malay/other Bumiputra ethnicities, rural, government/semigovernment, self-employed, unpaid workers and retirees, unemployed, lower education level, without home ownership and single/widowed/divorced, daily smoker, underweight body mass index, and current drinker. The likelihood of being uninsured also increased with increasing household size while the inversed trend was seen for household income. A substantial proportion of population in Malaysia did not have private health insurance, and these subgroups have limited preferential choices for provider, facility, and care.

Sustainability of Publicly Funded Health Care Systems: What Does Behavioural Economics Offer?

There has been a rapid increase in the use of behavioural economics (BE) as a tool for policy makers to deploy, including in health-related applications. While this development has occurred over the past decade, health care systems have continued to struggle with escalating costs. We consider the potential role of BE for making improvements to health care system performance and the sustainability of publicly funded health care systems, in particular. We argue that the vast majority of applications in this field have been largely focussed on BE and public health, or the prevailing level of risks to health in populations, and with policy proposals to 'nudge' individual behaviour (e.g. in respect of dietary choices). Yet, improvements in population health may have little, if any, impact on the size, cost or efficiency of health care systems. Few applications of BE have focussed on the management, production, delivery or utilisation of health care services per se. The latter is our focus in this paper. We review the contributions on BE and health care and consider the potential for complementing the considerable work on BE and public health with a clear agenda for behavioural health care economics. This agenda should complement the work of conventional microeconomics in the health care sector.

Moral hazard and selection for voluntary deductibles

This paper investigates whether the voluntary deductible in the Dutch health insurance system reduces moral hazard or acts only as a cost reduction tool for low-risk individuals. We use a sample of 14,089 observations, comprising 2,939 individuals over seven waves from the Longitudinal Internet Studies for the Social sciences panel for the analysis. We employ bivariate models that jointly model the choice of a deductible and health care utilization and supplement the identification with an instrumental variable strategy. The results show that the voluntary deductible reduces moral hazard, especially in the decision to visit a doctor (extensive margin) compared with the number of visits (intensive margin). In addition, a robustness test shows that selection on moral hazard is not present in this context.

Health care utilization and spending among privately insured children with medical complexity

Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.

Discussing patients' insurance and out-of-pocket expenses during GPs' consultations

Background

Generally, a significant portion of healthcare spending consists of out-of-pocket (OOP) expenses. Patients indicate that, in practice, there are often some OOP expenses, incurred when they receive medical care, which are unexpected for them and should have been taken into account when deciding on a course of action. Patients are often reliant on their GP and may, therefore, expect their GP to provide them with information about the costs of treatment options, taking into consideration their individual insurance plan. This also applies to the Netherlands, where OOP expenses increased rapidly over the years. In the current study, we observed the degree to which matters around patients’ insurance and OOP expenses are discussed in the Netherlands, using video recordings of consultations between patients and GPs.

Methods

Video recordings were collected from patient-GP consultations in 2015–2016. In 2015, 20 GPs and 392 patients from the eastern part of the Netherlands participated. In 2016, another eight GPs and 102 patients participated, spread throughout the Netherlands. The consultations were coded by three observers using an observation protocol. We achieved an almost perfect inter-rater agreement (Kappa = .82).

Results

In total, 475 consultations were analysed. In 9.5% of all the consultations, issues concerning patients’ health insurance and OOP expenses were discussed. The reimbursement of the cost of medication was discussed most often and patients’ current insurance and co-payments least often. In some consultations, the GP brought up the subject, while in others, the patient initiated the discussion.

Conclusions

While GPs may often be in the position to provide patients with information about treatment alternatives, few patients discuss the financial effects of their referral or prescription with their GP. This result complies with existing literature. Policy makers, GPs and insurers should think about how GPs and patients can be facilitated when considering the OOP expenses of treatment. There are several factors why this study, analysing video recordings of routine GP consultations in the Netherlands, is particularly relevant: Dutch GPs play a gatekeeper function; OOP expenses have increased relatively swiftly; and patients have both the right to decide on their treatment, and to choose a provider.

Health insurance subsidies and deductible choice: Evidence from regional variation in subsidy schemes

The extent to which premium subsidies can influence health insurance choices is an open question. In this paper, we explore the regional variation in subsidy schemes in Switzerland, designed as either in-kind or cash transfers, to study their impact on the choice of health insurance deductibles. Using health survey data and a difference-in-differences methodology, we find that in-kind transfers increase the likelihood of choosing a low deductible plan by approximately 4 percentage points (or 7%). Our results indicate that the response to in-kind transfers is strongest among women, middle-aged and unmarried individuals, which we explain by differences in risk-taking behavior, health status, financial constraints, health insurance and financial literacy. We discuss our results in the light of potential extra-marginal effects on the demand for health care services, which are however not supported by our data.

A voluntary deductible in health insurance: the more years you opt for it, the lower your premium?

Adverse selection regarding a voluntary deductible (VD) in health insurance implies that insured only opt for a VD if they expect no (or few) healthcare expenses. This paper investigates two potential strategies to reduce adverse selection: (1) differentiating the premium to the duration of the contract for which the VD holds (ex-ante approach) and (2) differentiating the premium to the number of years for which insured have opted for a VD (ex-post approach). It can be hypothesized that premiums will decrease with the duration of the contract or the number of years for which insured have opted for a VD, providing an incentive to insured to opt for a deductible also in (incidental) years they expect relatively high expenses. To test this hypothesis, we examine which premium patterns would occur under these strategies using data on healthcare expenses and risk characteristics of over 750,000 insured from 6 years. Our results show that, under the assumptions made, only without risk equalization the premiums could decrease with the duration of the contract or the number of years for which insured have opted for a VD. With (sophisticated) risk equalization, decreasing premiums seem unfeasible, both under the ex-ante and ex-post approach. Given these findings, we are sceptical about the feasibility of these strategies to counteract adverse selection.