Preferences and choices for care and health insurance

Understanding the use of patient-reported data by health care insurers: A scoping review

Background

Patient-reported data are widely used for many purposes by different actors within a health system. However, little is known about the use of such data by health insurers. Our study aims to map the evidence on the use of patient-reported data by health insurers; to explore how collected patient-reported data are utilized; and to elucidate the motives of why patient-reported data are collected by health insurers.

Methods

The study design is that of a scoping review. In total, 11 databases were searched on. Relevant grey literature was identified through online searches, reference mining and recommendations from experts. Forty-two documents were included. We synthesized the evidence on the uses of patient-reported data by insurers following a structure-process-outcome approach; we also mapped the use and function of those data by a health insurer.

Results

Health insurers use patient-reported data for assurance and improvement of quality of care and value-based health care. The patient-reported data most often collected are those of outcomes, experiences and satisfaction measures; structure indicators are used to a lesser extent and often combined with process indicators. These data are mainly used for the purposes of procurement and purchasing of services, quality assurance, improvement and reporting, and strengthening the involvement of insured people.

Conclusions

The breadth to which insurers use patient-reported data in their business models varies greatly. Some hindering factors to the uptake of such data are the varying and overlapping terminology in use in the field and the limited involvement of insured people in a health insurer’s business. Health insurers are advised to be more explicit in regard to the role they want to play within the health system and society at large, and accommodate implications for the use of patient-reported data accordingly.

Preferences heterogeneity of health care utilization of community residents in China: a stated preference discrete choice experiment

Background

To tackle the issue with the low usage of primary healthcare service in China, it is essential to align resource distribution with the preferences of the community residents. There are few academic researches for describing residents’ perceived characteristics of healthcare services in China. This study aims to investigate the preferences of healthcare services utilization in community residents and explore the heterogeneity. The findings will be useful for the policy makers to take targeted measures to tailor the provision of healthcare services.

Methods

The face-to-face interviews and surveys were conducted to elicit four key attributes (care provider; mode of services; cost; travel time) of the preference from community residents for healthcare utilization. A rational test was presented first to confirm the consistency, and then 16 pairs of choice tasks with 12 sociodemographic items were given to the respondents. Two hypothetical options for each set, without an opt-out option, were presented in each choice task. The latent class analysis (LCA) was used to analyse the data.

Results

Two thousand one hundred sixty respondents from 36 communities in 6 cities were recruited for our study. 2019 (93.47%) respondents completed valid discrete choice experiment (DCE) questionnaires. The LCA results suggested that four groups of similar preferences were identified. The first group (27.29%) labelled as “Comprehensive consideration” had an even preference of all four attributes. The second group (37.79%) labelled as “Price-driven” preferred low-price healthcare services. The third group labelled as “Near distance” showed a clear preference for seeking healthcare services nearby. The fourth group (34.18%) labelled as “Quality seeker” preferred the healthcare service provided by experts. Willingness to pay (WTP) results showed that people were willing to accept CNY202.12($29.37) for Traditional Chinese Medicine (TCM) services and willing to pay CNY604.31($87.81) for the service provided by experts.

Conclusions

Our study qualitatively measures the distinct preferences for healthcare utilization in community residents in China. The results suggest that the care provider, mode of services, travel time and cost should be considered in priority setting decisions. The study, however, reveals substantial disagreement in opinion of TCM between different population subgroups.

The Value Employees Place on Health Insurance Plans: A Discrete-Choice Experiment

BACKGROUND

The federally-facilitated Health Insurance Marketplace-also known as the Health Insurance Exchange-was designed as a tool to help people purchase insurance plans, yet many Americans remain uninsured, partially due to rising premiums. One possible strategy to stabilize its premiums is to encourage healthier people to purchase their plans through the Marketplace instead of through their employers.

OBJECTIVE

This study examined the values that single adults with employer-based coverage place on health insurance plan attributes using a discrete-choice experiment (DCE).

METHODS

As part of an online survey, each respondent completed 28 paired comparisons trading off four attributes: source of coverage, plan type, monthly out-of-pocket premium, and quality of coverage.

RESULTS

Based on our results (N = 2207), single employees slightly preferred their employer over the Marketplace as a source of coverage (0.726 odds ratio; p value < 0.01). Single employees would be willing to switch to the Marketplace for a US$25 reduction in monthly premiums. Preferred Provider Organization (PPO) plans were overwhelmingly preferred over all other plan types, especially compared to Fee-for-Service (FFS) plans (4.230 odds ratio; p value < 0.01). The predicted probability that a health insurance plan from the Marketplace would be chosen ranged from 42 to 43.7%.

CONCLUSION

This study demonstrated that a US$25 subsidy or providing slightly more generous coverage (Bronze-Silver) would motivate employees to purchase PPO plans through the Marketplace, potentially improving its risk pooling, reducing employers' administrative burden, and enhancing labor mobility.

Eliciting Preferences for Health Insurance in Iran Using Discrete Choice Experiment Analysis

BACKGROUND

The preferences of Iranians concerning the attributes of health insurance benefit packages are not well studied. This study aimed to elicit health insurance preferences among insured people in Iran during 2016.

METHODS

A mixed methods study using a discrete choice experiment (DCE) approach was conducted to elicit health insurance preferences on a total sample of 600 insured Iranians residing in Tehran. The final design of the DCE included 8 health insurance attributes. Data were analyzed using conditional logistic regression models.

RESULTS

The final model of this DCE study included 8 attributes, and the findings indicated statistically significant (P<.001) increase in the odds ratio (OR) of choosing health insurance at all levels of cost coverage except for the rehabilitation and para-clinical benefits, where at 70% cost coverage there was insignificant (P=.485) disutility (OR=0.95). With the increase in cost coverage level, the probability of choosing health insurance was significantly (P<.001) the highest for the private hospitals' benefits (OR=2.82) followed by public hospitals' benefits (OR=2.02) and outpatient benefits (OR=1.75), and the premium revealed statistically significant (P<.001) disutility (OR=0.96).

CONCLUSION

Our findings revealed that participants would be willing to choose health insurance plans with higher cost coverage of healthcare services and with lower premiums. However, the demographic characteristics, income, and health status of the insured individuals affected their health insurance preferences. The findings can contribute to the design of better health insurance policies, improve the participation of individuals in health insurance, and increase the insured individuals' utility from the insurance benefits packages.

Developing attributes and levels for a discrete choice experiment on basic health insurance in Iran

Background: Nonmarket stated preferences valuation, especially discrete choice experiments (DCEs), is one of the commonly used techniques in the health sector. The primary purpose of this approach is to help select attributes and attributes-levels that are able to properly describe health care products or services. This study aimed at developing attributes and attributes-levels for basic health insurance system in Iran.

Methods: This study was conducted in 3 phases. First, narrative review was performed to identify related attributes. Also, 9 experts were interviewed to identify relevant attributes of health insurance in context. Other 36 experts rated the attributes and levels. Then, the research team decided on the inclusion of attributes and levels in the final design. The design was constructed using generic and Defficient method with SAS 9.1. The design was divided into 3 blocks, each having 8 choice sets. Finally, the choice set was piloted with 45 participants.

Results: Public hospitals, and private hospitals benefits, dental insurance coverage, inpatient benefits, rehabilitation therapy, and paraclinical benefits, long-term care, medical devices benefits (Ortez, Protez, etc.), and monthly premium were identified and included in the final attribute design (D-efficiency = 98.16). The pilot study revealed that participants could easily understand and answer all the choice sets.

Conclusion: The results of our study indicated that health insurance service benefit packages and premium were among the most important attributes that need to be included in the final attribute design for Iranians. The policymakers and health insurance organizations should emphasize these attributes in the benefit packages to make improvements. The emphasis on these attributes can help elicit people’s preferences and willingness to pay for attributes.

Attributing a monetary value to patients' time: A contingent valuation approach

It is hard to ignore the importance of patient time investment in the production of health since the influential paper by Grossman (1972). Patients' time includes time to admission, travel time, waiting time, and treatment time and can be substantial. Patients' time is, however, often ignored in economic analyses. This may lead to biased results and inappropriate policy recommendations, which may eventually influence patients' health, wellbeing and welfare. How to value patient time is not straightforward. Although there is some emerging literature on the monetary valuation of patient time, an important challenge remains to develop an approach that can be used to monetarily value time of patients not participating in the labour market. We aim to contribute to the health economics literature by describing and empirically illustrating how to monetarily value the time of patients not participating in the labour market comprehensively, using the contingent valuation method. It is worth noting that our method can also be applied to people participating in the labour market. This paper describes the development of the contingent valuation survey. We apply our survey approach to a sample of 238 Dutch patients not participating in the labour market: n = 107 Radiotherapy department (data collected between November 2011 and January 2013); n = 44 Rehabilitation department (March 2012-May 2012); n = 87 Orthopaedics department (January to June 2013). Results show that those patients value waiting time the highest (€30.10 per hour) and value travel and treatment time equally with respectively €13.20 and €13.32 per hour. This paper encourages future empirical research refining and applying the developed survey methodology to create more data on how other subgroups of individuals value their patients' time.

Switching insurer in the Irish voluntary health insurance market: determinants, incentives, and risk equalization

BACKGROUND

The determinants of consumer mobility in voluntary health insurance markets providing duplicate cover are not well understood. Consumer mobility can have important implications for competition. Consumers should be price-responsive and be willing to switch insurer in search of the best-value products. Moreover, although theory suggests low-risk consumers are more likely to switch insurer, this process should not be driven by insurers looking to attract low risks.

METHODS

This study utilizes data on 320,830 VHI healthcare policies due for renewal between August 2013 and June 2014. At the time of renewal, policyholders were categorized as either 'switchers' or 'stayers', and policy information was collected for the prior 12 months. Differences between these groups were assessed by means of logistic regression. The ability of Ireland's risk equalization scheme to account for the relative attractiveness of switchers was also examined.

RESULTS

Policyholders were price sensitive (OR 1.052, p < 0.01), however, price-sensitivity declined with age. Age (OR 0.971; p < 0.01) and hospital utilization (OR 0.977; p < 0.01) were both negatively associated with switching. In line with these findings, switchers were less costly than stayers for the 12 months prior to the switch/renew decision for single person (difference in average cost = €540.64) and multiple-person policies (difference in average cost = €450.74). Some cost differences remain for single-person policies following risk equalization (difference in average cost = €88.12).

CONCLUSIONS

Consumers appear price-responsive, which is important for competition provided it is based on correct incentives. Risk equalization payments largely eliminated the profitable status of switchers, although further refinements may be required.

[Study of the Consumers' preference on the universal health coverage development strategy through health mutual in Ziguinchor Region, Southwest of Senegal]

In Senegal, the informal and rural sector that accounts for over 80% of the population is covered only up to 7% by a health insurance system. That is why, for the implementation of development strategy of the universal health coverage (UHC) through mutual health insurance providers, the Government of Senegal has focused on this sector. The objective of this study was to assess the consumer's preference on the UHC development strategies through mutual health insurance providers. This was a qualitative and exploratory study based on a literature review, and indepth interview with the heads of households. It was also based on focus groups of people with and without health mutual membership, and the Expert Committee meetings. The results showed that the most critical attributes in the decision-making of consumers to join the health mutual in Ziguinchor were the membership units; the content of the benefit package, the payment modalities of the premium, the premium amount, the availability of transportation, the co-payment level, convention arrangement with health facilities, and health mutual governance. For a successful implementation of the UHC development strategy through health mutual organizations, policymakers should explore the possibility of introducing the modality of payment in kind, the revision of the co-payment amount, and the promotion of equity through the introduction of a differentiated premium contribution by income. They should also establish a crossborder strategy with The Gambia and Guinea-Bissau to improve health care access to people living in the borders. The promotion of innovative funding and risk equalization between health insurance schemes is also recommended. In areas where the microfinance institutions are well organized and structured their substitution to health mutuals should be an option the decision-makers have to explore.

What health plans do people prefer? The trade-off between premium and provider choice

Within a healthcare system with managed competition, health insurers are expected to act as prudent buyers of care on behalf of their customers. To fulfil this role adequately, understanding consumer preferences for health plan characteristics is of vital importance. Little is known, however, about these preferences and how they vary across consumers. Using a discrete choice experiment (DCE) we quantified trade-offs between basic health plan characteristics and analysed whether there are differences in preferences according to age, health status and income. We selected four health plan characteristics to be included in the DCE: (i) the level of provider choice and associated level of reimbursement, (ii) the primary focus of provider contracting (price, quality, social responsibility), (iii) the level of service benefits, and (iv) the monthly premium. This selection was based on a literature study, expert interviews and focus group discussions. The DCE consisted of 17 choice sets, each comprising two hypothetical health plan alternatives. A representative sample (n = 533) of the Dutch adult population, based on age, gender and educational level, completed the online questionnaire during the annual open enrolment period for 2015. The final model with four latent classes showed that being able to choose a care provider freely was by far the most decisive characteristic for respondents aged over 45, those with chronic conditions, and those with a gross income over €3000/month. Monthly premium was the most important choice determinant for young, healthy, and lower income respondents. We conclude that it would be very unlikely for half of the sample to opt for health plans with restricted provider choice. However, a premium discount up to €15/month by restricted health plans might motivate especially younger, healthier, and less wealthy consumers to choose these plans.

Explaining Accessibility and Satisfaction Related to Healthcare: A Mixed-Methods Approach

Accessibility and satisfaction related to healthcare services are conceived as multidimensional concepts. These concepts can be studied using objective and subjective measures. In this study, we created two indices: a composite healthcare accessibility index (CHCA) and a composite healthcare satisfaction index (CHCS). To calculate the CHCA index we used three indicators based on three components of multidimensional healthcare accessibility: availability, acceptability and accessibility. In the indicator based on the component of accessibility, we included an innovative perceived time-decay parameter. The three indicators of the CHCA index were weighted through the application of a principal components analysis. To calculate the CHCS index, we used three indicators: the waiting time after the patient arrives at the healthcare service, the quality of the healthcare, and the healthcare service supply. These three indicators making up the CHCA index were weighted by applying an analytical hierarchy process. Three kinds of regressions were subsequently applied in order to explain the CHCA and CHCS indices: namely the Linear Least Squares, Ordinal Logistic, and Random Forests regressions. In these regressions, we used different independent social and health-related variables. These variables represented the predisposing, enabling, and need factors of people´s behaviors related to healthcare. All the calculations were applied to a study area: the city of Quito, Ecuador. Results showed that there are health-related inequalities in regard to healthcare accessibility and healthcare satisfaction in our study area. We also identified specific social factors that explained the indices developed. The present work is a mixed-methods approach to evaluate multidimensional healthcare accessibility and healthcare satisfaction, incorporating a pluralistic perspective, as well as a multidisciplinary framework. The results obtained can also be considered as tools for healthcare and urban planners, for more integrative social analyses that can improve the quality of life in urban residents.

Household Size and the Decision to Purchase Health Insurance in Cambodia: Results of a Discrete-Choice Experiment with Scale Adjustment

BACKGROUND

Community-based health insurance (CBHI) schemes have been introduced in low- and middle-income countries to increase health service utilization and provide financial protection from high healthcare expenditures.

OBJECTIVE

We assess the impact of household size on decisions to enroll in CBHI and demonstrate how to correct for group disparity in scale (i.e. variance differences).

METHODS

A discrete choice experiment was conducted across five CBHI attributes. Preferences were elicited through forced-choice paired comparison choice tasks designed based on D-efficiency. Differences in preferences were examined between small (1-4 family members) and large (5-12 members) households using conditional logistic regression. Swait and Louviere test was used to identify and correct for differences in scale.

RESULTS

One-hundred and sixty households were surveyed in Northwest Cambodia. Increased insurance premium was associated with disutility [odds ratio (OR) 0.61, p < 0.01], while significant increase in utility was noted for higher hospital fee coverage (OR 10.58, p < 0.01), greater coverage of travel and meal costs (OR 4.08, p < 0.01), and more frequent communication with the insurer (OR 1.33, p < 0.01). While the magnitude of preference for hospital fee coverage appeared larger for the large household group (OR 14.15) compared to the small household group (OR 8.58), differences in scale were observed (p < 0.05). After adjusting for scale (k, ratio of scale between large to small household groups = 1.227, 95 % confidence interval 1.002-1.515), preference differences by household size became negligible.

CONCLUSION

Differences in stated preferences may be due to scale, or variance differences between groups, rather than true variations in preference. Coverage of hospital fees, travel and meal costs are given significant weight in CBHI enrollment decisions regardless of household size. Understanding how community members make decisions about health insurance can inform low- and middle-income countries' paths towards universal health coverage.

Measuring Healthcare Providers' Performances Within Managed Competition Using Multidimensional Quality and Cost Indicators

BACKGROUND AND OBJECTIVES

The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition.

DATA AND METHODS

We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers.

RESULTS AND CONCLUSION

There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition.

Market competition and price of disease management programmes: an observational study

Background

Managed competition was introduced into the health care system in several countries including the Netherlands, although effects of competition of both providers and health insurers on the price of health care are inconclusive. We investigated the association between competition of both providers (care groups) and health insurers and the price of disease management programmes (DMPs).

Methods

Data from 76 DMP contractual agreements for type II diabetes mellitus in 2008, 2009 and 2010 were used to analyse the association between market competition and the price of DMPs. Market competition was calculated per municipal health services region (GGD). Insurer market competition was measured by the Herfindahl-Hirschman Index (HHI), care group competition by the number of care groups and the care group market share of GPs. The effect of competition was cross-sectionally studied with linear regression analyses.

Results

Insurer market concentration (HHI) and care group market share were not associated with the price of DMPs. The number of care groups in a GGD region was associated with a lower price (−€4.68; 95% CI: −8.36 - -1.00). The mean difference in the price of DMPs between health insurers was €58.

Conclusions

The price of DMPs seems to be more dependent on the particular health insurer than on market conditions. For competition among health insurers and provider groups to develop, preconditions such as selective contracting and option for patient to change provider should be in place.

Eliciting community preferences for complementary micro health insurance: a discrete choice experiment in rural Malawi

There is a limited understanding of preferences for micro health insurance (MHI) as a strategy for moving towards universal health coverage. Using a discrete choice experiment (DCE), we explored community preferences for the attributes and attribute-levels of a prospective MHI scheme, aimed at filling health coverage gaps in Malawi. Through a qualitative study informed by a literature review, we identified six MHI attributes (and attribute-levels): unit of enrollment, management structure, health service benefit package, copayment levels, transportation coverage, and monthly premium per person. Qualitative data was collected from 12 focus group discussions and 8 interviews in August-September, 2012. We constructed a D-efficient design of eighteen choice-sets, each comprising two MHI choice alternatives and an opt-out. Using pictorial images, trained interviewers administered the DCE in March-May, 2013, to 814 household heads and/or their spouse(s) in two rural districts. We estimated preferences for attribute-levels and relative importance of attributes using conditional and nested logit models. The results showed that all attribute-levels except management by external NGO significantly influenced respondents' choice behavior (P<0.05). These included: enrollment as core nuclear family (odds ratio (OR)=1.1574), extended family (OR=1.1132), compared to individual; management by community committee (OR=0.9494) compared to local micro finance institution; comprehensive health service package (OR=1.4621), medium service package (OR=1.2761), compared to basic service package; no copayment (OR=1.1347), 25% copayment (OR=1.1090), compared to 50% copayment; coverage of all transport (OR=1.5841), referral and emergency transport (OR=1.2610), compared to no transport; and premium (OR=0.9994). The relative importance of attributes is ordered as: transport, health services benefits, enrollment unit, premium, copayment, and management. To maximize consumer utility and encourage community acceptance of MHI, potential MHI schemes should cover transport costs, offer a comprehensive benefit package, define the core family as the unit of enrollment, avoid high copayments, and be managed by a competent financial institution.

"One for all and all for one": consensus-building within communities in rural India on their health microinsurance package

Introduction

This study deals with consensus by poor persons in the informal sector in rural India on the benefit-package of their community-based health insurance (CBHI). In this article we describe the process of involving rural poor in benefit-package design and assess the underlying reasons for choices they made and their ability to reach group consensus.

Methods

The benefit-package selection process entailed four steps: narrowing down the options by community representatives, plus three Choosing Healthplans All Together (CHAT) rounds conducted among female members of self-help groups. We use mixed-methods and four sources of data: baseline study, CHAT exercises, in-depth interviews, and evaluation questionnaires. We define consensus as a community resolution reached by discussion, considering all opinions, and to which everyone agrees. We use the coefficient of unalikeability to express consensus quantitatively (as variability of categorical variables) rather than just categorically (as a binomial Yes/No).

Findings

The coefficient of unalikeability decreased consistently over consecutive CHAT rounds, reaching zero (ie, 100% consensus) in two locations, and confirmed gradual adoption of consensus. Evaluation interviews revealed that the wish to be part of a consensus was dominant in all locations. The in-depth interviews indicated that people enjoyed the participatory deliberations, were satisfied with the selection, and that group decisions reflected a consensus rather than majority. Moreover, evidence suggests that pre-selectors and communities aimed to enhance the likelihood that many households would benefit from CBHI.

Conclusion

The voluntary and contributory CBHI relies on an engaging experience with others to validate perceived priorities of the target group. The strongest motive for choice was the wish to join a consensus (more than price or package-composition) and the intention that many members should benefit. The degree of consensus improved with iterative CHAT rounds. Harnessing group consensus requires catalytic intervention, as the process is not spontaneous.

Developing attributes and attribute-levels for a discrete choice experiment on micro health insurance in rural Malawi

Background

Discrete choice experiments (DCEs) are attribute-driven experimental techniques used to elicit stakeholders’ preferences to support the design and implementation of policy interventions. The validity of a DCE, therefore, depends on the appropriate specification of the attributes and their levels. There have been recent calls for greater rigor in implementing and reporting on the processes of developing attributes and attribute-levels for discrete choice experiments (DCEs). This paper responds to such calls by carefully reporting a systematic process of developing micro health insurance attributes and attribute-levels for the design of a DCE in rural Malawi.

Methods

Conceptual attributes and attribute-levels were initially derived from a literature review which informed the design of qualitative data collection tools to identify context specific attributes and attribute-levels. Qualitative data was collected in August-September 2012 from 12 focus group discussions with community residents and 8 in-depth interviews with health workers. All participants were selected according to stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three researchers to identify context-specific attributes and attribute-levels. Expert opinion was used to scale down the attributes and levels. A pilot study confirmed the appropriateness of the selected attributes and levels for a DCE.

Results

First, a consensus, emerging from an individual level analysis of the qualitative transcripts, identified 10 candidate attributes. Levels were assigned to all attributes based on data from transcripts and knowledge of the Malawian context, derived from literature. Second, through further discussions with experts, four attributes were discarded based on multiple criteria. The 6 remaining attributes were: premium level, unit of enrollment, management structure, health service benefit package, transportation coverage and copayment levels. A final step of revision and piloting confirmed that the retained attributes satisfied the credibility criteria of DCE attributes.

Conclusion

This detailed description makes our attribute development process transparent, and provides the reader with a basis to assess the rigor of this stage of constructing the DCE. This paper contributes empirical evidence to the limited methodological literature on attributes and levels development for DCE, thereby providing further empirical guidance on the matter, specifically within rural communities of low- and middle-income countries.

Patients' preference on selecting a medical institution

PURPOSE

The purpose of this paper is to evaluate the relative importance of attributes for patient selection of a medical institution and to quantitatively evaluate the impact of different types of organizational forms upon the patient's selection of a medical institution.

DESIGN/METHODOLOGY/APPROACH

By using a conjoint analysis, evaluation criteria in patient selection of a medical institution were examined. The paper assumed the selection of a medical institution under the situation of "being given a diagnosis of suspected diabetes with a physical examination and then visiting a medical institution". The attributes included in the questionnaire were: quality of the medical institution, distance to the hospital, amount paid at the initial visit, amount paid at hospitalization for examinations, and organizational form of the hospital. Relative importance of the attributes and relative importance of organizational form were assessed. A total of 140 people were requested to respond to the questionnaire by way of researchers who have a connection with the authors. Completed responses were obtained from 111 subjects (79 per cent).

FINDINGS

The results of the conjoint analysis revealed that the most important attribute was quality of the medical institution. Organizational form was the attribute with the lowest importance. The utility value of being a public hospital was the highest within the organizational form attribute for all respondents and being a private hospital was the lowest. The quality of the medical institution was considered the most important factor in selecting a medical institution and the type of organizational form was considered least important. Regarding organizational form, being a public hospital was most preferred and being a hospital managed by a company and a private hospital were least preferred respectively among healthcare professionals and other occupations.

ORIGINALITY/VALUE

The paper provides a relative evaluation of the factors thought to be important for patients in Japan when selecting a medical institution.

Moral hazard and supplier-induced demand: empirical evidence in general practice

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Understanding consumer preferences in the context of managed competition: evidence from a choice experiment in Colombia

BACKGROUND

In many countries, health insurance coverage is the primary way for individuals to access care. Governments can support access through social insurance programmes; however, after a certain period, governments struggle to achieve universal coverage. Evidence suggests that complex individual behaviour may play a role.

OBJECTIVES

Using a choice experiment, this research explored consumer preferences for health insurance in Colombia. We also evaluated whether preferences differed across consumers with differing demographic and health status factors.

METHODS

A household field experiment was conducted in Bogotá in 2010. The sample consisted of 109 uninsured and 133 low-income insured individuals. Each individual evaluated 12 pair-wise comparisons of hypothetical health plans. We focused on six characteristics of health insurance: premium, out-of-pocket expenditure, chronic condition coverage, quality of care, family coverage and sick leave. A main effects orthogonal design was used to derive the 72 scenarios used in the choice experiment. Parameters were estimated using conditional logit models. Since price data were included, we estimated respondents' willingness to pay for characteristics.

RESULTS

Consumers valued health benefits and family coverage more than other attributes. Additionally, differences in preferences can be exploited to increase coverage. The willingness to pay for benefits may partially cover the average cost of providing them.

CONCLUSION

Policy makers might be able to encourage those insured via the subsidized system to enrol in the next level of the social health insurance scheme through expanding benefits to family members and expanding the level of chronic condition coverage.

Spillover effects of supplementary on basic health insurance: evidence from The Netherlands

Like many other countries, the Netherlands has a health insurance system that combines mandatory basic insurance with voluntary supplementary insurance. Both types of insurance are founded on different principles. Since basic and supplementary insurance are sold by the same health insurers, both markets may interact. This paper examines to what extent basic and supplementary insurance are linked to each other and whether these links generate spillover effects of supplementary on basic insurance. Our analysis is based on an investigation into supplementary health insurance contracts, underwriting procedures and annual surveys among 1,700-2,100 respondents over the period 2006-2009. We find that health insurers increasingly use a variety of strategies to enforce a joint purchase of basic and supplementary health insurance. Despite incentives for health insurers to use supplementary insurance as a tool for risk selection in basic insurance, we find limited evidence of supplementary insurance being used this way. Only a minority of health insurers uses health questionnaires when people apply for supplementary coverage. Nevertheless, we find that an increasing proportion of high-risk individuals believe that insurers would not be willing to offer them another supplementary insurance contract. We discuss several strategies to prevent or to counteract the observed negative spillover effects of supplementary insurance.

Switching health insurance plans: results from a health survey

The study is designed to provide an informal summary of what is known about consumer switching of health insurance plans and to contribute to knowledge about what motivates consumers who choose to switch health plans. Do consumers switch plans largely on the basis of critical reflection and assessment of information about the quality, and price? The literature suggests that switching is complicated, not always possible, and often overwhelming to consumers. Price does not always determine choice. Quality is very hard for consumers to understand. Results from a random sample survey (n = 2791) of the Alkmaar region of the Netherlands are reported here. They suggest that rather than embracing the opportunity to be active critical consumers, individuals are more likely to avoid this role by handing this activity off to a group purchasing organization. There is little evidence that consumers switch plans on the basis of critical reflection and assessment of information about quality and price. The new data reported here confirm the importance of a group purchasing organizations. In a free-market-health insurance system confidence in purchasing groups may be more important for health insurance choice than health informatics. This is not what policy makers expected and might result a less efficient health insurance market system.

Willingness to participate in a lifestyle intervention program of patients with type 2 diabetes mellitus: a conjoint analysis

BACKGROUND

Several studies suggest that lifestyle interventions can be effective for people with, or at risk for, diabetes. The participation in lifestyle interventions is generally low. Financial incentives may encourage participation in lifestyle intervention programs.

OBJECTIVE

The main aim of this exploratory analysis is to study empirically potential effects of financial incentives on diabetes patients' willingness to participate in lifestyle interventions. One financial incentive is negative ("copayment") and the other incentive is positive ("bonus"). The key part of this research is to contrast both incentives. The second aim is to investigate the factors that influence participation in a lifestyle intervention program.

METHODS

Conjoint analysis techniques were used to empirically identify factors that influence willingness to participate in a lifestyle intervention. For this purpose diabetic patients received a questionnaire with descriptions of various forms of hypothetical lifestyle interventions. They were asked if they would be willing to participate in these hypothetical programs.

RESULTS

In total, 174 observations were rated by 46 respondents. Analysis showed that money was an important factor independently associated with respondents' willingness to participate. Receiving a bonus seemed to be associated with a higher willingness to participate, but having to pay was negatively associated with participation in the lifestyle intervention.

CONCLUSION

Conjoint analysis results suggest that financial considerations may influence willingness to participate in lifestyle intervention programs. Financial disincentives in the form of copayments might discourage participation. Although the positive impact of bonuses is smaller than the negative impact of copayments, bonuses could still be used to encourage willingness to participate.

Individual responsibility and health-risk behaviour: a contingent valuation study from the ex ante societal perspective

This study analyzes peoples' social preferences for individual responsibility to health-risk behaviour in health care using the contingent valuation method adopting a societal perspective. We measure peoples' willingness to pay for inclusion of a treatment in basic health insurance of a hypothetical lifestyle dependent (smoking) and lifestyle independent (chronic) health problem. Our hypothesis is that peoples' willingness to pay for the independent and the dependent health problems are similar. As a methodological challenge, this study also analyzes the extent to which people consider their personal situation when answering contingent valuation questions adopting a societal perspective. 513 Dutch inhabitants responded to the questionnaire. They were asked to state their maximum willingness to pay for inclusion of treatments in basic health insurance package for two health problems. We asked them to assume that one hypothetical health problem was totally independent of behaviour (for simplicity called chronic disease). Alternatively, we asked them to assume that the other hypothetical health problem was totally caused by health-risk behaviour (for simplicity called smoking disease). We applied the payment card method to guide respondents to answer the contingent valuation method questions. Mean willingness to pay was 42.39 Euros (CI=37.24-47.55) for inclusion of treatment for health problem that was unrelated to behaviour, with '5-10' and '10-20 Euros' as most frequently stated answers. In contrast, mean willingness to pay for inclusion treatment for health-risk related problem was 11.29 Euros (CI=8.83-14.55), with '0' and '0-5 Euros' as most frequently provided answers. Difference in mean willingness to pay was substantial (over 30 Euros) and statistically significant (p-value=0.000). Smokers were statistically significantly more (p-value<0.01) willing to pay for the health-risk related (smoking) problem compared with non-smokers, while people with chronic condition were not willing to pay more for the health-risk unrelated (chronic) problem than people without chronic condition. This suggests that sub groups of people might differ in terms of abstracting from their personal situation when answering valuation questions from a societal perspective.

Preferred providers and the credible commitment problem in health insurance: first experiences with the implementation of managed competition in the Dutch health care system

We investigate the impact of the transition towards managed competition in the Dutch health care system on health insurers' contracting behaviour. Specifically, we examine whether insurers have been able to take up their role as prudent buyers of care and examine consumers' attitudes towards insurers' new role. Health insurers' contracting behaviour is investigated by an extensive analysis of available information on purchasing practices by health insurers and by interviews with directors of health care purchasing of the four major health insurers, accounting for 90% of the market. Consumer attitudes towards insurers' new role are investigated by surveys among a representative sample of enrollees over the period 2005-2009. During the first four years of the reform, health insurers were very reluctant to engage in selective contracting and preferred to use 'soft' positive incentives to encourage preferred provider choice rather than engaging in restrictive managed care activities. Consumer attitudes towards channelling vary considerably by type of provider but generally became more negative in the first two years after the reform. Insurers' reluctance to use selective contracting can be at least partly explained by the presence of a credible-commitment problem. Consumers do not trust that insurers with restrictive networks are committed to provide good quality care. The credible-commitment problem seems to be particularly relevant to the Netherlands, since Dutch enrollees are not used to restrictions on provider choice. Since consumers are quite sensitive to differences in provider quality, more reliable information about provider quality is required to reduce the credible-commitment problem.

TOWARDS PATIENT-CENTERED CARE FOR DEPRESSION: CONJOINT METHODS TO TAILOR TREATMENT BASED ON PREFERENCES

BACKGROUND: Although antidepressants and counseling have been shown to be effective in treating patients with depression, non-treatment or under-treatment for depression is common especially among the elderly and minorities. Previous work on patient preferences has focused on medication versus counseling, but less is known about the value patients place on attributes of medication and counseling. OBJECTIVE: Conjoint analysis has been recognized as a valuable means of assessing patient treatment preferences. We examine how conjoint analysis be used to determine the relative importance of various attributes of depression treatment at the group level as well as to determine the range of individual-level relative preference weights for specific depression treatment attributes. In addition we use conjoint analysis to predict what modifications in treatment characteristics are associated with a change in the stated preferred alternative. STUDY DESIGN: 86 adults who participated in an internet-based panel responded to an on-line discrete choice task about depression treatment. Participants chose between medication and counseling based on choice sets presented first for a "mild depression" scenario and then for a "severe depression" scenario. Participants were given 18 choice sets which varied for medication based on type of side effect (nausea, dizziness, and sexual dysfunction) and severity of side effect (mild, moderate, and severe); and for counseling based on frequency of counseling sessions (once per week or every other week) and location of the sessions (mental health professional's office, primary care doctor's office or office of a spiritual counselor). RESULTS: Treatment type (counseling vs. medication) appeared to be more important in driving treatment choice than any specific attribute that was studied. Specifically counseling was preferred by most of the respondents. After treatment type, location of treatment and frequency of treatment were important considerations. Preferred attributes were similar in both the mild and severe depression scenarios. Side effect severity appeared to be most important in driving treatment choice as compared with the other attributes studied. Individual-level relative preferences for treatment type revealed a distribution that was roughly bimodal with 27 participants who had a strong preference for counseling and 14 respondents who had a strong preference for medication. CONCLUSION: Estimating individual-level preferences for treatment type allowed us to see the variability in preferences and determine which participants had a strong affinity for medication or counseling.