Exit and Voice in Dutch Social Health Insurance (original) (raw)
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Social Science & Medicine, 1994
This article reviews some of the salient features of the Belgian health care finance and delivery system. Special attention is paid to the role played by the third-party payers, i.e. the Health Insurance Associations (HIAs) in administering the compulsory national health insurance program. It is shown how, despite extensive government regulation, the markets for GP, specialist and hospital services exhibit fierce competition of the non-price variety. Next, the paper considers the three problems perceived to be the most pressing ones at present: (i) the problem of raising sufficient revenues to cover the public share of health expenditures; (ii) the (related) cost containment problem; and (iii) the problem of ensuring efficiency through appropriate incentive mechanisms. Finally, two recently proposed options for reform are discussed and complemented with a third proposal based on the ideas of regulated competition. It is concluded that strengthening the role of the third-party payers remains crucial in any attempt to reshape the system to make it efficient and affordable while keeping it equitable.
Incomplete risk adjustment and adverse selection in the German public health insurance system
2002
The German statutory health insurance market was exposed to competition in 1996. To avoid adverse selection, a prospective risk compensation scheme was introduced in 1994. Due to their low contribution rates, company-based sickness funds were able to attract a lot of new members. We analyze -using data from the German Socio-Economic Panel -the determinants of these transitions from 1995 to 2000. By estimating a simultaneous two equation system, we find that health status positively, and significantly, affects the probability of changing to a company-based sickness fund, especially after controlling for age. Thus the risk compensation scheme does not fully control for the health status of the changers. Consequently, the comparative advantages of company-based funds will increase over time. This observation provides evidence for the standard Rothschild-Stiglitz separating equilibrium.
Health affairs
The introduction in 1996 of free choice among sickness funds in Germany was accompanied by a "risk structure compensation" (RSC) mechanism based on average spending by age and sex. Because chronically ill people were not adequately taken into account, competition for newly insured consumers concentrated on the healthy. The introduction in 2002 of disease management programs addresses this problem: Insured people in such programs are treated as a separate RSC category, making them a more "attractive" group that no longer generates a deficit. The degree of sickness fund activities and the fierce dispute with physicians are valid indicators that the incentives work.
Statutory health insurance competition in Europe: A four-country comparison
Health Policy, 2013
This paper explores the goals and implementation of reforms introducing choice of and competition among insurers providing statutory health coverage in Belgium, Germany, the Netherlands and Switzerland. In theory, health insurance competition can enhance efficiency in health care administration and delivery only if people have free choice of insurer (consumer mobility), if insurers do not have incentives to select risks, and if insurers are able to influence health service quality and costs. In practice, reforms in the four countries have not always prioritised efficiency and implementation has varied. Differences in policy goals explain some but not all of the differences in implementation. Despite significant investment in risk adjustment, incentives for risk selection remain and consumer mobility is not evenly distributed across the population. Better risk adjustment might make it easier for older and less healthy people to change insurer. Policy makers could also do more to prevent insurers from linking the sale of statutory and voluntary health insurance, particularly where take-up of voluntary coverage is widespread. Collective negotiation between insurers and providers in Belgium, Germany and Switzerland curbs insurers' ability to influence health care quality and costs. Nevertheless, while insurers in the Netherlands have good access to efficiency-enhancing tools, data and capacity constraints and resistance from stakeholders limit the extent to which tools are used. The experience of these countries offers an important lesson to other countries: it is not straightforward to put in place the conditions under which health insurance competition can enhance efficiency. Policy makers should not, therefore, underestimate the challenges involved.
Financial incentives in the German Statutory Health Insurance: New findings, new questions
Health Policy, 2010
Objectives: This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition. Methods: The analysis included 70,429 insured enrolled in a prevention bonus program in a cohort study. The intervention group and their matched controls were followed for a three-year period. Matching was performed as nearest neighbor matching. The economic analysis comprised all costs relevant for Sickness Funds (SF) in the SHI and was carried out from a SHI perspective. Differences in cost trends between the intervention and the control group were examined applying the paired t-test. Results: Regarding mean costs there was a significant difference between the two groups of D 177.48 (90% CI [D 149.73; D 205.24]) in favor of the intervention group. If program costs were considered cost reductions of D 100.88 (90% CI [D 73.12; D 128.63]) were obtained. Conclusions: The uptake of a prevention bonus program led to cost reductions in the intervention group compared to the control group even when program costs were considered. However, the results must be interpreted with caution as in addition to financial aspects, socio-economic and health-status, selection bias and the function and use of bonus programs as marketing tools, as well as their long-term sustainability should be considered in future assessments.
Can insurer competition improve health system performance? Evidence from Western Europe
This article considers the potential for insurer competition to improve health system performance by strengthening purchasing. Economic theory suggests that insurer competition will enhance efficiency if: (1) people have free choice of insurer, (2) competition is based on price and quality rather than risk selection and (3) insurers have tools to influence health care costs and quality. The article assesses the extent to which these assumptions hold in Belgium, Germany, the Netherlands and Switzerland. It finds that health insurance market reforms in these countries have had mixed results in fulfilling these assumptions. In spite of significant investment in risk equalisation, incentives for risk selection remain. Consumer mobility is lower among older and chronically ill people, possibly due to close interaction between statutory and voluntary coverage. Although insurers in some countries increasingly have tools to enhance value, they may not always use them. The analysis suggests that the instrumental value of insurer competition rests on multiple assumptions that can only be upheld through frequently complex interventions often requiring elusive data. Making it work therefore requires action on several fronts, particularly to ensure incentives are aligned across the health system, and awareness of the political nature of some barriers to success.