《健康经济学》课件Chapter17

SocialhealthinsuranceinGermanyIn1881,thefirstChancellorofmodernGermany,OttovonBismarck,introducedapopularnewnationalpolicy:universalsicknessinsurance.Hisideawasbasedoncenturies-oldpracticesofPrussianminers,whobelongedtomutualaidsocietiesor“sicknessfunds”calledKnappschaftskasse.ThepassageofBismarck’s1883insurancebillisconsideredafoundationalmomentinthehistoryofthewelfarestate.Thegovernmenteventuallyextendedhealthinsurancecoveragetotheentirepopulation.ThespreadofsocialhealthinsuranceIn1958,JapanpassedtheNationalHealthInsuranceLaw,whichuniversallyguaranteedhealthinsurancetoJapanesecitizens.OtherEastAsiannationslikeSouthKoreaandTaiwanfollowedJapan’sleadinthelate20thcentury.ManyhealthcaresystemsincontinentalEurope,suchasthoseinFrance,Switzerland,andtheNetherlands,evolvedinsimilarwaysKeytraitsofBismarckhealthcaresystemsUniversalinsuranceCommunityratingRegulated,privatehealthcareprovisionKeytraitsofBismarckhealthcaresystemsUniversalinsurance:Allornearlyallofthepopulationhashealthinsurancecoverage,eitherthroughaplansponsoredbyanemployerorthroughthegovernment.Nooneisdeniedaccesstoinsurancebasedoninabilitytopayorpoorhealthstatus.CommunityratingRegulated,privatehealthcareprovisionKeytraitsofBismarckhealthcaresystemsUniversalinsuranceCommunityratingInsuranceisfinancedthroughtaxes(basedonincome),notpremiums(basedonhealthstatus)ThismeanstherichandhealthysubsidizethepoorandsickTheinsurancesystemoperatesundermanagedcompetition–tobediscussedlaterRegulated,privatehealthcareprovisionKeytraitsofBismarckhealthcaresystemsUniversalinsuranceCommunityratingRegulated,privatehealthcareprovisionManyhospitalsareprivatePhysiciansoperateprivately,notpublicemployeesBut,pricesaresetbythegovernmentinnegotiationwithprovidersPrivateprovidersdonothavetheoptionofofferingservicesathigher(orlower)pricesBismarck:balancingsolidarityandlibertySolidarity/equity:thepoorestandsickestmembersofsocietyaresupportedbythesystem,whichgrantssubsidizedhealthinsurancetothoseleastabletoaffordit.Thissubsidyisbornebythewealthiestandhealthiest,whopayhightaxesandactuarially-unfairpremiumstokeepthesystemafloat.Liberty:patientsanddoctorsareatlibertytomakefundamentaleconomicchoices,likewhichhospitaltovisit,whichinsurancecontracttotake,orwheretoopenanewclinicorhospital.Ch17|TheBismarckmodel:SocialhealthinsuranceABRIEFTOUROFTHEBISMARCKWORLDGermanyGermanpatientshavetheoptionofchoosingamongallavailablehealthinsuranceplans,includingplansrunbyothercompaniesorfarawaystates.Theseplansarenominallyprivateentities,theyareextensivelyregulated(managedcompetition).Premiumstofinanceinsurancearecollectedaspayrolltaxes,andvaryonlywithincome,nothealth.Patientsandinsurersarefreetochoosetheirhealthcareproviders,whocancompetetoattractthem.Remember,providersmustcompetebasedonqualityratherthanpriceSwitzerlandSwitzerland’ssystemcloselyresemblesGermany’s:insurersareheavilyregulatedandcompetetoattractcustomers,whoarerequiredtopurchasecoverage.Switzerlandisalsonotableforpioneeringmanagedcareplans,likeHMOs.Switzerlandfacesseveralhealthpolicychallenges:Inrecentyears,subsidieshavefailedtokeepupwithrisinginsurancepremiums,andvastdisparitiesinpremiumsbetweencantonshaveappeared.TheNetherlandsandIsraelTheNetherlandsTheNetherlands’systemresemblesGermany’smanaged-competitionmodel.UnlikeinGermany,insuranceisfinancedjointlybypayrollcontributionsandadditionalpremiums.IsraelA1995Israelilawestablishedthecurrentsystem,withfoursicknessfunds,anddefinedauniversalstandardbasketofservices.TheIsraelisystemfeaturesamanaged-competitionmodelsimilartotheEuropeansystems.JapanUnlikemostBismarckianhealthsystems,Japan’ssystemisnotbasedonamanagedcompetitionmodelwherebypatientschoosetheirinsurers.Instead,thesystememphasizesemployer-basedfinancingofhealthcare,wherebythetypeofcompanyoneworksfordeterminestheinsurancesocietytowhichonebelongs.However,patientscanchoosetheirproviders,whoareconstrainedbystrictpricecontrols,muchlikeotherBismarcknations.FranceFranceisalittledifferent,butisstillbestcategorizedasBismarckian:HealthinsuranceinFrancehasbeenuniversalsincethe1970s.Frenchworkersdonothaveachoicebetweenplans,butallplansaremoreorlessidentical.Thereisalargedegreeofchoice,though,whenitcomestoselectingadoctor.Franceisnotableforitsmodestcoverageofambulatoryservices(therearesupplementaryinsuranceplanstofillthegap).Ch17|TheBismarckmodel:SocialhealthinsuranceHEALTHINSURANCEMARKETSINTHEBISMARCKMODELInBeveridgenations,whereeveryoneisautomaticallyinsuredinthesamepool,adverseselectiondoesnotexist.ButBismarcksystemsarenotimmunetoadverseselection.Thecompulsorynatureofinsuranceenrollmentpreventstheworstofadverseselection.Peoplearepreventedfromleavingthepoolcompletelywhentheyarehealthy.Thisguaranteesthattherearealwayshealthypeoplepayingintothesystemtosubsidizecareforthesick.ButifpeoplecanchooseamongseveralinsuranceplanswithinaBismarcksystem,adverseselectioncanappear.AdverseselectionManagedcompetitionHealth

insurancemarketsinBismarcknationsfollowa“managedcompetition”model.Insuranceisnotrunbythegovernmentbutinsteadmultipleprivate,non-profitentitiescalledsicknessfunds.Therearefourmajorrulesinmanagedcompetitionmarkets.RulesofmanagedcompetitionMinimumstandards:eachinsurancecontractisrequiredtomeetaminimalstandardofcare;Therearealsolimitsoncopaymentsanddeductibles.Openenrollment:insurersmaynotrejectanyeligiblecustomers,eveniftheyareunhealthy.Compulsoryparticipation:customersaremandatedtohaveandpayforinsurancecoverageatalltimes.Communityrating:insurerscannotsetpremiumsusingriskrating;insteadtheymustbecommunityrated.RmunityratingRiskrating:chargingdifferentpremiumstodifferentcustomersbasedontheirpersonalriskofneedinghealthcare.Thealternativeiscommunityrating,whichentailschargingeveryoneinaninsurancepoolthesamepremium.RiskselectionAdverseselectionreferstothebehaviorofinsurancecustomers,whileriskselectionreferstothebehaviorofinsuranceproviders.Riskselectionoccurswheninsurersseektoenrolllow-riskcustomersandseektoavoidhigh-riskcustomers.Notonlydoesriskselectionputsickcustomersinadisadvantagedposition,itisalsowastefulfromasocialperspective.Theextentofriskselectioninpracticeisunknown,asitisalmostimpossibletoobservedirectly.TacticsforriskselectionAdvertisespecificallytocertaingroupsCloseofficesinhigh-costregionsRewardagentswhofindsickcustomersandconvincethemtoswitchtootherplansIgnorecallsfromsickcustomerswhowanttosignupProvidedeficientcaretothesicklyinhopesofchasingthemawayHoldsign-upsessionsinbuildingsthatarenotaccessibletothedisabledSomeorallofthesetacticsmaybeoutlawedbygovernmentstryingtolimitriskselection.TacticsforriskselectionEliminatingriskselectionOption1:Ex-postcost-basedcompensationSicknessfundswithsickercustomersandhigherexpendituresarereimbursedwithtransfersfromfundsthathadhealthiercustomersandlowerexpenditures.Thiserasesriskselection,butitalsoremovesanyincentiveforinsurancefundstotreattheirpatientsefficiently.Option2:RiskadjustmentTransfersarebasedonexanteriskassessmentsandnotactualcostoutcomes.Thus,insurancefundsthatdrawunhealthycustomersarereimbursedbasedonhowexpensivetheircustomersareexpectedtobe,notonhowexpensivetheyactuallyare.Thisreducesincentivesforcream-skimming,whilemaintainingefficiency.Howdoesriskadjustmentwork?Example:A52-year-olddiabeticmansignsupforaGermansicknessfund.Attheendoftheyear,acentralGermanagencycalculatestheaveragehealthexpendituresofall52-year-olddiabeticmenacrossGermany.Supposetheaveragecostforthispopulationis€12,000,buttheaveragecostnationwideis€5,000Then,thesicknessfundgetsacheckfor€7,000Meanwhile,fundswithunusuallyhealthycustomershavetopayintothecentralfundAdverseselectionincompulsoryinsurancemarketsAdverseselectionmayariseinBismarcksystemsiffrailcustomersdisproportionatelyenrollincertainfundsthatprovidethemostgenerouscoverage.ThiscouldresultinaseparatingequilibriumorevenanadverseselectiondeathspiralAdverseselectioncanalsobecomeextremelydestabilizingiffirmsarenotallowedtoadjusttheirpremiums(asisthecaseinIsrael).Inthefaceofadverseselectionandfixedpremiums,insurerssimplyhavenoincentivetoprovidequalitycareforthesick(vandeVenetal.2007).AdverseselectionincompulsoryinsurancemarketsTwomainoptionsforcombatingadverseselectioninBismarcksystems:Option1:Denycustomerstherighttochoosetheirinsurersinthefirstplace.Example:JapanOption2:Restrictproductdifferentiation.Ifinsurancefundscannotdistinguishthemselvessignificantlyfromcompetitors,thentherewillbelittletomotivateadverseselectioninthefirstplace,andlessinequalityifaseparatingequilibriumdoesemerge.Example:GermanyCh17|TheBismarckmodel: SocialhealthinsuranceCONTAININGCOSTSWITHPRICECONTROLSWhypricecontrols?WehavealreadydiscussedthemajorproblemofoligopolypowerinhospitalandphysicianmarketsPricecontrolsarepricesnegotiatedbetweenprovidersandpurchasersEssentially,apricecontrolnegotiationallowsthepurchasersofhealthcare(sicknessfunds)tobandtogetherandexercisemonopsonypowerThiscancounterbalanceoligopolypowerandlowerprices,butpricessetbyacentralagencycandistortmedicaldecisionmakingNegotiatedfeeschedulesNegotiatingfeeschedulesisonepolicyemployedbyBismarckcountriestocontrolhealthcarespending.Settinghealthcarepricesiscomplicatedsincetherangeofpossibleactivitiesissobroadandvaried.Priceschedulesmustadjudgetherelativevalueofseeingapatientforaroutinecheck-upperformingheartbypasssurgeryIsthelatterworthonethousandtimesasmuchastheformer?Onemilliontimes?NegotiatedfeeschedulesBothprivateandpublicprovidersareboundbythesepricenegotiations,andmustchargetheseprices—nomoreandnoless.Feeschedulesgivespolicymakersthepowertoinfluencethebehaviorofhealthcareproviders.Manipulationofthefeescheduleservesasoneoftheprimarymechanismsbywhichgovernmentsregulatethesupplyofmedicalservices,theuseofcare,andthelevelofaggregatehealthcarespending.ClinicaldistortionsTheprocessforsettingpriceswouldideallyresultinapriceforeachactivityequaltoitsmarginalcostsofproduction.However,forgovernmentsthisisanimpossibletask,givenlimitedinformation,politicalpressures,andlimitedhealthcarebudgets.Inevitably,theprocessofgovernmentprice-settingproducessomepricesthatdonotmatchtheactualmarginalcostsandbenefitsofcare.Suchpricemismatchescanintroducedistortionsinthewaythatdoctorselecttotreattheirpatients.ClinicaldistortionsExample1:PricesaresettoohighInJapan,officialpricesformostpharmaceuticalsaredeliberatelysethigherthanthepricechargedbydrugcompanies.Consequently,Japanesephysiciansoftenopttosellhigher-priceddrugs,tothepointwhereJapanesepharmaceuticalexpendituresconstitutednearly30%ofallhealthcarespendingin1993.2

Bycontrast,thisfigurewasonly11%thatsameyearintheUnitedStates.ClinicaldistortionsExample2:PricesaresettoolowWhenCochlearimplanttechnologywasfirstdeveloped,theU.S.MedicareandMedicaidsystemspricedreimbursementfortheprocedureatverylowlevels.Anydoctorperformingacochlearimplantationwouldhavetobuyanexpensiveimplantandperformthedifficultsurgery,onlytobereimbursedataratelessthanthecostofthedeviceitself.Asaresult,onlyalimitednumberofdeafpeoplehadcochlearimplantsplacedintheU.S.,whilethedeviceproliferatedinJapan(wherereimbursementratesweresethigher).LimitingaccesstospecialistsInordertolimithealthcareexpenditures,manyBismarckcountrieshaveinitiatedgatekeepingreforms.Example:BothFranceandGermanyhaveimposedgatekeepingreforms.UnlikeintheU.K.,boththeFrenchandGermangatekeepingsystemsarevoluntaryforpatients.Sincepatientscanavoidgatekeepersandgostraighttospecialistsiftheypayasmallfine,thereformsarecalled“softgatekeeping”.11Oretal.(2010)LimitingaccesstonewtechnologiesInrecentyears,manyBismarckcountrieshavealsomoved