Public and private health insurance in Germany: the ignored risk selection problem

Exploring the Challenges in Covering Dental Services through Complementary Insurance in Iran: A Qualitative Study

Background

Financial protection is crucial for attaining universal health coverage. The inclusion of costly dental services in insurance plans poses a significant challenge for all parties involved in the insurance sector. This study aimed to investigate the challenges of covering dental services by complementary insurance in Iran during 2020-2021.

Materials and Methods

This qualitative research was conducted in Iran during 2020-2021. A triangulation of methods and data sources were employed to achieve a comprehensive perspective. In-depth semistructured interviews were conducted on an individual basis, and all national documents, rules, regulations, and instructions pertaining to complementary dental insurance were thoroughly reviewed. Purposeful sampling was used to select participants from all stakeholder groups engaged in dental insurance coverage, including (1) health system policymakers, (2) insurers, (3) policyholders, (4) care providers (dentists), and (5) insured people. Six open-ended questions were formulated to explore various facets of dental insurance, including (1) development, (2) management, (3) population coverage, (4) premium calculation, (5) services coverage, and (6) payment and reimbursement mechanisms. With the consent of the participants, all interviews were recorded and transcribed verbatim. The gathered data were evaluated using a framework analysis approach in the MAXQDA20 software. Finally, the primary themes, each encompassing multiple subthemes, were identified and presented.

Results

A total of 26 interviews were conducted with five groups of interviewees, and nine national documents were evaluated. Six themes were extracted, which included 18 codes from the interviews and seven codes from the documents. The extracted themes were as follows: (1) Insurance commitments and service coverage, (2) reimbursement system, (3) information system, (4) economic issues, (5) population coverage, and (6) regulation and supervision. The high cost of dental services was the most frequent challenge, followed by the insurance commitments and service coverage.

Conclusions

The delivery of dental services through complementary insurance in Iran primarily faces economic and service coverage challenges. The resolution hinges on the collaboration between basic and complementary insurance sectors, the development of a unified information system for insured individuals, and the implementation of a risk-adjusted premium plan.

Unravelling risk selection in Spanish general government employee mutual funds: evidence from cancer hospitalizations in the public health network

Government employees in Spain are covered by public Mutual Funds that purchase a uniform basket of benefits, equal to the ones served to the general population, from private companies. Companies apply as private bidders for a fixed per capita premium hardly adjusted by age. Our hypothesis is that this premium does not cover risks, and companies have incentives for risk selection, which are more visible in high-cost patients. We focus on a particularly costly disease, cancer, whose prevalence is similar among government employees and the general population. We compare hospitalisations in the public hospitals of the government employees that have chosen public provision and the general population. We analysed a database of hospital discharges in the Valencian Community from 2010 to 2015 (3 million episodes). Using exact matching and logistic models, we find significant risk selection; thus, in hospitalised government employees, the likelihood for a solid metastatic carcinoma and non-metastatic cancer to appear in the registry is 31% higher than in the general population. Lymphoma shows the highest odds ratio of 2.64. We found quantitatively important effects. This research provides indirect evidence of risk selection within Spanish Mutual Funds for government employees, prompting action to reduce incentives for such a practice. More research is needed to figure out if what we have observed with cancer patients occurs in other conditions.

Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Voluntary private health insurance, health-related behaviours and health outcomes: evidence from Russia

This paper contributes to the discussion around ex-post (increased utilisation of health care) and ex-ante (changes in health behaviours) moral hazard in supplemental private health insurance. Applying a range of methodologies to data from the Russian Longitudinal Monitoring Survey-Higher School of Economics we exploit a selection mechanism in the data to compare the impact of workplace provided and individually purchased supplemental health insurance on the utilisation of health care, on a range of health behaviours and on self-assessed health. We find compelling policy-relevant evidence of ex-post moral hazard that confirms a theoretical prediction and empirical regularity found in other settings. In contrast to other empirical findings though, our data reveals evidence of ex-ante moral hazard demonstrated by clear behavioural differences between those with self-funded supplemental health insurance and those for whom the workplace finances the additional insurance. We find no evidence that either form of insurance is related to improved self-assessed health.

What Are the Determinants of the Decision to Purchase Private Health Insurance in China?

The objective of this study was to assess the determinants of the decision to purchase private health insurance (PHI) in China. Nationally representative data from the fourth wave of the China Household Finance Survey from 2017 were used, and the dataset comprised 105,691 individuals aged 18 years or older. The Andersen health services utilization model was used to inform the research. Chi-square tests and logistic regression analyses were used to estimate the decision to purchase PHI. The proportion of the sample that had PHI was small, at 5.06%, but coverage for social basic medical insurance (SBMI) was 90.64%. Among PHI holders, the overwhelming majority (87.40%) also had SBMI. Logistic regression analysis demonstrated that predisposing factors (age, education, marital status, household size), enabling factors (household income, SBMI status, geographical factors, household medical expense, and medical debt), and needs-based factors (health status) were statistically significant determinants of the decision to purchase PHI. This study suggests that the socio-economic circumstances of households play a crucial role in the decision to acquire PHI. The findings may be used by the insurance industry to inform actions to enhance PHI coverage and by policy decision-makers that seek to improve equality in access to PHI.

The effect of a ban on gender-based pricing on risk selection in the German health insurance market

Starting from December 2012, insurers in the European Union were prohibited from charging gender-discriminatory prices. We examine the effect of this unisex mandate on risk segmentation in the German health insurance market. Although gender used to be a pricing factor in Germany's private health insurance (PHI) sector, it was never used as a pricing factor in the social health insurance (SHI) sector. The unisex mandate makes PHI relatively more attractive for women and less attractive for men. Based on data from the German socio-economic panel, we analyze how the unisex mandate affects the difference between women and men in switching rates between SHI and PHI. We find that the unisex mandate increases the probability of switching from SHI to PHI for women relative to men. On the other hand, the unisex mandate has no effect on the gender difference in switching rates from PHI to SHI. Because women have on average higher health care expenditures than men, our results imply a worsening of the PHI risk pool and an improvement of the SHI risk pool. Our results demonstrate that regulatory measures such as the unisex mandate can affect risk selection between public and private health insurance sectors.

Adjusting selection bias in German health insurance records for regional prevalence estimation

BACKGROUND

Regional prevalence estimation requires epidemiologic data with substantial local detail. National health surveys may lack in sufficient local observations due to limited resources. Therefore, corresponding prevalence estimates may not capture regional morbidity patterns with the necessary accuracy. Health insurance records represent alternative data sources for this purpose. Fund-specific member populations have more local observations than surveys, which benefits regional prevalence estimation. However, due to national insurance market regulations, insurance membership can be informative for morbidity. Regional fund-specific prevalence proportions are selective in the sense that the morbidity structure of a fund's member population cannot be extrapolated to the national population. This implies a selection bias that marks a major obstacle for statistical inference. We provide a methodology to adjust fund-specific selectivity and perform regional prevalence estimation from health insurance records. The methodology is applied to estimate regional cohort-referenced diabetes mellitus type 2 prevalence in Germany.

METHODS

Records of the German Public Health Insurance Company from 2014 and Diagnosis-Related Group Statistics data are combined within a benchmarked multi-level model. The fund-specific selectivity is adjusted in a two-step procedure. Firstly, the conditional expectation of the insurance company's regional prevalence given related inpatient diagnosis frequencies of its members is quantified. Secondly, the regional prevalence is estimated by extrapolating the conditional expectation using corresponding inpatient diagnosis frequencies of the Diagnosis-Related Group Statistics as benchmarks. Model assumptions are validated via Monte Carlo simulation. Variable selection is performed via multivariate methods. The optimal model fit is determined by analysis of variance. 95% confidence intervals for the estimates are constructed via semiparametric bootstrapping.

RESULTS

The national diabetes mellitus type 2 prevalence is estimated at 8.70% with a 95% confidence interval of [8.48%, 9.35%]. This indicates an adjustment of the original fund-specific prevalence from - 32.79 to - 25.93%. The estimated disease distribution shows significant morbidity differences between regions, especially between eastern and western Germany. However, the cohort-referenced estimates suggest that these differences can be partially explained by regional demography.

CONCLUSIONS

The proposed methodology allows regional prevalence estimation in remarkable detail despite fund-specific selectivity. This enhances and encourages the use of health insurance records for future epidemiologic studies.

Clinical burden of illness in patients with phenylketonuria (PKU) and associated comorbidities - a retrospective study of German health insurance claims data

BACKGROUND

Phenylketonuria (PKU) is an inherited deficiency in the enzyme phenylalanine hydroxylase (PAH), which, when poorly-managed, is associated with clinical features including deficient growth, microcephaly, seizures, and intellectual impairment. The management of PKU should start as soon as possible after diagnosis to prevent irreversible damage and be maintained throughout life. The aim of this study was to assess the burden of illness in PKU patients in general and in PKU patients born before and after the introduction of newborn screening in Germany.

METHODS

This retrospective matched cohort analysis used the Institut für angewandte Gesundheitsforschung Berlin (InGef) research database containing anonymized healthcare claims of approximately 4 million covered lives. PKU patients were compared with matched controls from the general population within the same database (1:10 ratio via direct, exact matching on age and gender without replacement). PKU patients were included if they were aged ≥18 years on 01/01/15 and were continuously enrolled from 01/01/10 to 31/12/15. The 50 most commonly reported comorbidities and 50 most commonly prescribed medications in the PKU population were analyzed. Differences between groups were tested using 95% confidence interval (CI) of prevalence ratio (PR) values.

RESULTS

The analysis included 377 adult PKU patients (< 5 of which were receiving sapropterin dihydrochloride) and 3,770 matched controls. Of the 50 most common comorbidities in the PKU population, those with a statistically significant PR > 1.5 vs controls included major depressive disorders (PR = 2.3), chronic ischemic heart disease (PR = 1.7), asthma (PR = 1.7), dizziness and giddiness (PR = 1.8), unspecified diabetes mellitus (PR = 1.7), infectious gastroenteritis and colitis (PR = 1.7), and reaction to severe stress and adjustment disorders (PR = 1.6). The most commonly prescribed Anatomical Therapeutic Chemical (ATC) subcodes among PKU patients (vs the control population) are for systemic antibacterials (34.7% vs 32.8%), anti-inflammatory and antirheumatic (29.4% vs 27.5%), renin-angiotensin agents (30.0% vs 27.0%), acid-related disorders (29.4% vs 20.2%), and beta-blockers (24.9% vs 19.9%).

CONCLUSION

The overall clinical burden on patients with PKU is exacerbated by a significantly higher risk of numerous comorbidities and hence, prescribing of the requisite medication, both for recognized (e.g. major depressive disorders) and more unexpected comorbidities (e.g. ischemic heart disease).

Retrospective analysis into differences in heart failure patients with and without iron deficiency or anaemia

Aims

The aim of this study was to assess the burden of heart failure (HF) patients with/without iron deficiency/iron deficiency anaemia (ID/A) from the health insurance perspective.

Methods and results

We conducted a retrospective claims database analysis using the Institut für angewandte Gesundheitsforschung Berlin research database. The study period spanned from 1 January 2012 to 31 December 2014. HF patients were identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision, German Modification codes (I50.‐, I50.0‐, I50.00, I50.01, I50.1‐, I50.11, I50.12, I50.13, I50.14, I50.19, and I50.9). HF patients were stratified into HF patients without ID/A and HF patients with ID/A (D50.‐, D50.0, D50.8, D50.9, and E61.1). HF patients with ID/A were stratified into three subgroups: no iron treatment, oral iron treatment, and intravenous iron treatment. A matching approach was applied to compare outcomes for HF patients without ID/A vs. HF patient with untreated incident ID/A without iron treatment and for HF patients receiving no iron treatment vs. oral iron treatment vs. intravenous iron treatment. Matching parameters included exact age, sex, and New York Heart Association functional class. An optimization algorithm was used to balance total health care costs in the baseline period for the potential matched pairs without sample size reduction. In total, 172 394 (4537.4 per 100 000) HF patients were identified in the Institut für angewandte Gesundheitsforschung Berlin research database in 2013. Of these, 11.1% (19 070; 501.9 per 100 000) were diagnosed with ID/A and/or had a prescription for iron medication in 2013. The mean age of HF patients was 77.0 years (±12.0 years). Women were more frequently diagnosed with HF (54.6%). HF patients with untreated incident ID/A (1.77%) had a significantly higher all‐cause mortality than HF patients without ID/A (33.1% vs. 24.1%, P < 0.01). The analysis of health care utilization revealed significant differences in the rate of all‐cause hospitalization (72.9% vs. 50.5%, P < 0.01). The annual health care costs for HF patients with untreated incident ID/A amounted to €17 347 with incremental costs of €849 (P < 0.01) attributed to ID/A.

Conclusions

Heart failure is associated with a major burden for patients and the health care system in terms of health care resource utilization, costs, and mortality. Our findings suggest that there is an unmet need for treating more HF patients with ID/A with iron medication.

Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency?

This article evaluates the performance of 3 industrialized nations that have pursued market-based financing models, focusing on equity in access to care, care quality, health status, and efficiency. It then assesses the consistency of the findings with those of different research teams. Using secondary data obtained from a semi-structured review of articles from 2000 to 2017, we discuss the hypothesis that commercial health care insurance is detrimental to accessing professional health care and to population health status. The results show that in 2010 the unmet care needs of both poor and rich Americans exceeded those of the poor in several industrial countries. The number of Dutch adults experiencing financial obstacles to health care quadrupled between 2007 and 2013, and 22% of Swiss adults reported skipping needed care in a 2016 survey. The most negative impacts of “managed care” on care quality are its tight constraints on physicians’ professional autonomy; a large reliance on the physicians’ material motivation; health service fragmentation; and the tendency to apply evidence-based medicine too rigidly. Countries with a commercial insurance monopoly generally remained above the maternal, infant, and neonatal mortality rates versus the health-spending regression line. We conclude that the most inefficient system is where the insurance market has achieved its maximal development and that care industrialization contributes to the comparatively poor performance of the U.S., Dutch, and Swiss health systems.

Fellowship and Subspecialization in Urology: An Analysis of Robotic-assisted Partial Nephrectomy

OBJECTIVE

To evaluate the impact of a urologic fellowship on physician case-volume and immediate patient outcomes, and to assess predictors of undergoing a robotic-assisted partial nephrectomy by a fellowship-trained (FT) urologist.

METHODS

We retrospectively reviewed all robotic (ICD-9 17.4) partial nephrectomies (PN; ICD-9 55.4) reported in the Statewide Planning and Research Cooperative Systems (SPARCS) database of New York State (NYS) from 2009 to 2014. Perioperative outcomes assessed included length of stay, 30-day readmission rates, 90-day readmission rates, and complication rates. Pearson chi-square tests were used to compare categorical variables, and unpaired Student t tests were used to assess continuous variables.

RESULTS

FT urologists performed 2199 (56%) RAPN during the study period, and nonfellowship trained (NFT) urologists completed 1700 (44%) RAPN. FT urologists performed more RAPN in teaching hospitals than NFT urologists (23% vs 7%). The average surgical volume per year for a FT urologist conducting RAPN was 9.6 ± 2.2 cases/y. NFT urologists had an average surgical volume of 7.2 ± 1.5 cases/y (P = <.0001). No significant difference was found in length of stay, 30- or 90-day readmission rate, or complication rate between the groups. RAPN conducted at teaching hospitals were more likely to be conducted by FT urologists. Patients who were self-payers were less likely to have a RAPN by FT urologists.

CONCLUSION

There were no differences for RAPN perioperative outcomes between FT urologists and their NFT peers. FT urologists perform a higher case-volume of RAPN in NYS, and this trend is increasing.

Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time.

How can the regulator show evidence of (no) risk selection in health insurance markets? Conceptual framework and empirical evidence

If consumers have a choice of health plan, risk selection is often a serious problem (e.g., as in Germany, Israel, the Netherlands, the United States of America, and Switzerland). Risk selection may threaten the quality of care for chronically ill people, and may reduce the affordability and efficiency of healthcare. Therefore, an important question is: how can the regulator show evidence of (no) risk selection? Although this seems easy, showing such evidence is not straightforward. The novelty of this paper is two-fold. First, we provide a conceptual framework for showing evidence of risk selection in competitive health insurance markets. It is not easy to disentangle risk selection and the insurers' efficiency. We suggest two methods to measure risk selection that are not biased by the insurers' efficiency. Because these measures underestimate the true risk selection, we also provide a list of signals of selection that can be measured and that, in particular in combination, can show evidence of risk selection. It is impossible to show the absence of risk selection. Second, we empirically measure risk selection among the switchers, taking into account the insurers' efficiency. Based on 2-year administrative data on healthcare expenses and risk characteristics of nearly all individuals with basic health insurance in the Netherlands (N > 16 million) we find significant risk selection for most health insurers. This is the first publication of hard empirical evidence of risk selection in the Dutch health insurance market.

Risk Selection under Public Health Insurance with Opt-Out

This paper studies risk selection between public and private health insurance when some, but not all, individuals can opt out of otherwise mandatory public insurance. Using a theoretical model, I show that public insurance is adversely selected when insurers and insureds are symmetrically informed about health-related risks, and that there can be adverse or advantageous selection when insureds are privately informed. Using data from the German Socio-Economic Panel, I find that (i) public insurance is, on balance, adversely selected under the German public health insurance with opt out scheme, (ii) individuals advantageously select public insurance based on risk aversion and residential location, and (iii) there is suggestive evidence of asymmetric information in the market for private health insurance. Copyright © 2016 John Wiley & Sons, Ltd.

Risk selection and heterogeneous preferences in health insurance markets with a public option

Conventional wisdom suggests that if private health insurance plans compete alongside a public option, they may endanger the latter's financial stability by cream-skimming good risks. This paper argues that two factors may contribute to the extent of cream-skimming: (i) degree of horizontal differentiation between public and private options when preferences are heterogeneous; (ii) whether contract design encourages choice of private insurance before information about risk is revealed. I explore the role of these factors empirically within the unique institutional setting of the German health insurance system. Using a fuzzy regression discontinuity design to disentangle adverse selection and moral hazard, I find no compelling support for extensive cream-skimming of public option by private insurers despite their ability to fully underwrite risk. A model of demand for private insurance supports the idea that heterogeneity in non-pecuniary preferences and long-term structure of private insurance contracts may be muting cream-skimming in this setting.

Who Opts out of the Statutory Health Insurance? A Discrete Time Hazard Model for Germany

The coexistence of social health insurance and private health insurance in Germany is subject to intense public debate. As only few have the opportunity to choose between the two systems, they are often regarded as privileged by the health insurance system. Applying a hazard model in discrete time, this paper examines the role of incentives set by the regulatory framework and the influence of individual personality characteristics on the decision to opt out of the statutory system. To address potential endogeneity of one of the key explanatory variables, an instrumental variable approach is also applied. The estimation results yield robust evidence on the choice of health insurance type that is consistent with pragmatic decision making, with both incentives set by regulation and personality traits as relevant determinants. Copyright © 2014 John Wiley & Sons, Ltd.