A more equal allocation of healthcare funds for patients who must pay high costs of care ensures the welfare of society. This study aimed to estimate the optimal co-insurance for outpatient drug ...costs for health insurance.
The research population includes outpatient prescription claims made by the Health Insurance Organization that outpatient prescriptions in a timely manner in 2016, 2017, 2018, and 2019 were utilized to calculate the optimal co-insurance. The study population was representative of the research sample.
At the secondary level of care, 11 features of outpatient claims were studied cross-sectionally and retrospectively using data mining. Optimal co-insurance was estimated using Westerhut and Folmer's utility model.
One hundred ninety-three thousand five hundred fifty-two individuals were created from 21 776 350 outpatient claims of health insurance. Because of cost-sharing, insured individuals in a low-income subsidy plan and those with refractory diseases were excluded.
Insureds were divided into three classes of low, middle, and high risk based on IQR and were separated to three clusters using the silhouette coefficient. For the first, second, and third clusters of the low-risk class, the optimal co-insurance estimates are 0.81, 0.76, and 0.84, respectively. It was equal to one for all middle-class clusters and 0.38, 0.45, and 0.42, respectively, for the high-risk class. The insurer's expenses were altered by $3,130,463, $3,451,194, and $ 1,069,859 profit for the first, second, and third clusters, respectively, when the optimal co-insurance strategy is used for the low-risk class. For middle risks, it was US$29,239,815, US$13,863,810, and US$ 14,573,432 while for high risks, US$4,722,099, US$ 6,339,317, and US$19,627,062, respectively.
These findings can improve vulnerable populations' access to costly medications, reduce resource waste, and help insurers distribute funds more efficiently.
Do insurance plans offered through the Marketplace implemented by the State of California under the Affordable Care Act restrict consumers' access to hospitals relative to plans offered on the ...commercial market? And are the hospitals included in Marketplace networks of lower quality compared to those included in the commercial plans? To answer these questions, we analyzed differences in hospital networks across similar plan types offered both in the Marketplace and commercially, by region and insurer. We found that the common belief that Marketplace plans have narrower networks than their commercial counterparts appears empirically valid. However, there does not appear to be a substantive difference in geographic access as measured by the percentage of people residing in at least one hospital market area. More surprisingly, depending on the measure of hospital quality employed, the Marketplace plans have networks with comparable or even higher average quality than the networks of their commercial counterparts.
This paper presents a lab-in-the-field experiment with 2111 Dutch homeowners in floodplain areas to examine the impacts of financial incentives and behavioral motivations for self-insurance under ...different flood insurance schemes. We experimentally varied the insurance type (mandatory public versus voluntary private) and the availability of a premium discount incentive for investing in flood damage mitigation measures. This set-up allowed us to examine the existence of moral hazard, advantageous selection and the behavioral motivations of individual agents who face these different insurance types, without the selection bias that makes a causal inference from survey studies problematic. The main results show that a premium discount can increase investments in self-insurance under both private and public insurance. Moreover, we find no support for moral hazard in our natural disaster insurance market, but we do find a substantial share of cautious people who invest both in private insurance as well as in self-insurance, indicating advantageous selection. The results have implications for the design of insurance schemes to cope with increasing natural disaster risks.
The aim of this study was to evaluate the concordance between claims records in the National Health Insurance Research Database and patient self-reports on clinical diagnoses, medication use, and ...health system utilization.
In this study, we used the data of 15,574 participants collected from the 2005 Taiwan National Health Interview Survey. We assessed positive agreement, negative agreement, and Cohen's kappa statistics to examine the concordance between claims records and patient self-reports.
Kappa values were 0.43, 0.64, and 0.61 for clinical diagnoses, medication use, and health system utilization, respectively. Using a strict algorithm to identify the clinical diagnoses recorded in claims records could improve the negative agreement; however, the effect on positive agreement and kappa was diverse across various conditions.
We found that the overall concordance between claims records in the National Health Insurance Research Database and patient self-reports in the Taiwan National Health Interview Survey was moderate for clinical diagnosis and substantial for both medication use and health system utilization.
This paper uses a unique panel data set of an insurer's transactions with repeat customers. Consistent with the asymmetric learning hypothesis that repeated contracting enables sellers to obtain an ...informational advantage over their rivals, I find that the insurer makes higher profits in transactions with repeat customers who have a good claims history with the insurer, the insurer reduces the price charged to these repeat customers by less than the reduction in expected costs associated with such customers, and repeat customers with bad claim histories are more likely to flee their record by switching to other insurers.
On Dec 6, 2023, the President of Tanzania Samia Suluhu Hassan passed into law the Universal Health Insurance Bill, an ambitious piece of legislation aimed at guiding the nation to achieve Universal ...Health Coverage, and protect its 60 million population from catastrophic health expenditures. ...many people in Tanzania's substantial informal-employment sector were not enrolled—only 15% of the population (around 9 million people) were covered by health insurance. The roll-out of universal health insurance will undoubtedly raise expectations for improved health services, he said, emphasising the need not only for “affordable basic minimum packages” that guarantee quality services while remaining accessible to all, but also investing in personnel, equipment, and infrastructure across the health-care landscape.
Purpose
This paper explores and identifies customer-value-related sacrifices that consumers attach to interactive health/life insurance. This paper aims to increase understanding of why individual ...consumers are not willing to embrace behaviour-tracking-based insurance applications.
Design/methodology/approach
The authors analysed data from a qualitative survey of Finnish insurance consumers who were not keen on adopting interactive insurance products.
Findings
Developed through thematic analysis, the framework presented in this paper illustrates consumers’ value sacrifices on four dimensions: economic, functional, emotional and symbolic value.
Research limitations/implications
The framework and insights emerging in the study hold several implications related to increased understanding of consumers’ perceptions of insurance and to developing interactive insurance services. In addition, this work provides a promising foundation and avenues for further considerations related to digital ethics in insurance.
Originality/value
To the best of the authors’ knowledge, this paper is the first piece applying a value sacrifice perspective in studying consumers’ unwillingness to adopt interactive insurance products.
The 'Seguro Médico Siglo XXI' (SMSXXI), a universal coverage medical insurance programme for children under 5 years of age, started in 2006 to help avoid catastrophic health expenditures in poor ...families without social security in Mexico. The study used information from the National Health Information System for the 2006-14 period. An ecological approach was followed with a panel of the 2457 municipalities of Mexico as the units of analysis. The outcome variables were the municipality-level neonatal mortality and infant mortality rates in population without access to social security. The programme variable was the coverage of the SMSXXI programme at the municipality level, expressed as a proportion. Demographic and economic variables defined at the municipality level were included as covariates. Impact was estimated by fitting a fixed-effects negative binomial regression model. Results reveal that the SMSXXI significantly reduced both infant and neonatSal mortality in the target population, although in a non-linear fashion, with minimum mortality levels found around the 70% coverage range. The effect is mostly given by the transition from the first quintile to the fourth quintile of coverage (<13% vs 70.5-93.7% coverage), and it is attenuated significantly at coverage levels very close to or at 100%. The observed risk reduction amounted to an estimated total of 11 358 infant deaths being avoided due to the SMSXXI during the 2006-14 period, of which 48% were neonatal. In conclusion, we found a significant impact of the SMSXXI programme on both infant mortality and neonatal mortality. An attenuation of the effect of the insurance on mortality rates at levels close to 100% coverage may reflect the saturation of health units in detriment of the quality of care.
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