1 Risk adjustment as a tool to improve solidarity and incentives for cost containment under consumer cost sharing Richard van Kleef Second Health Policy Workshop November 9, 2011
2 Outline Background: cost sharing in health plans Limitations of traditional forms of cost sharing Risk adjustment as a solution Empirical illustration Discussion NB: arguments and illustrations are from two recent publications: Kleef, R.C. van, W.P.M.M. van de Ven, and R.C.J.A. van Vliet. (2011/2012). Riskadjusting the doughnut-hole to improve efficiency and equity, Inquiry, forthcoming. Kleef, R.C. van, W.P.M.M. van de Ven and R.C.J.A. van Vliet. (2009). Shifted deductibles for high risks: more effective in reducing moral hazard than traditional deductibles, Journal of Health Economics, 28:
3 Background The responsiveness of the demand for medical care to net price is beyond doubt (Zweifel and Manning, HHE 2000) Natural experiments, observational comparisons of individuals, and the RAND-experiment have shown that insurance leads to an increase in the demand for medical care (i.e. moral hazard). Many health insurance plans worldwide include some form of consumer cost sharing to counteract moral hazard. RAND-experiment: in health plans with cost sharing the total medical expenses per person were substantially lower (up to 31%) than in health plans with full insurance coverage. A shortcoming of traditional forms of cost sharing, however, is that they do not take into account individual variation in health.
4 The concept of a deductible Up to a certain amount (d) consumers pay their medical expenses themselves before the insurer starts reimbursement. Simplified graphical illustration:
5 Limitations of deductibles Limitation 1: Expected out-of-pocket expenses will be higher for the chronically ill than for the healthy. Limitation 2: Incentives for cost containment will be weak for the chronically ill.
6 Explanation of limitation 2 Newhouse (1993, page 81) argues: Consider someone with a deductible of $1,000 who has to decide whether to visit his doctor for a market price of $40 on the first day of the contract period. If he would know for sure that his total expenses in the contract period will not exceed $1,000, the perceived price of the visit equals the market price. However, if he would know for sure that his total expenses will exceed $1,000 (i.e., if he would anticipate free care later in the contract period), the perceived price of the visit equals $0.
7 Illustration: data Administrative data from a Dutch insurer on total medical expenses (for inpatient care, outpatient care and pharmaceuticals among others) in 1994 (year t) and drug prescriptions in 1993 (year t-1) for about individuals Individuals were classified as being chronically ill if they had had at least 4 drug prescriptions in 1993, related to one of the following diseases: psychosis, mood disorders, COPD, inflammatory disorders, heart disease, thyroid disorders, high cholesterol, gout, peripheral artery disease, glaucoma, epilepsy, high blood pressure, diabetes, gastric disorders, inflammatory bowel disease, chronic pain, rheumatism, Parkinson's disease, cancer, cystic fibrosis
8 Table 1. Mean and standard deviation (S.D.) of expenses, by health category Health category based on drug prescriptions in year t-1 Prevalence in year t (%) Mean of expenses in year t (euros) S.D. of expenses in year t (euros) None of health problems below ,109 3,869 Psychosis ,468* 5,556 Mood disorders ,743* 4,654 COPD ,113* 5,819 Inflammations ,405* 5,768 Heart disease ,720* 6,795 Thyroid disorders ,042* 7,537 High cholesterol ,024* 6,173 Gout ,084* 6,772 Peripheral artery disease ,488* 5,688 Glaucoma ,761* 6,668 Epilepsy ,083* 9,040 High blood pressure ,676* 9,981 Diabetes ,175* 8,388 Gastric disorders ,842* 10,208 Inflammatory bowel disease ,056* 9,338 Chronic pains ,167* 7,097 Rheumatism ,366* 12,995 Parkinson's disease ,910* 17,427 Cancer ,441* 17,681 Cystic fibrosis ,593* 18,750 Total ,674 5,450 * Statistically significant from the group of individuals with none of the 20 health problems (p.001)
9 Applying a deductible of 500 euro
10 Table 2. Applying a deductible of 500 euro Health category based on drug prescriptions in year t-1 Probability of exceeding deductible in year t Expected out-of-pocket expenses in year t (euros) None of health problems below Psychosis 0.53* 377* Mood disorders 0.65* 418* COPD 0.65* 432* Inflammations 0.61* 400* Heart disease 0.61* 416* Thyroid disorders 0.61* 406* High cholesterol 0.86* 478* Gout 0.85* 475* Peripheral artery disease 0.70* 433* Glaucoma 0.69* 441* Epilepsy 0.71* 443* High blood pressure 0.83* 470* Diabetes 0.85* 473* Gastric disorders 0.90* 481* Inflammatory bowel disease 0.75* 442* Chronic pains 0.81* 457* Rheumatism 0.91* 485* Parkinson's disease 0.96* 497* Cancer 0.96* 492* Cystic fibrosis 0.94* 486* Total * Statistically significant from the group of individuals with none of the 20 health problems (p.001)
11 Doughnut hole as a solution? After reaching a certain level of medical expenses (s), consumers face a gap (d) in coverage. Simplified graphical illustration:
12 Applying a doughnut hole of 500 euro Starting at the mean of annual expenses
13 Table 3. Applying a doughnut hole of 500 euro starting at 1,674 euro Health category based on drug prescriptions in year t-1 Starting point Prob. of reaching DH Prob. of exceeding DH Expected out-ofpocket expenses None of health problems below 1, Psychosis 1, * 0.27* 162* Mood disorders 1, * 0.34* 197* COPD 1, * 0.34* 194* Inflammations 1, * 0.36* 201* Heart disease 1, * 0.33* 184* Thyroid disorders 1, * 0.39* 206* High cholesterol 1, * 0.47* 262* Gout 1, * 0.49* 267* Peripheral artery disease 1, * 0.45* 254* Glaucoma 1, * 0.40* 228* Epilepsy 1, * 0.43* 235* High blood pressure 1, * 0.49* 278* Diabetes 1, * 0.64* 344* Gastric disorders 1, * 0.68* 369* Inflammatory bowel disease 1, * 0.53* 290* Chronic pains 1, * 0.70* 370* Rheumatism 1, * 0.74* 391* Parkinson's disease 1, * 0.90* 454* Cancer 1, * 0.82* 440* Cystic fibrosis 1, * 0.78* 411* Total 1, * Statistically significant from the group of individuals with none of the 20 health problems (p.001)
14 Proposal: Risk-adjusted doughnut hole Let the starting point of the doughnut hole increase with the individual expected expenses. For healthy individuals with low expected expenses the doughnut hole starts at a relatively low expenditure level For the chronically ill with high expected expenses the doughnut hole starts at a relatively high expenditure level
15 Where to locate the doughnut hole? Raising the starting point reduces the probability of exceeding the doughnut hole and, thereby, increases incentives for cost containment in area [0, s+d] (= effect 1) However, raising the starting point also reduces the probability of reaching the doughnut hole and, thereby, reduces incentives for containment in area [0, s] (= effect 2) The challenge is to find the starting point at which the first effect no longer dominates the second. Probably this point is to be found somewhere in the center of the individual s expenditure distribution where the uncertainty about reaching/exceeding the doughnut hole is highest. In our illustration we locate the doughnut hole such that for each health category the individual expected out-of-pocket expenses equal 250 euro.
16 Table 4. Applying a doughnut hole of 500 euro with a risk-adjusted starting point Health category based on drug prescriptions in year t-1 Starting point Prob. of reaching DH Prob. of exceeding DH Expected out-ofpocket expenses None of health problems below Psychosis Mood disorders 1, COPD 1, Inflammations 1, Heart disease 1, Thyroid disorders 1, High cholesterol 1, Gout 1, Peripheral artery disease 1, Glaucoma 1, Epilepsy 1, High blood pressure 1, Diabetes 2, Gastric disorders 3, Inflammatory bowel disease 2, Chronic pains 3, Rheumatism 4, Parkinson's disease 5, Cancer 4, Cystic fibrosis 11, Total
17 Compared to traditional deductibles and doughnut holes, risk-adjusted doughnut holes can improve both solidarity and incentives for cost containment Of course, there are some important issues for further research / consideration
18 Issue 1: data and risk adjusters Individual-level data on medical expenses and risk characteristics must be available. Several criteria need to be taken into account when selecting appropriate risk adjusters, e.g. measurability, validity and no possibilities for manipulation. NB: In the Netherlands data and appropriate risk adjusters are already used for the purpose of risk equalization.
19 Issue 2: criterion for locating the DH In our example we located the doughnut hole such that the expected outof-pocket expenses were equal across health categories. This criterion does not necessarily maximize the incentives for cost containment. Theoretically, a better criterion to maximize incentives for cost containment is the variance in expected out-of-pocket expenses A drawback of this alternative, however, is its complexity and the fact that it does not necessarily lead to equal expected out-of-pocket expenses This implies that the choice for a criterion requires a trade-off among incentives for cost containment, solidarity and simplicity.
20 Issue 3: level of differentiation The health categories in our empirical illustration are probably heterogeneous in terms of expected expenses. This implies that further differentiation i.e. taking into account more risk characteristics might further improve solidarity and incentives for cost containment. At the same time, however, further differentiation will reduce the transparency of the health plan. This implies that the level of differentiation requires a trade-off between solidarity and incentives for cost containment on one hand and transparency on the other.
21 Issue 4: will consumers understand? To achieve incentives for cost containment it is crucial that consumers understand how the cost-sharing concept works. Hsu et al. (2008) have shown that beneficiaries who were aware that their plan included a doughnut hole were more likely to report any cost response compared to the complementary group. Hsu et al. (2008) have also shown that consumer knowledge about cost sharing does not come naturally. This implies that some education might be desirable. It might also be wise to start off simple, e.g. to distinguish between just two risk groups.
22 Issue 5: risk-adjusted coinsurance rate Table 1 shows a positive relationship between the expected value and variance of expenses. This implies that even with a risk-adjusted doughnut hole the chronically ill have a lower probability that their expenses in the contract period end up somewhere in/around the doughnut hole than the healthy This implies that an interesting extension to a risk-adjusted starting point might be a risk-adjusted coinsurance rate.
23 Table 4. Applying a doughnut hole of 500 euro with a risk-adjusted starting point Health category based on drug prescriptions in year t-1 Starting point Prob. of reaching DH Prob. of exceeding DH Expected out-ofpocket expenses None of health problems below Psychosis Mood disorders 1, COPD 1, Inflammations 1, Heart disease 1, Thyroid disorders 1, High cholesterol 1, Gout 1, Peripheral artery disease 1, Glaucoma 1, Epilepsy 1, High blood pressure 1, Diabetes 2, Gastric disorders 3, Inflammatory bowel disease 2, Chronic pains 3, Rheumatism 4, Parkinson's disease 5, Cancer 4, Cystic fibrosis 11, Total
24 Issue 6: potential cost savings? How large will be the extra cost savings when replacing traditional deductibles/doughnut holes with risk-adjusted doughnut holes? Van de Ven and Schut (TPE 2010) simulate that replacing a traditional deductible of 165 euro by a risk-adjusted doughnut hole of 165 euro in the Netherlands would substantially increase the reduction in moral hazard. Further research is needed to examine the relationship between price sensitivity and ex-ante probabilities of reaching/exceeding coverage gaps.
25 Conclusion Cost sharing can benefit from risk adjustment in terms of solidarity and incentives for cost containment. It might be desirable to start off simple, e.g. by distinguishing just two groups. When technical requirements have been met and consumers are familiar with the concept solidarity and incentives for cost containment can be further improved by more detailed risk adjustment.
How Can We Bend the Cost Curve? Richard C. van Kleef Wynand P. M. M. van de Ven René C. J. A. van Vliet Risk-Adjusting the Doughnut Hole to Improve Efficiency and Equity An important goal of consumer cost-sharing
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