Evaluation of deductibles in health insurance

Transcription

1 Evaluation of deductibles in health insurance The case of the Netherlands Second Health Policy Workshop Incentives in health insurance: the role of cost sharing Utrecht, 9 November 2011 Dr. Wija Oortwijn

2 Outline Dutch health care system and health insurance Evaluation of the introduction of a deductible in Dutch health care Methods Results Discussion

3 The Dutch health care system GP-gatekeeper system Health insurance before 2006 was a mixture of: mandatory public insurance (67%) voluntary private insurance (33%) From 2006: mandatory private insurance (100%) competition between health insurance companies and between health providers on quality still much (detailed) government regulation: insurance, drug licences, prices, quality, patient rights

4 Is going Dutch the answer? Free GP services for everyone, free healthcare for the under 18s and prescription medicines that don t cost a penny. This isn t Nirvana it s the Dutch health system The Irish Times - Tuesday, February 15, 2011

5 Mandatory deductible 2008: Mandatory deductible (18+) for all health care costs except GP, obstetrics, maternal care and dental care (<21) Purposes: shifting a greater share of health care expense and responsibility onto consumers make consumers of care cost-conscious Compensation for specific groups (chronically ill, handicapped) Can be used by health care insurers to steer clients, e.g. to preferred health care providers

6 Evaluation Requested by Parliament Research questions: What are the effects on health care consumption? What are the financial effects? What kind of information do health insurers provide to their clients? Are GPs and Dutch citizens aware of the deductible? How is the policy measure executed; and how much are the related costs? Do health insurers use the deductible to steer their clients?

7 Project team and final report Ecorys (main contractor): Sandra Adamini, Marcel Canoy, Arthur ten Have, Wija Oortwijn, Vincent Thio, Mathijn Wilkens Berenschot (focused on execution of policy measure): Piet de Bekker, Arjo Boendermaker Report (in Dutch) can be downloaded at: n-en-publicaties/kamerstukken/2011/06/10/brief-aande-tweede-kamer-over-evaluatie-verplicht-eigenrisico.html

8 Methods used Desk research Data analysis looking for a natural experiment Interviews (n=50) with relevant stakeholders Survey of GPs (n=810) General population (n=1398) Health insurers (n=11)

9 What are the effects on health care consumption and the financial effects of the deductible that was introduced in 2008?

10 Land mark study in cost sharing RAND: Health Insurance Experiment (HIE) Randomized experiment between 1971 and 1982 HIE remains the only long-term study of cost sharing and its effect on service use, quality of care, and health Cost sharing reduced the use of nearly all health services, did not significantly affect the quality of care and did not have adverse effects on participant health, with a few exceptions

11 Out-of-pocket health expenditure as a share of final household consumption (2008) OECD Health Data 2010

12 Recent public discussion of cost sharing in NL NL: relatively small share of out-of-pocket expenses in total health expenditure (OECD, 2010) CPB (2004, 2006, 2008): financial effects of deductible were estimated between 60 to 100 million euro Based on model and existing price elasticity Method used in our evaluation differs from existing work

13 Looking for a natural experiment Problem is: health insurance applies to everyone deductible applies to everyone above 18 no-claim measure before 2008 no control group: no comparison over time and/or between groups

14 Approach Data used: annual health care consumption on individual level Also, included: type of health care age sex region... Analysis excluded people with excessive health care costs (chronically ill)

15 Deductible only for 18+ Treatment group - 17 in 2007, 18 in No deductible/noclaim in 2007, deductible in 2008 Control group in 2007, 1517 in No deductible/noclaim in 2007 and in 2008 Compare control and treatment group over time: control for exogenous variation between individuals (e.g. sex, region, income) and over time (e.g. price changes)

16 Hypothesis

17 Results Change in health care consumption would have been between 2,6 and 7,3 percentage points higher without deductible Extrapolation to whole population shows that this can be translated into an effect of 275 to 772 million euro (i.e. avoided health care cost) Shifting health care expenses from public to consumers (private) is estimated to be 1,3 billion euro

18 Limitations of the analysis Results are not exact due to assumptions Analysis is limited to 1518 years old Different health care consumption (level, type) Different price elasticity Not all health care costs are included Conclusions should be for whole population

19 Are Dutch citizens aware of the deductible?

20 The devil is in the details The information provided to Dutch citizens, e.g. by health insurers, is sufficient The majority of the Dutch insured are aware of the deductible, however: They do not exactly know for which health care services the deductible applies 26% believes that the deductible applies for GP

21 Do health insurers use the deductible to steer their clients?

22 Limited use of policy measure by health insurers Health insurers can decide that clients do not have to pay the deductible if they make use of preferred providers, medicines, medical devices or prevention programmes Some insurers stopped using the policy measure due to negative views of patients Those who use it, use it especially for services with clear evidence on price and quality Is it possible to steer patients using financial incentives?

23 Effectiveness of the policy measure Health insurers find it difficult to explain the policy measure to their clients Most citizens are not aware that health insurers can use the policy measure for steering purposes GPs seem to play a bigger role in steering patients than financial incentives

24 Reaction of Minister to Parliament re evaluation Letter of June 10, 2011 Deductible is an effective instrument it does what it is supposed to do! Improvements are targeted at providing information to the citizens, its execution and the use of the policy measure to steer patients (A higher) deductible will lead to a sustainable health care in the long term

25 THANK YOU!