Regulating health insurance: the challenges of managed networks

The role of the regulator in health insurance is examined in the context of the change in nature of regulatory oversight necessary to monitor the activities of the regulated parties. Health insurance to this point has been largely regulated by insurance departments that have historically focused on monitoring the solvency and meeting the contractually required reimbursements for indemnity carriers. Now as the indemnity carrier has either migrated to managed care or faced a declining book of business, the historic role of regulation must change to match the new environment. This article examines the role of the health insurance/managed care regulator department under this new paradigm and identifies where and how the regulator can exert influence in such a system.     

Die Marktabgrenzung im Versicherungskartellrecht am Beispiel der Berufshaftpflichtversicherungen

The definition of the relevant market is crucial to the application of European and German competition law and especially difficult when dealing with insurance markets. Generally, the product and geographic market comprises all products or services that are regarded as substitutable by consumers. In addition, the supply-side substitutability can be taken into consideration. In defining insurance product markets, the supply-side substitutability is decisive, because insurance products are seldom interchangeable from a policy holder’s point of view. Applying the concept of supply-side substitutability to professional indemnity insurances leads to product markets correlating with the different professional groups: Indemnity insurances for physicians constitute a product market; insurances for lawyers, notary publics, tax advisers and public accountants form another market and insurances for architects and construction engineers another one. These product markets are still national markets. Professional indemnity insurances are extensively shaped by the differing legal systems, namely by national insurance contract law, by liability provisions and by a legal obligation to insure. Consequently, policy holders cannot substitute their indemnity insurance with foreign insurance products and insurers are confronted with market entry barriers. However, the proposed directive on services on the internal market and the adopted directive on insurance mediation could result in community-wide markets in the near future.     

A Comparison of HMO Efficiencies as a Function of Provider Autonomy

Current debates in the insurance and public policy literatures over health care financing and cost control measures continue to focus on managed care and HMOs. The lower utilization rates found in HMOs (compared to traditional fee‐for‐service indemnity plans) have generally been attributed to the organization's incentive to eliminate all unnecessary medical services. As a consequence HMOs are often considered to be a more efficient arrangement for delivering health care. However, it is important to make a distinction between utilization and efficiency (the ratio of outcomes to resources). Few studies have investigated the effect that HMO arrangements would have on the actual efficiency of health care delivery. Because greater control over provider autonomy appears to be a recurrent theme in the literature on reform, it is important to investigate the effects these restrictions have already had within the HMO market. In this article, the efficiencies of two major classes of HMO arrangements are compared using “game‐theoretic” data envelopment analysis (DEA) models. While other studies confirm that absolute costs to insurance firms and sponsoring companies are lowered using HMOs, our empirical findings suggest that, within this framework, efficiency generally becomes worse when provider autonomy is restricted. This should give new fuel to the insurance companies providing fee‐for‐service (FFS) indemnification plans in their marketplace contentions.     

Die Haftpflichtversicherung nach der VVG-Reform

The reform of the German Insurance Contract Act (Versicherungsvertragsgesetz, ?VVG“) also targets key aspects of third-party liability insurance. The changes go beyond the findings made by both the courts and legal authorities to date.Compulsory insurance aside, the law still provides that an injured third party has no standing to assert a claim directly against the tortfeasor’s liability insurer. The tortfeasor may assign its indemnity claim against the insurer solely to the injured third party and may no longer be precluded from doing so under the General Insurance Conditions (AVB). Consequently, the tortfeasor’s indemnity claim against the insurer effectively becomes a pecuniary claim. This is criticised by the insurance industry particularly with regard to eliminating the prohibition against acknowledgment and satisfaction of claims.In the future, third parties will be able to assert claims directly against the tortfeasor’s insurer and this will be the case for compulsory insurance across the board. Provisions currently in effect in the motor vehicle liability insurance industry will be carried over to the entire compulsory insurance sector. Compulsory insurance does permit agreements involving self-deductibles. However, such agreements are generally effective only as between the insurer and the tortfeasor inter se, i.e. they are not effective as against third parties — in contrast to valid disclaimers of risk.Another change in compulsory insurance is the hierarchy of claims for compensatory damages and relief in the event the insured amount is inadequate. Specifically, the hierarchy gives preference to individual claims of injured parties which are not otherwise covered, such as claims for pain and suffering.The prohibition against the retroactive loss of provisional coverage for failure to pay the first premium, which had been criticised primarily by motor vehicle liability insurers, has been omitted in the Government bill.     

不真正连带债务理论在保险活动中的应用——兼评“无责免赔”问题

保险活动中,保险人与其他责任人对同一损失同时负有补偿义务的情形时常发生,保险界对其如何处理至今尚未找到明确统一的、具有说服力的理论或者法律依据,以致于虽然《保险法》第60条对相关问题进行了规定,但保险实务中仍然出现了包括机动车保险中"无责免赔"这类被法院认定为无效条款的约定,交通事故人身损害赔偿纠纷中保险人也被不当地判决承担连带责任。将不真正连带债务理论应用于保险活动中,能够为保险竞合和包括保险人补偿义务在内的补偿义务竞合情形提供广为接受的处理方案,能够为保险条款和《保险法》的完善提供理论指导,能够为"无责免赔"争议和交通事故人身损害赔偿纠纷中保险人权利义务合理确定等现实问题的解决提供思路。     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”     

A proposal to apply the Kiwi-VAT to insurance services in the European Union

In the spirit of the European Commission’s call for a simpler, more robust and efficient VAT system, this article proposes to integrate exempt insurance services into the European VAT, and to abolish the discriminatory, excise-type insurance premium taxes levied by the various Member States. The current VAT exemption (no taxation of insurance services and no credit for the VAT on inputs) is administratively complex and economically distortionary. Instead, the value added of property and casualty insurance companies can be taxed on a transactions basis by applying the VAT to insurance premiums (creditable by VAT-liable businesses) and allowing a presumptive tax credit for the VAT imputable to payouts (plus a credit for the actual VAT on purchases). The presumptive tax credit should be taxed at the level of business recipients, but individuals would receive the VAT along with indemnity payments without having to file a return. Exceptionally, the tax-credit VAT would not be applied to life and health insurance premiums, but insurers would be taxed on an accounts basis on the sum of wages and business cash flow.     

Let's put consumers in charge of health care

Businesses spend billions on health insurance. And what do they get for their money? A lot of unhappy employees. Workers fret about the quality of the care they receive, the burden of their out-of-pocket expenses, and the gaps in their coverage. For businesses, health care has become a lose-lose proposition: They pay way too much, and they get way too little. The problem is that the health care industry has been shielded from consumer pressure--by employers, insurers, and the government. As a result, costs have exploded even as choices have narrowed. But if companies embrace a new model of health coverage--one that places control over both costs and care directly into the hands of employees--the competitive forces that spur productivity and innovation in consumer markets can be loosed upon the inefficient, tradition-bound health care system. Moving to consumer-driven health care requires that companies revamp their health benefits in six ways: Give employees incentives to shop intelligently; offer a real choice of insurance plans; charge employees prices that accurately reflect the company's costs; let providers set their own prices; adjust payments for each enrollee based on need; and provide relevant information. Putting consumers in charge of health care may seem like a radical approach. But individuals are highly motivated to educate themselves about their health, their insurance, and their care, and they want to seek the most value for their money. Promoting that economic dynamic--the same that fuels consumer markets everywhere--is the best way to enhance the health care industry's productivity and quality.     

An Exploratory Analysis of Insurer Groups

Grouping is a widespread and interesting phenomenon of the insurance industry, among both life‐health insurers and property‐liability insurers. Recognizing the potentially important implications of group membership for insurer behavior and characteristics, numerous academic researchers using insurance company data have included a dummy variable in their regression analysis to control for group membership. However, it has never been clear exactly what is being controlled for when such a variable is included. This article attempts to shed light on this question. Results indicate that group affiliated insurers tend to be larger than unaffiliated insurers, are more likely to be licensed in New York, are more likely to be stock firms than mutuals, and are likely to be less geographically concentrated.     

Health Care Reform,Efficiency of Health Insurers,and Optimal Health Insurance Markets

This research examines the efficiency of the U.S. health insurers. It shows that more insurers are less efficient than in the previous sample year; however, the results suggest that the federal health care reform has no significant effect on the overall efficiency of all insurers as a whole, which is very low but does not change much over time. This research explores how to improve the efficiency of the health insurance market by proposing state, regional, and national efficiency-based goal-oriented market models and an efficiency duplicating system, and it discusses important implications to the health care compacts, the health insurance exchanges or marketplaces, and the national multistate programs. It also analyzes further moves for efficiency enhancement with regard to payment methods and the health care delivery system. One interesting finding is that the Medicaid program is very efficient because it provides support to the offering of Medicaid coverage and further expansion, which enhances the health welfare of society with fewer resources inputs from the perspective of efficiency. This research should provide important insights for state and federal governments, policy makers, regulators, the health insurance industry, and consumers.     

评新《保险法》新增不可抗辩条款的修法价值与建议

2009年2月28日,新<保险法>颁布,其引入了不可抗辩条款.这一条款不仅能够规范保险人行为,保护投保方利益,更能适应国际惯例,提高我国保险人的竞争能力,迎接外资保险的挑战.本文回顾了不可抗辩条款的历史进程,并对其修法价值进行了陈述,最后立足国情,对不可抗辩条款在实际操作中提出了一些的建议.     

Equilibrium in Competitive Insurance Markets Under Adverse Selection and Yaari's Dual Theory of Risk

Under Yaari's dual theory of risk, we determine the equilibrium separating contracts for high and low risks in a competitive insurance market, in which risks are defined only by their expected losses, that is, a high risk is a risk that has a greater expected loss than a low risk. Also, we determine the pooling equilibrium contract when insurers are assumed non-myopic. Expected utility theory generally predicts that optimal insurance indemnity payments are nonlinear functions of the underlying loss due to the nonlinearity of agents' utility functions. Under Yaari's dual theory, we show that under mild technical conditions the indemnity payment is a piecewise linear function of the loss, a common property of insurance coverages.     

保险法损失补偿原则规范功能之重塑——以“禁止得利”向“充分补偿”之学说演进为中心

损失补偿原则的规范功能具有"二元性",即禁止被保险人不当得利和充分填补被保险人的损失。但在传统保险法理论和实践中,为了达到防范道德风险的功能,损失补偿原则完全被禁止不当得利原则所取代。随着保险技术与保险观念的进步,传统理论下的保险制度难以满足被保险人充分补偿需求并容易造成保险合同效率的低下,因此损失补偿原则规范之重心应完成从"禁止得利"向"充分补偿"的转变。在制度设计及保险合同中,应恰当缩减合同条款对补偿金额的限制、重视发展重置成本保险、重复保险中应完成分摊中按份责任向连带责任之转变、优先实现被保险人的剩余损害赔偿请求权,以更全面保障被保险人的利益。     

Spillover effects of increased health insurance enrollment on workers’ compensation insurance

The Patient Protection and Affordable Care Act (ACA) was designed to increase the accessibility and affordability of health insurance. While the ACA did not contain direct provisions related to workers’ compensation (WC), because health‐related coverage is a significant portion of WC costs, the ACA could have unintentionally impacted the WC market. Specifically, expanded health insurance enrollment could reduce WC losses and result in higher performance among insurers participating in the WC market. Using insurer‐state level data, we consider the impact of increased health insurance enrollment on the performance of property‐casualty (PC) insurers. Utilizing multiple measures of performance, we find that the post‐ACA period is generally associated with greater profitability for PC insurers operating in the WC market, a positive unintended consequence of this federal regulation.     

Unfair Discrimination and Homeowners Insurance Availability: An Empirical Analysis

There has been an active public policy debate about the availability and cost of homeowners insurance in urban markets, and insurers have been charged with intentional discrimination, or redlining, against minority buyers and neighborhoods with a large proportion of minority population. Studies of relative price, loss costs, agency location, and product quality have attempted to determine whether insurers unfairly discriminate against minority homeowners in urban areas. This study focuses on insurance availability, and examines whether there is a systematic difference in the breadth of insurance coverage in the market that corresponds to the proportion of minority residents in a state. The market share of dwelling fire insurance polices across states for years 2000 and 2003 is analyzed, and evidence is presented that shows a positive correlation between the proportion of minority homeowners in a state and the share of more restrictive dwelling fire policies. However, this difference is not statistically significant once other risk-related and economic factors are included in the analysis.     

Determinants of International Insurers' Participation in Foreign Non-Life Markets

Mirroring the trend in the broader marketplace, the global insurance industry is steadily moving toward increased liberalization and deregulation. This study seeks to develop the first empirical model that examines the importance of foreign market characteristics as they relate to the participation of international insurers in the non‐life business of those countries. The analysis reveals that market structure is an important factor in determining whether international insurers participate in a given foreign market. In addition, for markets that are not competitive, removing trade barriers would significantly improve the desirability of those countries as host markets. The results also suggest that countries with higher gross domestic product tend to attract more involvement from international insurers. While this research focuses on the markets of industrialized countries, the findings will provide significant implications for those emerging markets that have not yet collected relevant data on a number of the variables included in this study.     

Finding a lasting cure for U.S. health care

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.     

Insurance Redlining and Disparate Impact: The Application of a Federal Civil Rights Doctrine to Homeowners Insurance

ABSTRACT: Allegations of inner-city insurance redlining are increasingly facilitated through the jurisprudence of "disparate impact," a legal doctrine holding that a policy or practice based on race-neutral criteria may nevertheless constitute illegal discrimination if it has a disproportionate adverse impact on racial minorities or women. Disparate impact analysis would require insurers to document a precise cause-and-effect relationship between a challenged underwriting variable and its associated risk. Moreover, they would be required to show that no "less discriminatory" risk-assessment technique is available. If it is not possible—or too costly—to meet this burden, insurers will have no choice but to abandon the use of those risk-selection practices and cost-based pricing mechanisms that yield a disparate racial impact. This will result in higher premiums and less insurance availability for consumers. Furthermore, dubious charges of unfair discrimination will exacerbate racial tensions and divert attention from the social and economic pathologies of which insurance costs are merely symptomatic.     

The Determinants of Financial Health of Asian Insurance Companies

Previous studies of financial health of insurance companies are mainly focused on insurers operating in the United States and developed economies. This article focuses on the solvency of general (property‐liability) and life insurance companies in Asia using firm data and macro data separately. It uses different classification methods to classify the financial status of both general and life insurance companies. With the exception of Japan, failures of insurers in Singapore, Malaysia, and Taiwan are nonexistent. We find that, first, the factors that significantly affect general insurers' financial health in Asian economies are firm size, investment performance, liquidity ratio, surplus growth, combined ratio, and operating margin. Second, the factors that significantly affect life insurers' financial health are firm size, change in asset mix, investment performance, and change in product mix, but the last three factors are more applicable to Japan. Third, the financial health of insurance companies in Singapore seems to be significantly weakened by the Asian Financial Crisis. As the insurance industry in different Asian economies is at different stages of development, they require different regulatory guidelines.     

“Bounds for Ruin Probabilities in the Presence of Large Claims and their Comparison”, Vladimir Kalashnikov,April, 1999

Abstract

Performance measurement systems and report cards which attempt to measure and report the quality of care provided by managed health-care organizations, have become mainstream in health insurance markets as managed care penetration continues to increase. However, little is known about the impact formal plan evaluations have on the contracting and enrollment decisions made by health insurance purchasers and consumers. Information regarding the link between performance evaluations and enrollment is crucial for those charged with projecting future enrollments in and risk profiles of managed care organizations. This paper describes the performance measurement systems currently being used to evaluate managed care plans and reviews the empirical literature for evidence regarding the impact of measures on plan enrollments.