政府购买医疗保障服务政策下商业健康保险的盈利模式

新医改提出政府向商业健康保险公司购买医疗保障管理服务的思路,为私营医疗保险市场的进一步发展提供了政策支持。但医改方案公布后,除人保健康进入这一市场外,其他公司仍举旗观望,提供该类服务的公司寥寥无几。这一困境出现的原因是保险机构对政府购买经办服务政策下,相关产品组合的盈利模式缺乏认识。对可得的有限数据进行分析,期望总结中...     

COST EFFICIENCY IN AUSTRALIAN GENERAL INSURERS: A NON-PARAMETRIC APPROACH

Data envelopment analysis is used to calculate pure technical, scale, allocative and cost efficiency indices for a sample of forty-six Australian general insurers. The inputs used are labour, physical capital (in the form of both information technology and plant and equipment), and financial capital. The outputs are net premium revenues for housing-related, transport-related, indemnity-related, mortgage-related, and other insurance, along with invested assets. The results indicate that the major source of overall cost inefficiency would appear to be allocative inefficiency rather than technical inefficiency and that the largest 20% of insurers are significantly more efficient than the remaining firms. A second-stage analysis uses limited dependent variable regression techniques to relate efficiency scores to firm-specific information. Cost efficiency appears to be closely related to asset size but not to stock exchange listing or product diversification or specialization.     

Health insurance--a challenge in India

In India, indemnity health insurance started about 3 decades ago. Mediclaim was the most popular product. Indian insurers and multinational companies have not been enthusiastic about starting health insurance in spite of the availability of a good market because health insurers have historically incurred losses. Losses have been caused by poor administration. Because it is a small portion of their total businesses, insurers have never tried sincerely to improve deficiencies or taken special interest. Hospital management and medical specialists have the spirit of entrepreneurship and are prepared to learn quickly and follow managed care principles, though they are not currently practiced in India. Actuarial data from the health insurance industry is sparse, but data from alternative sources will be helpful for starting managed healthcare. In my opinion, if properly administered, a "limited" managed care product with appropriate precautions and premium levels will be successful and profitable and will compete with present indemnity products in India.     

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.     

Medical savings accounts: why do they work?

This article analyzes and reviews the cost and design characteristics of medical savings accounts (MSAs). By placing premium savings from high-deductible health insurance in medical savings accounts, individuals have an incentive to shop for medical services. A more market-oriented health insurance and delivery system results, as individuals are now both users and buyers of health care. Data show that most families would accumulate balances in their MSAs that may be used for future medical expenses or savings. Through program design, the potential problems of adverse selection and cost to risk can be greatly reduced.     

Health insurers' use of quality improvement expenses to achieve a minimum medical loss ratio requirement

Health insurer medical loss ratios (MLRs) are the percentage of premium dollar spent on medical claims and healthcare quality improvement expenses (QIEs). QIEs include activities to improve patient health outcomes and safety, reduce medical errors, and prevent hospital readmissions. The Affordable Care Act mandates minimum MLRs in certain health insurance markets lest rebates be paid to policyholders. QIEs are reported in all markets regardless of whether that market is subject to minimum MLR requirements. Using health insurer statutory filings for a sample of group market insurers from 2010 to 2018, we employ a mixed regression discontinuity/regression kink approach to evaluate whether QIEs are used by insurers as a potential strategy for meeting the minimum MLR requirement. We show that health insurers' QIE increase in the loss ratio until meeting the minimum MLR requirement, have a significant discontinuous jump at the threshold, and decrease above the threshold after the introduction of the MLR mandate.     

On the Economics of Postassessments in Insurance Guaranty Funds: A Stakeholders’ Perspective

This article proposes a model that suggests there are contagion effects among members of an insurance guaranty fund when postassessments are charged to all other insurers upon the failure of a member company. Indeed, these extraordinary payments are shown to increase the default rate of other firms in the industry, ultimately lowering the value of corporate claims as well as government tax claims. The model is also used to examine the efficiency of different recoupment mechanisms (both existing and new) used by regulators and insurers to potentially reduce these contagion effects. Analysis allows us to stipulate the conditions under which a “tax carryforward” provision could be more efficient than the usual recoupment mechanisms known as “premium rate surcharge” and “premium tax credit.”     

The Health Insurance Reform Debate

This article provides an overview of the U.S. health care reform debate and legislation, with a focus on health insurance. Following a synopsis of the main problems that confront U.S. health care and insurance, it outlines the health care reform bills in the U.S. House and Senate as of early December 2009, including the key provisions for expanding and regulating health insurance, and projections of the proposals' costs, funding, and impact on the number of people with insurance. The article then discusses (1) the potential effects of the mandate that individuals have health insurance in conjunction with proposed premium subsidies and health insurance underwriting and rating restrictions, (2) the proposed creation of a public health insurance plan and/or nonprofit cooperatives, and (3) provisions that would modify permissible grounds for health policy rescission and repeal the limited antitrust exemption for health and medical liability insurance. It concludes by contrasting the reform bills with market-oriented proposals and with brief perspective on future developments.     

Health insurers' operations in the face of health care reform: An analysis of the Supplemental Health Care Exhibit

The Patient Protection and Affordable Care Act (ACA) introduced significant changes to the health insurance marketplace in the United States. The act also imposed reporting requirements on insurers. The law has required insurers since 2010 to file yearly the Supplemental Health Care Exhibit (SHCE). The SHCE provides unique information on how health insurers operate. We analyze data in the SCHE to understand how insurers have complied with one of the major new regulations affecting health insurers' operations arising from the ACA—the Medical Loss Ratio (MLR) Provision. This requires that insurers spend a minimum percentage of their premium revenue on medical claims, quality improvement expenses, and deductible fraud and abuse detection and recovery expenses. Our analysis of the 2010–2017 SHCE indicates that insurers' underwriting performance worsened in the early years of the ACA as they worked to increase MLRs to become ACA‐compliant. Analysis of the SHCE further reveals that insurers' profits from managing uninsured plans grew as the profitability of underwriting insured plans decreased. Future research on health insurer operations is warranted. The currently underutilized and data‐rich SHCE provides unique information that makes future research possible.     

农村小额养老保险需求影响因素的实证分析

本文利用607户农户样本数据,基于Lewis的寿险需求理论和Logistic模型,分析了影响农村小额养老保险需求的人口、社会和经济因素。研究结果显示:尽管经济收入提高,大多数农户仍主要选择"自我储蓄养老"的方式,只有少部分农户选择购买传统养老保险。农村小额养老保险作为新型农村养老保险制度的有益补充,建议参照国外小额保险运作机制,通过政府搭台宣传并提供补贴,由保险机构采用专业化管理,以降低政府经营成本,实现农户、政府和保险公司的"多赢"。     

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.     

论互助保险公司在法国医疗保险制度中的作用

法国的医疗保险制度较好的保障了法国人民的健康状况和生活质量,在世界上享有良好的声誉。本文在介绍了法国医疗保险的财政支持的基础上,分析了互助保险公司在法国医疗保险制度运行中所发挥的重要作用,并以MGEN（法国最大的互助保险公司）为例,介绍了其建立原则、历史沿革、经济模型、覆盖的医疗服务及其发展的评估,探讨了其完善和促进法国卫生保障事业的功效,同时也缓和了社会不平等现象。基于互助保险公司非盈利、联盟和责任感的价值观,MGEN还在眼科医疗方面提供更多的服务。     

Health Benefit Downward Rigidity: Employers’ Responses to Rising Insurance Costs

The article examines employers’ responses to rising insurance costs using Census Bureau Medical Expenditure Panel Survey–Insurance Component data from 1997 to 2005. The findings confirm that employers did not take dramatic actions to reduce benefit in response to the rising insurance cost during our study period. Most employers did not drop health insurance coverage, reduce workers’ eligibility for insurance, or substantially scale back their health insurance coverage. Instead, companies controlled the insurance cost in more subtle ways by adopting cost‐efficient health plans and requesting employee contribution to the insurance premium and out‐of‐pocket expenses for medical treatments. Our results show that the effect of those tactics was limited. The share of employee spending did not rise along with the growth of insurance premiums. Employers absorbed a large portion of the increased insurance cost.     

Relate hospital charges to use of services.

Despite their constantly rising charges that provoke government regulators and insurance companies to impose "caps," hospitals and other health care institutions continue to use antiquated cost control systems. This author describes a new accounting system, based on the amount of care each patient needs, that has been in use at Massachusetts Eye and Ear Infirmary for six years. In this system, basic "clinical care units" (determined by a peer review process and in collaboration with third-party payers) establish the acceptable standard for a given diagnosis. With charges and reimbursement based more directly on the labor and services involved, hospitals can plan more efficient use of nursing staff and other personnel and services. Use of established norms for each diagnosis also helps staff and third-party insurers determine when hospital resources are being used most productively.     

我国社区卫生服务发展的现状、问题和对策

完善社区卫生服务是解决我国医疗卫生体制看病难、看病贵的重要举措,是完善基本医疗保险制度改革的关键。然而,当前我国社区卫生服务却存在着服务功能缺失、同基本医疗保险结合程度低、配套措施不完善、政府资金投入不足等问题。对此,需要政府及有关部门出台政策、积极扶持,解决制约社区卫生服务的瓶颈问题,促进社区卫生服务的发展。     

On the medical loss ratio (MLR) and sticky selling general and administrative costs: Evidence from health insurers

The Patient Protection and Affordable Care Act of 2010 (ACA) imposed an important constraint on health insurers: if the medical loss ratio (MLR), determined as the ratio of claims paid to premiums collected, declined below certain legislative targets, the insurer would be obliged to rebate a portion of the premiums to the customer. It might be expected that this increase in the MLR would result in a decrease in premium dollars available to cover selling, general and administrative costs (SG&A) and a concomitant decrease in profits. However, there is earlier evidence that SG&A “cost stickiness” presents a counter-effect in this instance: namely, that an increase in SG&A costs per each dollar of revenue increase is more than the magnitude of a decrease in SG&A costs per each dollar of revenue decrease. In this context, this paper offers the first preliminary evidence of the impact of the MLR regulatory change on SG&A cost stickiness in the health insurance industry.Applying the Anderson et al. (2003) methodology, our sample of publicly-traded health insurers shows evidence of significant mitigation of the SG&A cost stickiness after the implementation of the ACA medical loss ratio rules and that in periods of revenue declines, SG&A costs decreased more significantly post-ACA than pre-ACA. These results further illustrate the tension created by regulatory policy designed to improve healthcare cost efficiency and its impact on the profit seeking activities of for-profit healthcare enterprises. Thus, this paper contributes to both healthcare and accounting literature by documenting a significant effect of regulatory policy on managerial decisions regarding cost control.     

Competition leverage: how the demand side affects optimal risk adjustment

We study optimal risk adjustment in imperfectly competitive health insurance markets when high‐risk consumers are less likely to switch insurer than low‐risk consumers. Insurers then have an incentive to select even if risk adjustment perfectly corrects for cost differences. To achieve first best, risk adjustment should overcompensate insurers for serving high‐risk agents. Second, we identify a trade‐off between efficiency and consumer welfare. Reducing the difference in risk adjustment subsidies increases consumer welfare by leveraging competition from the elastic low‐risk market to the less elastic high‐risk market. Third, mandatory pooling can increase consumer surplus further, at the cost of efficiency.     

How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013–2015 All-Payer Claims Data to 2004–2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost-sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost-sharing have higher levels of healthcare spending, controlling for past healthcare use. We estimate demand elasticities of total health care spending among this low-income population of approximately −0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost-sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.     

Cost efficiency and board composition under different takaful insurance business models

This study examines the link between cost efficiency and board composition in non-life takaful insurance firms operating in 17 Islamic countries using panel data for 2004–2007. Nonparametric data envelopment analysis (DEA) is used to compute cost efficiency scores and a second-stage logit transformation regression model is then employed to test the influence of corporate characteristics on these efficiencies. We find that average levels of cost efficiency in takaful insurance markets mirror the efficiency in developed non-life insurance markets. The relative influence of board composition, such as the proportion of non-executive directors on the board, on the cost efficiency of takaful insurers depends on its interaction with other firm-specific characteristics such as board size. Hence, the effect of corporate governance systems on the cost efficiency of takaful insurers can be complicated by various firm-specific factors. Our results could have important commercial and policy implications.     

The Cost of Duplicative Regulation: Evidence From Risk Retention Groups

A vast majority of insurers are regulated by each state in which they conduct business; however, a small subset of specialized firms, risk retention groups (RRGs), are largely exempt from most aspects of duplicative regulation no matter how many states they operate. This article analyzes the differences between RRGs and standard insurers specializing in commercial liability insurance to determine the cost of duplicative regulation. The costs associated with multi‐state regulation are significantly higher than those for single‐entity regulation. These high regulatory compliance costs reduce the technical efficiency of firms, deter firms from operating in additional states, and increase the price of insurance.