Why a new malpractice crisis is coming

This article predicts escalating premiums and a greater risk of malpractice suits based on the increasing frequency and cost of claim payouts. The number of insurance claims increased by 12% in 1978 after a decrease of 11% in 1976 and by 2% in 1977. The percentage of premium income paid out has followed the same pattern. It was a high of 66.5% in 1975 and then fell into the 40% range in the next two years. Last year it bounced back to 60.6%. Some insurance authorities view the 1976-77 drop in claims as artificial and attribute it to a reluctance to file suits during the period immediately following new malpractice laws. The reluctance to sue has apparently relaxed. About 16% of the cases actually go to court. Out of those, 90% of the verdicts favor doctors. The rise in cases going to court shows that reform! legislation passed in several states to reduce malpractice litigation is not yet working. The average payout was up 20% between 1976 and 1978 with the greatest rise in large awards; million-dollar settlements are not uncommon. Escalating payouts are attributed to general inflation anf rising medical costs. In addition, the public has become better medically informed and been taught that for every wrong ther is a remedy.     

The effect of state health insurance benefit mandates on premiums and employee contributions

The average US state has 40 benefit mandates, laws requiring health insurance to cover particular conditions, treatments, providers or people. We investigate the extent to which these mandates increase the health insurance premiums paid by employers, and the extent to which these higher premiums are passed on to employees in the form of higher employee contributions. We use state-level data on premiums and employee contributions to health insurance from the insurance component of the 1996–2011 Medical Expenditure Panel Survey. Our main analysis is a fixed effects regression that controls for age, race, income, union membership and the presence of state mandate waivers. We find robust evidence that the average mandate increases premiums by approximately 0.6%, and that mandates lead to similar increases in employee contributions for single-coverage health insurance plans. Alternative specifications using an AR(1) error structure estimate a larger effect of mandates, while those using generalized estimating equations estimate smaller effects. We find that mandates requiring insurers to cover a specific benefit, as opposed to a specific type of provider or person, lead to the largest increases in employee contributions.     

Impact of hospitalist care on hospital malpractice premiums using California hospital data

This study assessed the impact of hospitalist care on hospital malpractice premiums. The retrospective cohort study used hospital financial data from the California Office of Statewide Health Planning and Development and the annual hospital survey conducted by the American Hospital Association. The sample included 1000 California hospitals from 2006 to 2010. The effect of hospitalist care on hospital malpractice premiums was evaluated using generalized estimation equation models with log link normal distribution after controlling for hospital and market characteristics, patient utilization and staffing patterns. In multivariable analyses, hospitals with more full-time hospitalists per average daily census were associated with lower malpractice insurance premiums. For example, a one-hospitalist increase per 100 daily censuses resulted in a 5.1% reduction in malpractice insurance premiums. Hospitalist care was associated with a reduction in malpractice insurance expenses. The data reveal that hospitalist care is more efficient and effective in patient treatment and preventing complications. The improved efficiency may reduce malpractice insurance expenses.     

Broker monitoring of premium adequacy: the role of contingent commissions

Contingent commissions, which are payments made by an insurer to brokers based on the volume and profitability of insurance placed with the insurer, have been criticized as damaging to the relationship between the insured and its broker. The argument is made that contingent commission payments encourage brokers to select insurers for their clients based on the potential to earn contingent commissions, rather than on the needs of the insured. We argue that contingent commission payments, which while directly paid by the insurer are ultimately paid by the insured through higher premiums, are beneficial to insureds because they provide an incentive for the broker to place their coverage with an insurer that is charging an adequate premium. We contend that although inadequate premiums are perhaps good for the insured in the short term, in the longer term, inadequate premiums will result in price hikes or coverage restrictions that are harmful to the insureds. Our empirical analysis demonstrates that insurers who pay contingent commissions experience less price fluctuation over the underwriting cycle than insurers who do not pay contingent commissions in the US property and casualty insurance industry.     

A Critique of the Private Health Insurance Regulations

The private health insurance sector is one of the most regulated sectors in Australia. The Private Health Insurance Incentives Scheme, along with community rating, is intended to make private insurance equitable, profitable and popular. We argue that the subsidy to health insurance ought to be a very effective tool for increasing insurance–but it was ineffective because community rating was ineffective. Using data from the Household Expenditure Survey we find that despite community rating rules which prohibit age‐adjusted premiums, young adults paid considerably less for their insurance than older adults. We conclude that insurers circumvented community rating through plan design, screening older consumers into more expensive plans. We also find that the penalty of 2 per cent per year for delaying insurance, introduced as part of the lifetime cover plan, is too low to be effective. We reflect on the New Zealand experience, where a completely deregulated insurance industry continues to be profitable and enjoys similar rates of coverage to those of Australia, and we ask whether Australia too could not benefit from complete deregulation.     

Capital asset pricing models with default risk: Theory and application in insurance

The Capital Asset Pricing Model has been used frequently to derive a fair price of insurance. But the use of this model overestimates insurance premiums because it does not account for the insolvency risk of insurers. This paper examines how the insurance price should be fairly adjusted when insurers' default risk is considered. It develops a model which shows that fair insurance premiums are lower when insurance firms have a positive probability of being insolvent. Using data of property liability insurers during the period from 1943–99, the paper further estimates the effects of the insolvency risk on insurers' underwriting profit rate. It shows that the incorporation of the default risk of insurers in the model, by significantly reducing the required price for insurance, would lead to lower profit potentials. Some writers argue that including the insolvency risk when calculating insurance premiums is not so necessary because of the existence of states' guaranty insurance funds which protect consumers. However, as shown in the paper, these funds have provided inadequate protection to consumers. Therefore, because of the increase in the number of insolvencies in recent years, and because of the limited coverage provided by states' guaranty funds, it seems that considering the insolvency risk in insurance pricing has become very necessary.     

Information Asymmetries and Risk Management in Healthcare Markets: The U.S. Affordable Care Act in Retrospect

This article critically examines the pertinent issues in ex ante and ex post moral hazard in healthcare markets, with the U.S. Affordable Care Act (ACA) as its focal point of inquiry. First, it compares the various types of information asymmetries resulting from the production, allocation, and utilization of health insurance. Second, it reviews the literature on adverse selection, moral hazard, and risk mitigation against which salient ACA reforms are analyzed. In contrasting conventional moral hazard from an alternative theory of welfare maximization, it suggests that healthcare (over)utilization cannot necessarily be considered wasteful, even if it ends up costing insurers more on a short-term basis. Costs and savings attributable to healthcare spending under the ACA will vary between the consumer, insurer, and regulator-subsidizer. Despite the ambiguities surrounding definitions of “health,” the challenge of containing inefficient moral hazard, and encouraging its desirable counterpart, lies in the tradeoffs that arise between consumer access to affordable and quality healthcare and the market competitiveness of health insurers. The new Trump administration will have to address these tradeoffs in repealing and replacing the ACA, particularly in light of escalating insurance premiums and deductibles, narrower provider networks, and technical implementation issues.     

DETERMINANTS OF BANK ACQUISITION PREMIUMS: ISSUES AND EVIDENCE

The recent interstate bank merger phenomenon has received little attention in the literature. Specifically, existing studies fail to explain sufficiently the variation of premiums paid and fail to investigate adequately the bank merger wave in terms of its interstate banking context.
This study employs models with substantial overall explanatory levels. The interstate banking context proves to be very significant. First, the study considers and finds significant the effective date of a state's interstate statute in relation to a deal's announcement date. This contrasts sharply with other studies. Second, the study uses and also finds significant a binary variable distinguishing intrastate deals from interstate deals. The premiums paid for interstate market entry, on average, exceeded those paid for intrastate transactions. Third, including regional binary variables reveals a pattern of variation in pricing throughout the country. The Southeast, the study's base of comparison, exhibited the highest premium level.
Other significant determinants of premiums paid include profitability as measured by returns on equity, growth proxied by state deposit growth and future expected population growth, and charge-offs to total loans as an indicator of loan quality.     

DETERMINANTS OF BANK ACQUISITION PREMIUMS: ISSUES AND EVIDENCE

The recent interstate bank merger phenomenon has received little attention in the literature. Specifically, existing studies fail to explain sufficiently the variation of premiums paid and fail to investigate adequately the bank merger wave in terms of its interstate banking context.
This study employs models with substantial overall explanatory levels. The interstate banking context proves to be very significant. First, the study considers and finds significant the effective date of a state's interstate statute in relation to a deal's announcement date. This contrasts sharply with other studies. Second, the study uses and also finds significant a binary variable distinguishing intrastate deals from interstate deals. The premiums paid for interstate market entry, on average, exceeded those paid for intrastate transactions. Third, including regional binary variables reveals a pattern of variation in pricing throughout the country. The Southeast, the study's base of comparison, exhibited the highest premium level.
Other significant determinants of premiums paid include profitability as measured by returns on equity, growth proxied by state deposit growth and future expected population growth, and charge-offs to total loans as an indicator of loan quality.     

Medical practice and malpractice litigation in an evolutionary context

We model the interactions between the behaviors of physicians and patients, subject to clinical and legal risks, by means of evolutionary game theory. We propose an original game in which patients may sue their physician for medical malpractice, and physicians have to choose between two alternative treatments, with different levels of benefits and risks. The safer treatment is also the less effective, therefore its provision corresponds, under the assumptions of our model, to practicing negative defensive medicine. We study the Nash equilibria, test their stability in the replicator dynamics, and analyze their welfare properties. We find that the accuracy of the judicial system plays an important role, with possible counter-intuitive effects related to legal reforms. If the court is not sufficiently accurate, defensive medicine can be favored, paradoxically, by an increase in the probability that defensive physicians are sanctioned by the court. A similar outcome can be generated also by an increase in the compensation paid to patients by physicians, when sanctioned for medical malpractice.     

Private Information in Life Insurance,Annuity, and Health Insurance Markets

Economic theory predicts that private information on risks in insurance markets leads to adverse selection. To counterbalance private information, insurers collect and use information on applicants to assess their risk and to calculate premiums in an underwriting process. Using data from the English Longitudinal Study of Ageing (ELSA), this paper documents that differences in the information used in underwriting across life insurance, annuity, and health insurance markets attenuate private information to different extents. The results are in line with – and might help to reconcile – the mixed empirical evidence on adverse selection across these markets.     

Exclusive vs. independent agents: a separating equilibrium approach

We provide a separating equilibrium explanation for the existence of the independent insurance agent system despite the potentially higher costs of this system compared to those of the exclusive agents system (or direct underwriting). A model is developed assuming asymmetric information between insurers and insureds; the former do not know the riskiness of the latter. We also assume that the claims service provided by the independent agent system to its clients is superior to that offered by direct underwriting system, that is, insureds using the independent agent system are more likely to receive reimbursement of their claims. Competition compels the insurers to provide within their own system the best contract to the insured. It is shown that in equilibrium the safer insureds choose direct underwriting, whereas the riskier ones choose independent agents. The predictions of the model agree with previous research demonstrating that the independent agent system is costlier than direct underwriting. The present model suggests that this does not result from inefficiency but rather from self-selection. The empirical implication of this analysis is that, ceteris paribus, the incidence of claims made by clients of the independent agents system is higher than that of clients of direct underwriting. Implications for the coexistence of different distribution systems due to unbundling of services in other industries such as brokerage houses and the health care industry are discussed.     

Insurance Taxation and Insurance Fraud

It is common practice in the United States to impose a sales tax on insurance premiums. Insurance benefits are not taxed, and it is typically argued that they should not be taxed because they compensate for a loss. In this paper I present a case where the taxation of insurance benefits is preferable to the taxation of premiums. When insurance fraud is present—in the form of ex post moral hazard—a tax on insurance premiums increases the number of fraudulent claims in the economy, whereas a tax on insurance benefits may reduce fraud. More importantly, however, policyholders are made better off with a benefit tax than with a premium tax.     

The relationship between the markets for health insurance and medical malpractice insurance

This article evaluates the interdependence of medical malpractice insurance markets and health insurance markets. Prior research has addressed the performance of these markets, individually, without specifically quantifying the extent to which they are linked. Increasing levels of health insurance losses could increase the scale of potential malpractice claims, boosting medical malpractice losses, or could embody an improvement in medical care quality, which will reduce malpractice losses. Our results for a state panel data set from 2002 to 2009 demonstrate that health insurance losses are negatively related to medical malpractice insurance losses. An additional dollar of health insurance losses is associated with a $0.01–$0.05 reduction in medical malpractice losses. These findings have potentially important implications for assessments of the net cost of health insurance policies.     

Endogenous Categorization in Insurance

This paper analyzes the welfare properties of equilibrium when insurers use observable actions to classify consumers into different risk categories, and consumers' choice is influenced by the insurance market consequences of their actions. Specifically, we analyze this problem at the example of a car insurance market, in which individual preferences over car types are correlated with risk type and used by insurance firms for ratemaking. Equilibrium premiums for each car are determined by the losses that it generates. Consumers take insurance premiums into account when deciding which car to buy. This creates an incentive to buy the car that is preferred by more low risk individuals. From a utilitarian point of view, this incentive is excessive. Depending on parameters, it may even be possible to construct a tax‐subsidy scheme with balanced budget that Pareto improves on the market equilibrium.     

Health insurer market power and employer size: an empirical evaluation of insurer concentration and wages through compensating differentials

This article explores the differentiated effects of health insurer market concentration on net compensation of employees across distinct firm sizes. Consistent with the existing literature evaluating insurer market concentration and the theory of compensating differentials, we find evidence of higher premiums and reduced net compensation for employees in markets with more concentrated insurers. Furthermore, we find evidence that the magnitude of these effects is distinctly smaller for large employers. This implies that mergers of large health insurance companies may have a significant impact on small businesses but that the effect is mitigated for larger employers.     

DO HEALTH INSURERS CONTRACT THE BEST PROVIDERS? PROVIDER NETWORKS,QUALITY, AND COSTS

We provide a modeling framework to analyze selective contracting in the health‐care sector. Two health‐care providers differ in quality and costs. When buying health insurance, consumers observe neither provider quality nor costs. We derive an equilibrium where health insurers signal provider quality through their choice of provider network. Selective contracting focuses on low‐cost providers. Contracting both providers signals high quality. Market power reduces the scope for signaling, thereby leading to lower quality and inefficiency.     

Children's Height and Parental Unemployment: A Large-Scale Anthropometric Study on Eastern Germany, 1994–2006

Abstract. The average height of children is an indicator of the quality of nutrition and healthcare. In this study, we assess the effect of unemployment and other factors on this variable. In the Eastern German Land of Brandenburg, a dataset of 253,050 preschool height measurements was compiled and complemented with information on parents' schooling and employment status. Unemployment might have negative psychological effects, with an impact on parental care. Both a panel analysis of districts and an assessment at the individual level yield the result that increasing unemployment, net out-migration and fertility were in fact reducing height.     

SUBSIDY TO NUCLEAR POWER THROUGH PRICE-ANDERSON LIABILITY LIMIT: COMMENT

Dubin and Rothwell (1990) use details of insurance premiums to develop a methodology for inferring the value to nuclear operators of the Price-Anderson liability limit from but misinterpret the terms of the insurance contracts for which the premiums are paid. This leads them to overstate the subsidy due to the limit by a factor of between four and ten.     

Insurance development,banking activities,and regional output: evidence from China

This paper applies panel cointegration tests and panel vector error correction models to investigate the interrelationship among the banking sector, insurance market, and regional output based on the samples from 25 Chinese provinces. We first find that there is a fairly strong long-run cointegrating relationship among real GDP, banking credit, and real insurance premiums. Second, both insurance markets (life and non-life) and the banking sector have a positive effect on real output. Third, we determine that banking activities and economic growth exhibit long-run and short-run bidirectional causalities. Fourth, there is fairly strong evidence in favor of the hypothesis for the long-run bidirectional causal relationships between insurance premiums and economic growth, taking into account the critical channel of the banking sector. Finally, we provide some beneficial suggestions for investors and policy-makers.