外文翻译.docx
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外文翻译.docx
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外文翻译
外文文献翻译材料
(2010届)
瑞士社会健康保险:
共同支付
学生姓名应天城
学号06022229
院系医学院
专业公共事业管理(卫生事业管理)
指导教师潘传德
填写日期2009年11月3日
SWISSSOCIALHEALTH
INSURANCE:
CO-PAYMENTS
WORK
STEFANFELDERAND
ANDREASWERBLOW
Fromtheperspectiveofaninsurancecommunity,co-paymentsareonlyinterestingiftheyaffecttotalexpenditurebyadecreaseintheprobabilityorthesizeofdamages.Iftheinsuredtakepreventive
actionstoreducetheriskorchangetheirbehaviorwhendamagesoccur,theirexpenditurewilldecrease.Ifinsurancecoverageiscomprehensive,
importantincentivesforpreventionandrestrictingdamagesareabsent.Economistsspeakofmoralhazard,referringtotheeffectoftheextentofinsurancecoverageonthebehavioroftheinsured.
Inhealthinsurance,theinsuredhaveaparticularlylargeinfluenceontheamountofservicestheydemand.Healthyfood,sufficientphysicalmotion,preventionofstress,allthesereducetheprobabilityofanillness.Moreover,thebehaviorincaseofanillness,i.e.thechoiceoftherapyorthepatients’compliancewiththephysicians’prescriptionswillsubstantiallyaffecthealthcareexpenditure.Docopaymentsreducemoralhazardinhealthinsurance?
Swisssocialhealthinsuranceisanidealcandidateforstudyingthisissue,asco-paymentshavealongtraditionthere.
CharacteristicsoftheSwisshealthinsurancesystem
InSwitzerland,100percentofthepopulationisenrolledinthestatutory(basic)healthinsurancesystem.Inthecomplementaryprivateinsurance
sector,theequivalenceprincipleholds–theinsuredpayriskequivalentpremiums.Bycomparison,communityratingappliesinsocialhealthinsurance,i.e.everypersonwithinasicknessfundpaysthesamepremiumirrespectiveofhis/herrisk.Thisimpliesthattheso-calledgoodrisks(personswhosepaymentsexceedtheirexpectedexpendsubsidizethebadrisks(personswithpaymentsbelowtheexpectedexpenditure).Withthe
givenhealthcareexpenditureprofiles,communityratingmeansforinstancethattheyoungsubsidizetheoldandthatmensubsidizewomen.
IncontrasttoGermanyandothercountries,Switzerlanddoesnotimposeanysubstantialinterregionalredistributioninfinancinghealthcare.
Premiumsaredifferentiatedaccordingtoregionaldifferencesinhealthcareexpenditure.Furthermore,contributionstohealthinsurancearenotpaidfromthepayrollbutfunctionasinotherinsurancesectors.
Everyindividual–adult,adolescentorchild–thereforepayshis/herownpremium.Nevertheless,lowincomepersonsreceiveasubsidyfromthelocalgovernmentaswellasfromthefederalstatetopayforhealthinsurance.Theaveragehealthinsurancepremiumisaround€170permonth.
Co-paymentsinSwisshealthinsuranceincludeaminimal€160deductibleperyear.Expenditurethatexceedsthisthresholdissubjecttoa10percentco-insurancerate.Thesystemiscapped:
themaximumco-paymentforapersonis€560.Thisimpliesthatmedicalbillsupto€4,160(€160plus€4,000)aresubjecttodemand-sideco-insurance.90percentoftheinsuredhaveexpenditurebelowthisthreshold.Exemptionsforchronicallyillorlow-incomepersonsfromthecompulsorycopayment
rulesdonoexist.Thisconsistentemploymentofcoinsuranceisdirectedatmoralhazard.Theadverseequityimplicationisseenastheprice
thatthecommunitymustpayforachievingamoreefficientuseofhealthcareservices.
InSwitzerland,theinsuredcanoptforadeductibleabove€160.Theoptionaldeductiblesamountto€270,€400,€800and€1,000.Theycomewith(maximal)premiumrebatesof8percent,15percent,30percentand40percent.The10percentcoinsurancerateforexpenditureabovethedeductibledoesnotchange.Thisisalsovalidforthecap,whichisonlyadjustedbythechosendeductible.
Thegoaloftheoptionaldeductiblesistoinfluencethedemandforhealthcareservicesbytheinsured,i.e.tofightmoralhazard.However,thereisadisadvantagetotheseoptions.Theyallowtheinsuredtochoosetheinsurancecontractthatsuitstheirexpectedhealthcareexpenditurebest.Inotherwords,goodriskswilloptforahighdeductible,whereasbadriskswillstayputwiththecompulsoryminimaldeductible.Still,eventhoughindividualswillrationallychoosethesizeofthedeductible,theincentivesofthemeasureremain.Yet,theyarereinforcedsincetheextent
ofco-paymentshasbeenenlargedbytheseoptions.
Moralhazardorself-selection?
–Thatisthequestion!
While60percentoftheinsuredsticktotheminimaldeductible,40percentchooseoneofthehigherdeductibles(seeFig.1thatsummarizesthesharesforarepresentativesampleof60,000personsinthecantonofZurich).Oftheseindividuals,threefourthsoptedforthe€270deductible.Thefigurerevealsasubstantialdecreaseingrosshealth
careexpenditurewithanincreasingdeductible.Apersonwiththeminimaldeductible(€160)onaverageincurred€2,150healthcareexpenditure
peryear;theaverageinthehighestdeductible(€1,000)onlyamountedto€510.ThesecondbarineachcategoryofFigure1representshealthcareexpenditurenetofthepatients’co-payments.Thethirdbarillustratestheaveragepremiumperdeductible.Acomparisonwiththeexpendituresshowsthatdespitelargerebates,asubstantiallyfinancialredistributionfromlow-tohigh-riskindividualsoccurs.
Theseobservationsdonottellwhetherthelowerexpenditureinthehigherdeductibleclassesisinthefirstplaceaconsequenceofthecontractselectionbytheinsured,expectingdifferentfuturehealthcareexpenditure,orwhetheritisareflectionofachangeinthebehavioroftheinsured.Onewouldexpectthatbothself-selectionandmoralhazardmatter.Theseparationofthetwoeffectsismethodologicallychallenging,asthetwosimultaneouslyshowupinthehealthcareexpendituredata.Whileoneobserveslowerexpenditureoftheinsuredwhohaveoptedforahighdeductible,onedoesnotknowthereasonforit.
Inthe1980s,theRANDcorporationsponsoredanextensivestudydesignedtodetectthepriceeffectofdeductiblesonthedemandforhealthcare.Inacontrolledrandomizedexperiment,personswereallocatedwithhealthinsurancecontractsthatdifferedwithrespecttotheco-insurancerate.Sincethepersonshadnopossibilitytochoosetheircontract,
aselectioneffectcouldbeexcluded.Onaverage,theRANDresearchersdetectedareductionof20-30percentinthedemandforhealthcaredue
toco-insurance(seeManningetal.1987).IntheSwisssystem,personshavethechoicebetweendifferentdeductibles.Ifoneexpectsthatthechoicereflectstheexpectationoffuturehealthcareexpenditure,theproblemofself-selectioncanbesolvedbyexplicitlyincorporatingthechoiceofcontracts.This,indeed,wastheapproachwetookintheSwiss
study.Inthefirststep,weestimatedthechoiceoftheindividualswithrespecttothesizeofthedeductible.Inthesecondstep,takingintoaccounttheresultsofthefirststep,weestimatedtheinfluenceofthe
deductiblesonthedemandforhealthcareservices.Threemonthspriortotheendofoneyear,aninsuredhastochoosethedeductibleinhis
healthinsurancecontractforthenextyear.Inthisdecision,he/shewilltakeintoaccountthehealth-careexpenditurehe/sheexpectsforthefollowingyear.Ifthepremiumrebateexceedstheexpectedadditional
co-payments,he/shewilllikelyoptforahighdeductible.Whyshouldapersonwhoexpectsverylowhealth-careexpenditurenotgoforthehighestdeductible?
Achronicallyillperson,bycomparison,willlikelyadheretotheminimaldeductible.
IntheSwissstudywemodeledthecontractchoiceusingindividual
healthcareexpendituredataofthefollowingthreeyears,1997–1999.Theexpenditurein1997and1998wereusedtoformtheexpectationof
futureexpenditure,astheyindicatethehealthstatusofanindividual.Additionalexplanatoryvariablesforthechoiceofthecontractfor1999aretheindividual’sage,sex,incomeaswellashis/herpremium(fordetails,seeWerblowandFelder2003).
Theestimationresultsconfirmthehypotheses:
Thehigherhealthcareexpenditureinthepast,thehighertheprobabilitythatanindividualdistanceshimselffromchoosinganoptional(higher)deductible.Low-incomeindividualslikewisepreferthecompulsoryminimaldeductible.Individualswithalowincomefeartheriskofhighco-paymentsmorethanhigh-incomepersons.Individualslivinginhigh-premiumregionsmorelikelychooseahigherdeductible.Thishastodowiththeregulation
ofproportionalrebates.Foranydeductible,therebateinabsoluteterms,therefore,increaseswiththepremiumlevel.Forthisreason,inhighpremiumregions,itismoreprofitabletorestrictinsurancecoveragebymeansofahighdeductible.
DoesmoralhazardexistinSwisshealth-careinsurance?
Inthesecondstepoftheestimation,wedealtwiththeexplanationofthedemandforhealth-careservices,giventhechoiceofcontract.Bytakingintoaccounttheendogeneityofthechoice,itispossibletonet-outtheeffectofselectionfromthechangeindemand.Inthesecondestimation,age,sexandincome,butalsosupply-sidefactorssuchasthe
densityofphysiciansintheneighborhoodofaninsuredserveasexplanatoryvariablesforthedemandforhealth-careservices.Theestimationresultsconfirmtoalargeextenttheexistenceofmoralhazard.Despiteself-selection,health-careexpenditureforhigh-deductibleindividualsissignificantlylowercomparedtoindividualswithaminimaldeductible.
Figure2summarizestheresultsforanaveragemaleperson.Thefirstbarineachcategoryshowstheobservedreductionofhealth-careexpenditureforthefouroptionaldeductiblescomparedtothelevelofthemin
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