外文翻译.docx

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：

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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