外文翻译 瑞士社会健康保险：共同支付.doc

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 学 号 院 系 医 学 院 专 业 公共事业管理(卫生事业管理) 指导教师 填写日期 SWISS SOCIAL HEALTHINSURANCE: CO-PAYMENTSWORKSTEFAN FELDER ANDANDREAS WERBLOWFrom the perspective of an insurance community,co-payments are only interesting if they affect total expenditure by a decrease in the probability or the size of damages. If the insured take preventiveactions to reduce the risk or change their behavior when damages occur, their expenditure will decrease. If insurance coverage is comprehensive,important incentives for prevention and restricting damages are absent. Economists speak of moral hazard, referring to the effect of the extent of insurance coverage on the behavior of the insured.In health insurance, the insured have a particularly large influence on the amount of services they demand. Healthy food, sufficient physical motion, prevention of stress, all these reduce the probability of an illness. Moreover, the behavior in case of an illness, i.e.the choice of therapy or the patientscompliance with the physiciansprescriptions will substantially affect health care expenditure. Do copayments reduce moral hazard in health insurance?Swiss social health insurance is an ideal candidate for studying this issue, as co-payments have a long tradition there.Characteristics of the Swiss health insurance systemIn Switzerland, 100 percent of the population is enrolled in the statutory (basic) health insurance system. In the complementary private insurancesector, the equivalence principle holds the insured pay risk equivalent premiums. By comparison,community rating applies in social health insurance, i.e. every person within a sickness fund pays the same premium irrespective of his/her risk.This implies that the so-called good risks (persons whose payments exceed their expected expendisubsidize the bad risks (persons with payments below the expected expenditure). With thegiven health care expenditure profiles, community rating means for instance that the young subsidize the old and that men subsidize women.In contrast to Germany and other countries,Switzerland does not impose any substantial interregional redistribution in financing health care.Premiums are differentiated according to regional differences in health care expenditure. Furthermore,contributions to health insurance are not paid from the payroll but function as in other insurance sectors.Every individual adult, adolescent or child therefore pays his/her own premium. Nevertheless, lowincome persons receive a subsidy from the local government as well as from the federal state to pay for health insurance. The average health insurance premium is around170 per month.Co-payments in Swiss health insurance include a minimal160 deductible per year. Expenditure that exceeds this threshold is subject to a 10 percent co-insurance rate. The system is capped: the maximum co-payment for a person is560. This implies that medical bills up to4,160 ( 160 plus4,000) are subject to demand-side co-insurance.90 percent of the insured have expenditure below this threshold. Exemptions for chronically ill or low-income persons from the compulsory copaymentrules do no exist. This consistent employment of coinsurance is directed at moral hazard.The adverse equity implication is seen as the pricethat the community must pay for achieving a more efficient use of health care services.In Switzerland, the insured can opt for a deductible above160. The optional deductibles amount to270, 400, 800 and1,000.They come with(maximal) premium rebates of 8 percent, 15 percent,30 percent and 40 percent. The 10 percent coinsurance rate for expenditure above the deductible does not change. This is also valid for the cap, which is only adjusted by the chosen deductible.The goal of the optional deductibles is to influence the demand for health care services by the insured,i.e. to fight moral hazard. However, there is a disadvantage to these options. They allow the insured to choose the insurance contract that suits their expected health care expenditure best. In other words, good risks will opt for a high deductible, whereas bad risks will stay put with the compulsory minimal deductible.Still, even though individuals will rationally choose the size of the deductible, the incentives of the measure remain.Yet, they are reinforced since the extentof co-payments has been enlarged by these options.Moral hazard or self-selection? That is the question!While 60 percent of the insured stick to the minimal deductible, 40 percent choose one of the higher deductibles (see Fig. 1 that summarizes the shares for a representative sample of 60,000 persons in the canton of Zurich). Of these individuals,three fourths opted for the270 deductible. The figure reveals a substantial decrease in gross healthcare expenditure with an increasing deductible. A person with the minimal deductible (160) on average incurred2,150 health care expenditureper year; the average in the highest deductible(1,000) only amounted to510.The second bar in each category of Figure 1 represents health care expenditure net of the patientsco-payments. The third bar illustrates the average premium per deductible. A comparison with the expenditures shows that despite large rebates, a substantially financial redistribution from low- to high-risk individuals occurs.These observations do not tell whether the lower expenditure in the higher deductible classes is inthe first place a consequence of the contract selection by the insured, expecting different future health care expenditure, or whether it is a reflection of a change in the behavior of the insured.One would expect that both self-selection and moral hazard matter. The separation of the two effects is methodologically challenging, as the two simultaneously show up in the health care expenditure data.While one observes lower expenditure of the insured who have opted for a high deductible, one does not know the reason for it.In the 1980s, the RAND corporation sponsored an extensive study designed to detect the price effect of deductibles on the demand for health care. In a controlled randomized experiment, persons were allocated with health insurance contracts that differed with respect to the co-insurance rate. Since the persons had no possibility to choose their contract,a selection effect could be excluded. On average,the RAND researchers detected a reduction of 20-30 percent in the demand for health care dueto co-insurance (see Manning et al. 1987).In the Swiss system, persons have the choice between different deductibles. If one expects that the choice reflects the expectation of future health care expenditure, the problem of self-selection can be solved by explicitly incorporating the choice of contracts.This, indeed, was the approach we took in the Swissstudy. In the first step, we estimated the choice of the individuals with respect to the size of the deductible. In the second step, taking into account the results of the first step, we estimated the influence of thedeductibles on the demand for health care services.Three months prior to the end of one year, an insured has to choose the deductible in hishealth insurance contract for the next year. In this decision,he/she will take into account the health-care expenditure he/she expects for the following year. If the premium rebate exceeds the expected additionalco-payments, he/she will likely opt for a high deductible.Why should a person who expects very low health-care expenditure not go for the highest deductible? A chronically ill person, by comparison,will likely adhere to the minimal deductible.In the Swiss study we modeled the contract choice using individualhealth care expenditure data of the following three years, 19971999. The expenditure in 1997 and 1998 were used to form the expectation offuture expenditure, as they indicate the health status of an individual. Additional explanatory variables for the choice of the contract for 1999 are the individuals age, sex,income as well as his/her premium (for details, see Werblow and Felder 2003).The estimation results confirm the hypotheses:The higher health care expenditure in the past, the higher the probability that an individual distances himself from choosing an optional (higher)deductible. Low-income individuals likewise prefer the compulsory minimal deductible. Individuals with a low income fear the risk of high co-payments more than high-income persons. Individuals living in high-premium regions more likely choose a higher deductible. This has to do with the regulationof proportional rebates. For any deductible,the rebate in absolute terms, therefore, increases with the premium level. For this reason, in highpremium regions, it is more profitable to restrict insurance coverage by means of a high deductible.Does moral hazard exist in Swiss health-care insurance?In the second step of the estimation, we dealt with the explanation of the demand for health-care services,given the choice of contract. By taking into account the endogeneity of the choice, it is possible to net-out the effect of selection from the change in demand. In the second estimation, age, sex and income, but also supply-side factors such as thedensity of physicians in the neighborhood of an insured serve as explanatory variables for the demand for health-care services. The estimation results confirm to a large extent the existence of moral hazard. Despite self-selection, health-care expenditure for high-deductible individuals is significantly lower compared to individuals with a minimal deductible.Figure 2 summarizes the results for an average male person. The first bar in each category shows the observed reduction of health-care expenditure for the four optional deductibles compared to the level of the minimal deductible (corresponds to the bars in Fig. 1). The next two bars present the division of this change between self-selection andmoral hazard.A forty-year-old man who opted for a deductible of270 on average incurs 30 percent lower health care expenditure than a man of the same age and a minimal deductible of 160. Two thirds of this reduction are according to our estimations due to self-selection. The remaining one third is caused by a change in behavior. The same divisionbetween self-selection and moral hazard occurs at the deductible level of 400.For the two highest deductibles, moral hazard is more prone. Of the observed change in health care expenditure 70 percent is due to moral hazard.With a higher reduction of health-care expenditure in total, self-selection makes up 30 percent.Deductibles in Switzerland reduce health-care demandThe Swiss social health insurance system includes differentiated optional deductible schemes. The insured appear to deal rationally with these options, i.e. as in other insurance sectors theychoose their coverage depending on the expected damages and the premiums. Our study based on health-care expenditure data of 60,000 individuals shows that price signals from deductibles significantly affect behavior even when taking into account the endogeneity of the contract choice.Optional deductibles substantially reduce healthcare expenditure.Even though part of the reduction of health care expenditure is due to the rational choice of contracts,co-insurance induces a change in demandthat significantly contributes to the reduction.Depending on the size of the deductible, between one third and 70 percent is due to moral hazard.Furthermore, the higher the deductible, the higher the change in behavior of the insured.There is an efficiency-equity trade-off when the government goes for optional deductibles in social health insurance. However, it is noteworthy that there is an efficiency gain involved. If demand-side coinsurance in health care were only redistributive,no one would have to care about co-insurance.The efficiency-equity trade-off can be handled with restricting the rebate, which persons can attain whenever they choose a higher deductible. It is important, however, that some incentives for the insured remain, taking into account the costs whenever they demand health care services.ConclusionPatients co-payments are a suitable measure to reduce health care expenditure. They positively affect prevention and foster the expenditureawareness of the insured. These effects can be identified in Swiss social health insurance, a system that contains a compulsory deductible of 200 extended by optional deductibles up to 1,000.瑞士社会健康保险：共同支付Stefan Felder医学博士.教授Andreas Werblow经济学博士.教授马格德堡大学概要从保险的角度出发，共同付款唯一所关心的是它们是否影响总的支出或减少被保险人的损伤大小概率采取预防行动，以减少风险或改变他们的行为。当损害发生时，他们的开支将会减少，如果保险覆盖面是全面的话。重要诱因预防和限制赔偿。经济学家谈论道德风险是指对被保险人行为的保险覆盖范围的影响。在医疗保险中，被保险人有一个特别大的影响，他们的服务量需求。健康的食物，足够的物理运动，预防压力，所有这些减少疾病的概率。还有，在生病时的行为，治疗或即经选择的患者遵守医师的处方会严重影响医疗支出费用。做共同支付可以减少健康保险的道德风险吗？瑞士社会医疗保险为研究这个问题提供了理想的方案，作为共同支付，是一个有悠久传统。特色的瑞士医疗保险系统在瑞士，百分之百的人参加了法定（基本）医疗保险系统.在私人保险的补充部门，等价原则认为，在被保险人支付的风险等价保费。通过对照，社会评价适用于社会健康保险，每个人在生病基金支付同样的保费，不论他/她的风险。这意味着，所谓的良好的风险（支付超过其预期支出）资助的不良风险（低于预期的支出款项的人）。随着提供健康服务的开支概况，社区等级代表了年轻的补贴，例如老人和妇女，男人补贴。相对于德国和其他国家，瑞士没有施加任何实质性区域间的再分配医疗融资。保费是根据区域差异在卫生保健的差异开支。此外，医疗保险费不从工资支付，但在其他保险行业，每个人包括成人，青少年或儿童都有支付他/她自己的费用。还有，低收入者可以得到当地政府补贴以及从联邦政府支付健康保险，平均健康医疗保险费大约在每月170欧元。共同支付在瑞士的医疗保险金每年最少包括160欧元，开支超过这个阈值是要受百分之十的共同保险率，结果显示：这最大共同支付为每人 560欧元。这意味着，医疗费用高达4160欧元（160欧元加4000欧元）受需求方面的共同保险。90%被保险人开支在这标准以下，长期病患者或低收入者强制豁免部分负担的规则不复存在，这种一致共同保险是针对道德风险的要求。不良资产的影响被认为是价格的社会必须实现的卫生保健服务的更有效的利用。在瑞士，被保险人可以选择一个扣除160欧元以上，也可选免赔额金额为 270欧元、400欧元、欧元800和欧元1000的。他们提出（最大）的保险费回扣8%，15%、30%、40%，对于上述扣减开支百分之十共同保险率不会改变。这也是有效的上限，这是唯一的选择调整扣除。可选免赔额的目标是影响由被保险人的医疗服务需求，对抗道德风险，然而，是对这些选项的缺点。他们允许被保险人选择适合自己的保险合同，符合预期的最好的医疗开支，换句话说，良好的风险会选择一个高扣除，坏的风险便会停滞不前的强制性最低扣除。不过，即使个人将理性地选择该扣除的规模，鼓励措施的多边环境协定，然而，他们是因为共同支付的范围已扩大了强化这些选项。道德风险或自我选择？ - 这就是问题所在！虽然百分之六十被保险人坚持最小扣除，同时百分之四十选择一个较高的免赔额（见图1，概述了60000人的代表样本在苏黎世州）。这些人，四分之三选择了了扣除270欧元。这个数字揭示了一个越来越扣减的毛医疗开支大幅下降。带有最小扣除（平均160欧元）每年发生卫生保健开支在2150欧元；其最高扣除（平均1000欧元）只达到510欧元。图1第二条代表在每个类别中的健康照顾病人的共同支付支出净额。第三栏显示了平均每扣除保险费。与支出的比较表明，扣减数还是很大的，一个从低到高风险的个人所发生重大财务再分配。人均开支的保费及被保险人的份额为免赔额苏黎世州1999年蓝色代表：总支出 灰色代表：总支出净额共同付款 红色代表：保险费用计量单位：欧元这些意见不知道较低的支出扣除是不是在高阶层，首先合同的后果由被保险人的选择，期待不同的未来医疗开支，或是否是一个在行为变化的中反映保险。人们期望双方自我选择和道德风险问题这两个效应的分离在方法论上具有挑战性，因为这两个同时出现在医疗开支上升的数据，同时一个不知道什么原因，在一个低支出的人观察下，被保险人选择高扣除开支。在20世纪80年代，兰德公司赞助了一项旨在检测医疗保健需求的免赔额价格的影响广泛研究。在受控制的随机实验中，人员分配与医疗保险合同有关的合作，保险费率各不相同。既然人已没有可能选择自己的合同，选择效果可能被排除在外。平均而言，兰德公司的研究人员发现了医疗合作保险需求减少了20%-30%（见曼宁等。1987年）。在瑞士医疗保险制度中，每个人有选择不同的免赔额。如果人们期望的选择反映了未来的医疗开支的期望，自我选择的问题是可以解决的，明确纳入合同的选择。这确实是我们需要在瑞士学习到的做法。在第一步，我们估计抵扣大小的个人选择。在第二步，考虑到第一步的结果，我们估计对医疗服务的需求免赔额影响。3个月之前的一年结束时，投保人须选择明年扣除他的健康保险合同。在这个决定，他/她会考虑保健开支，他/她期望接下来的一年。如果保险费回扣