برنامه های بهداشتی طلا و نقره : انطباق تقاضا ناهمگونی در رقابت های مدیریت

New regulation of health insurance markets creates multiple levels of health plans, with designations like “Gold” and “Silver.” The underlying rationale for the heavy-metal approach to insurance regulation is that heterogeneity in demand for health care is not only due to health status (sick demand more than the healthy) but also to other, “taste” related factors (rich demand more than the poor). This paper models managed competition with demand heterogeneity to consider plan payment and enrollee premium policies in relation to efficiency (net consumer benefit) and fairness (the European concept of “solidarity”). Specifically, this paper studies how to implement a “Silver” and “Gold” health plan efficiently and fairly in a managed competition context. We show that there are sharp tradeoffs between efficiency and fairness. When health plans cannot or may not (because of regulation) base premiums on any factors affecting demand, enrollees do not choose the efficient plan. When taste (e.g., income) can be used as a basis of payment, a simple tax can achieve both efficiency and fairness. When only health status (and not taste) can be used as a basis of payment, health status-based taxes and subsidies are required and efficiency can only be achieved with a modified version of fairness we refer to as “weak solidarity.” An overriding conclusion is that the regulation of premiums for both the basic and the higher level plans is necessary for efficiency.

In economic terms, an individual’s utility from medical treatment generally depends on her health status (e.g., her general medical condition, the illness she suffers from, and the severity of this illness) as well as other factors such as her income, education and tastes which affect utility and demand for most goods and services. Respecting individual preferences calls for taking into account both sets of factors in deciding her best treatment. However, particularly in managed care environments, supply-side factors and rationing rules also affect care provided. The clinician treating this patient may not weigh all of the factors affecting her utility equally. Either because of professional inclination or unfamiliarity with patient preferences, clinicians may be more responsive to the individual’s health status than to other “taste” factors affecting her utility. An immediate consequence of this simple observation is that individuals in a health plan will receive similar treatment if their health status is the same, even if their benefits from the services are not. Social efficiency will not generally be served by such uniform treatment, and welfare could be improved if individuals with greater “taste” for health services were in different plans than those with lower taste. In the U.S., pursuit of public policy objectives of extending coverage and controlling costs brings health insurance more under public control, and consequently, accommodating demand heterogeneity becomes an issue for regulation rather than simply being “left to the market.” One public policy response to demand heterogeneity creates “Gold,” “Silver” and possibly other heavy-metal plans representing levels of coverage and generosity. The publicly created health insurance market in Massachusetts designates Platinum, Gold and Silver Plans, and national health care reform calls for Platinum, Gold, Silver and Bronze. The design of efficient and equitable health policy in this policy context is the focus of this paper. We carry out the analysis when two types of health plans can efficiently serve tastes, a basic plan which we term “Silver” and a more generous plan which we term “Gold.” This paper studies how to efficiently and fairly implement a “Silver” and “Gold” health insurance plan within a policy context of managed competition. In managed competition, private plans compete for enrollees subject to regulation of premiums and benefits (Enthoven, 1980). Managed competition characterizes health policy in many countries, including Germany, Israel, Netherlands, Switzerland, the U.S. and other countries where regulated private plans compete in a market for enrollees. Our “Silver Plan” covers a basic bundle of health care services. The “Gold Plan” offers better coverage/higher quality of care, but is more expensive. For efficiency, we want groups with a higher willingness to pay for health care to be in the Gold Plan. For fairness, we want the sick and the healthy to pay the same for plan membership in both plans. As far as we know, the literature does not contain a description of an enrollee premium–plan payment policy that achieves these two objectives. After a literature review in Section 2, Section 3 describes our model in which consumers differ in two dimensions, health status and “taste” for health care, and are served by competing managed health care plans. A Regulator pays plans and may levy plan-specific taxes. Plans compete on services and premiums. We lay out explicit criteria for what we mean by efficiency and fairness. Efficiency is based on maximizing net consumer benefit. Fairness is based on the solidarity principle that the sick should pay the same as the healthy for health insurance. Section 4 considers the case in which both health status and “taste” are available as a basis of payment. The natural interpretation of “taste” in this case is “income,” a taste-related individual characteristic that can be used to condition premiums or as basis for taxation. We show that incremental cost pricing of individual premiums is efficient but unfair, and that average cost premiums are fair but not efficient. By use of a new policy with an income-based tax on plan membership the Regulator can achieve both an efficient and fair allocation. Many factors affecting demand (e.g., subjective valuation of health) cannot be used as a basis for either Regulator payment to plans or premiums charged to enrollees. Section 5 considers regulation when taste cannot be used as a basis for payment. We show that no payment policy leads to both efficiency and fairness. When we weaken the solidarity principle to be that the sick pay no more for health insurance than the healthy, efficiency and fairness can be achieved. We describe the tax and premium policy that achieves efficiency and “weak solidarity” in this context. Section 6 concludes the paper and comments on applications of our analysis to payment systems built around the idea of managed competition.

Heterogeneity in demand for health care is one of the most well-established set of facts in health services research. Basic demographics and measured health status explain 10% or less of variation in health care utilization. Although provider-side factors also matter, much of the balance of the variation is linked to income, education, attitudes and other factors we refer to here as “taste” affecting demand for most goods and services. This paper derives the implications of the empirically important and systematic taste-related demand for health care for the regulation of competing health insurance plans. Health plans can be differentiated in a horizontal (think “location”) as well as a vertical dimension. If, in addition, there are only one or a few plans at each location, another efficiency problem, monopoly power, is introduced. Our results on premium setting for efficient sorting on the basis of vertical differentiation are very likely to hold in this more general case. For example, consider a simple case of horizontal differentiation with a pair of Gold and a Silver Plans located at each end of a line, with consumers distributed along the line. Suppose both the risk-adjusted plan payments and the premiums charged to consumers are regulated. The Regulator can raise the risk adjusted premiums high enough to induce the efficient quality of care, even with monopoly power. Then the Regulator would need to follow rules much like we laid out in the text, to ensure efficient sorting and fairness. In the presence of a range of demands for health care due to taste, efficiency calls for plans with higher levels of service for the higher-demand groups. The key barrier to achieving efficiency is that the healthy among the high taste group will find the basic plan attractive. The discriminatory premiums necessary to sort consumers efficiently may not be feasible or fair. This paper identifies ways around this problem by showing how, when there must be a single premium for the Gold Plan, efficiency and fairness can be attained. The emphasis in the literature on managed competition has been on regulation of the basic (our Silver) plan, describing the appropriate risk adjustment, defining the benefit, and limiting premium discrimination by health-related factors. The main conclusion of our paper is that a more active regulatory policy can improve both efficiency and fairness. Rather than letting the market set the premium for a Gold Plan, the Regulator should specify the premium for Gold Plans. Then, the Regulator should subsidize the poor and tax the rich if they go to the Silver Plan. If income taxes and subsidies do not capture enough of taste differences, targeted subsidies and taxes on health status measures may be necessary. These taxes and subsidies can be set so that the sick pay no more for a health plan than the healthy (our “weak solidarity”). As health care costs continue to increase, a viable Gold Plan may become an important element in national health policy. The extra costs in a Gold Plan are paid by consumers electing the plan. By permitting this outlet for higher demand, the publicly financed system can be kept at the basic level, conserving public funds. Health policy in a number of countries accommodates demand with some form of upgrade available to higher demand groups. In Germany, most residents must choose among “Silver Plans” with specified benefits that compete on service and premiums (within narrow bounds).16 Higher income groups can opt out of the Silver Plan choice and choose among “Gold Plans” competing on premiums and service and also subject to some regulation. In Israel and Switzerland, an “upgrade” consists of a complementary insurance policy to the basic plan.17 Questions of fairness are at the forefront of policy debates about health care and health insurance. Managed competition with differentiated plans is inherently less equal than a national policy oriented around a single plan for all, even if it attains equity in terms of “solidarity” principles. Other conceptions of fairness could be introduced into our analysis and may change the nature of the analysis and conclusions. To study tradeoffs between efficiency and other approaches to fairness, it is necessary to have a working model of managed competition with demand heterogeneity, and this paper describes a model that might be useful for such subsequent analysis.