رقابت های مدیریت و حساسیت قیمت مصرف کننده در بیمه سلامت اجتماعی

This paper examines whether the introduction of managed competition in Dutch social health insurance has resulted in effective price competition among insurance funds. We find evidence of limited price competition, which may be caused by low consumer price sensitivity. Using aggregate panel data from all insurance funds over the period 1996–1998, estimated premium elasticities of market share are −0.3 for compulsory coverage and −0.8 for supplementary coverage. These elasticities are much smaller than in managed competition settings in US group insurance. This may be explained by differences in switching experience and higher search costs associated with individual insurance.

In an increasing number of industrialized countries, governments are considering the use of market forces in social health insurance as a strategy to increase efficiency and consumer choice. Traditionally, social health insurance programs have been designed to guarantee financial access. Participation was mandatory and revenues collected centrally and allocated to non-competing administrative bodies. However, the increasing cost of social health insurance programs and the lack of efficiency incentives place governments under increasing pressure to reform these programs. The model of managed competition (Enthoven, 1978 and Enthoven, 1988) combines universal financial access with competition and incentives for efficiency. Although the model is elegant in theory, and notwithstanding attempts in several countries to introduce managed competition into their health care systems, nowhere has the model been fully implemented. Empirical evidence of the model’s efficacy is thus limited. In the US, the employee health insurance program of Wisconsin (Hill and Wolfe, 1997), the Federal Employees Health Benefits Program (Feldman et al., 1999) and the health benefits programs of such large universities as the University of California and Harvard and Stanford Universities (Buchmueller and Feldstein, 1997, Cutler and Reber, 1998 and Royalty and Solomon, 1999) incorporate several features of the managed competition model. However, none of these programs have risk-adjusted premium contributions, a crucial element of the managed competition model. Recent reforms of the Dutch social health insurance system have been strongly influenced by the model of managed competition. In 1988, the Dutch government adopted the Dekker Plan, which aimed at the introduction of a national health insurance scheme with managed competition. The Dekker Plan has much in common with the abandoned Clinton Plan in the US (Health Security Act 1994) but unlike Clinton’s Plan, the Dekker Plan has been implemented. Nevertheless, its initial ambitious goals to reform all existing health insurance schemes (including private health insurance and long-term care insurance) were duely modified to a less comprehensive reform of the mandatory social health insurance scheme covering about two-thirds of the Dutch population. After years of political debate and preparatory measures, the actual implementation of managed competition reforms began in 1992, although it took until 1996 before social health insurance funds (or sickness funds) were allowed to compete on price. Key features of the reforms are the transition from retrospective to risk-adjusted prospective payments to sickness funds, the introduction of flat-rate out-of-pocket premiums and freedom of choice for subscribers. Sickness funds were allowed to engage in selective contracting and in managing care, but have not to date done so. One reason for this is that the supply and price of health services is still heavily regulated by government. Hence, the Dutch social health insurance system is in a transitional phase, moving from supply-side regulation towards managed competition. In this paper we empirically analyze the response of sickness funds and their enrollees to the introduction of managed competition. The period studied is the initial stage of managed competition in which sickness funds could primarily compete on price. We investigate whether sickness funds compete on price, whether price competition is effective in restraining profits and how the prevailing price variation may be explained. A crucial precondition of effective price competition is that consumers are inclined to search for lower-priced substitutes. We therefore examine the sensitivity of consumers to premium differences. We have used a set of panel data gathered from all 25 Dutch sickness funds over the period 1996–1999. We then compare consumer price sensitivity in the Dutch social health insurance sector with that in managed competition settings in US employment-based group insurance. We conclude that price elasticities in US managed competition settings are substantially higher than in the Dutch reformed social health insurance setting. Likely explanations are differences in search costs and switching experience. Search costs appear to be lower in group insurance than in individual insurance because the employer facilitates consumer choice. Furthermore, in contrast to US employees, many Dutch insured are not used to or perhaps unaware of the possibility of switching between health insurance funds. Our findings imply that structuring and facilitating consumer choice is crucial to the success of managed competition in health insurance. Enhancing consumer choice appears to be more difficult in an individual health insurance setting than in a group insurance setting. This disadvantage of individual insurance has to be balanced against the choice limitations of group insurance (Pauly et al., 1999).

The introduction of managed competition in the Dutch social health insurance scheme has been based on the assumption that sickness funds would engage in price competition. A crucial precondition for effective price competition is that consumers are inclined to search for lower priced substitutes. In this paper, we have examined both the extent of price competition among sickness funds and the sensitivity of consumers to premium differences. We find evidence of weak price competition among sickness funds. Although rich sickness funds were increasingly prepared to compete on price to gain market share, sickness funds still have considerable latitude in setting premiums. One of the main reasons for the limited effectiveness of price competition may be the rather low sensitivity of consumers to differences in out-of-pocket premiums. The estimated out-of-pocket premium elasticity of a fund’s market share is only about −0.3. Although the premium elasticity for supplementary coverage is considerably higher (−0.8), the price elasticity of joint coverage is only −0.4. Due to the low premium elasticities, raising premiums is quite profitable, at least in the short run. The main reason that prevents sickness funds from increasing premiums seems to be fear of losing market share in the long-term. The estimated out-of-pocket premium elasticities of health plan choice in The Netherlands are much smaller than comparable estimates in managed competition settings in US group insurance. The most likely explanations for this difference are lower search costs and more switching experience of employees in the US settings. The comparison with US group insurance suggests that a straightforward method to encourage price competition among sickness funds would be to reduce search cost for sickness funds enrollees by structuring and facilitating consumer choice. An active government policy aimed at facilitating consumer choice among sickness funds would be consistent with the introduction of managed competition in social health insurance. Obviously, effective consumer search is easier to organize in a group insurance setting than in an individual health insurance market. Moreover, if health plans differ markedly with respect to provider network and benefit structure, the pre-selection of health plans by employers may reduce costs of comparing policies. An additional advantage of organizing managed competition in a group insurance setting is that employers have more market power than individual consumers so they can more effectively bargain with health insurers. The price of lower search costs and active employer involvement, however, is less freedom of choice and the potential of cost and risk-shifting from group to individual insurance.