رفتار بیمه غیر انتفاعی قیمت گذاری در بازار بیمه سلامت اجتماعی رقابتی ضعیف

In this paper we examine the pricing behaviour of nonprofit health insurers in the Dutch social health insurance market. Since for-profit insurers were not allowed in this market, potential spillover effects from the presence of for-profit insurers on the behaviour of nonprofit insurers were absent. Using a panel data set for all health insurers operating in the Dutch social health insurance market over the period 1996–2004, we estimate a premium model to determine which factors explain the price setting behaviour of nonprofit health insurers. We find that financial stability rather than profit maximisation offers the best explanation for health plan pricing behaviour. In the presence of weak price competition, health insurers did not set premiums to maximize profits. Nevertheless, our findings suggest that regulations on financial reserves are needed to restrict premiums.

During the last fifteen years several countries (e.g. Germany, the Netherlands and Switzerland) have introduced some form of managed competition in their social health insurance schemes. The goal of these reforms is increase incentives for efficiency while maintaining universal access to affordable health insurance. An important question, that has not been addressed so far, is how competing health insurers set prices if they are not allowed to distribute profits. In other words, which factors determine nonprofit health insurers’ pricing decisions? The answer to this question may have important implications for policy decisions to impose, maintain or remove restrictions on ownership type for health insurers. In this paper we examine the pricing behaviour of health insurers in the Dutch social health insurance system where health insurers are allowed to compete for customers but – until 2006 – faced a legal non-distribution constraint. Given that prior to 2006 the market is purely nonprofit, health insurer behaviour in that period could not have been affected by the presence of for-profit insurers. Hence, spillover effects from other ownership types were absent. This makes it possible to investigate the “pure” drivers of nonprofit insurers’ price setting behaviour. Hence, the central question is whether nonprofit health insurers set premiums to maximize profits or do they behave differently? The paper is organized as follows. Section 2 provides a brief description of the Dutch health insurance market. In Section 3, we discuss the potential impact of nonprofit ownership on insurers’ pricing decisions, and describe an empirical model to examine the price setting behaviour of health insurers in this context. Next, we discuss which variables are likely to explain pricing behaviour of nonprofit insurers and we provide descriptive statistics as well as information about the sources from which the data were obtained. In Section 5 we present the estimation results of several estimation models. Finally, we discuss the implications of our findings for the role and regulation of ownership in competitive health insurance markets.

How do nonprofit health insurers set premiums in a social health insurance market with managed competition? The Dutch social health insurance market prior to 2006 offers a unique setting to answer this question. During our study period (1996–2004) health insurers were allowed to compete for customers but were not allowed to distribute profits. In addition, all health insurers were legally obliged to offer a standardized benefits package, so insurance products were quite homogeneous and primarily differed in price. Since potential spillover effects from the presence of for-profit insurers were absent, ‘pure’ nonprofit insurer pricing behaviour could be observed using a rich panel data set including all health insurers over an eight years period. Given the low price sensitivity of consumers found in other studies (Schut and Hassink, 2002, Schut et al., 2003, Douven et al., 2007 and Van Dijk et al., 2008), one would expect that health insurers displaying profit-maximizing behaviour would charge high premiums and realize huge profits. Indeed, Schut and Hassink (2002) show that raising premiums would be a very profitable strategy for health insurers. Instead of premiums converging towards a monopoly level, however, we find evidence of substantial and persistent premium variation. Furthermore, in most years the average mark-up was rather small. In 2001 and 2002 health insurers even incurred substantial losses, resulting in decreasing financial reserves (see Table 2). These losses seem to be caused by a general underestimation of health care cost inflation (particularly in 2002, see Fig. 1) as a result of a temporary release of government control on hospital cost in an attempt to reduce waiting lists. The incurred losses may also explain why all health insurers substantially raised their premiums in the two subsequent years. Rather than maximizing profits we find that most important drivers for health insurers’ pricing behaviour was the solvency regulation imposed by the government and the price signal by the insurers’ association. In addition, our findings suggest that setting a maximum limit to insurers’ financial reserves had a significant downward effect on insurers’ premiums. Hence, although nonprofit ownership may have prevented charging excessively high prices, regulation was needed to enforce lower premiums. Instead of by restricting ownership and imposing caps on insurers’ financial reserves, governments may also restrain premiums by strengthening the incentives for competition, which were rather weak in the Dutch health insurance market throughout our study period. As a matter of fact, strengthening competition among health insurers was a major goal of the profound health insurance reform that was implemented in 2006 (Van de Ven and Schut, 2008). A first empirical study shows that the reforms indeed induced strong price competition among health insurers and was effective in constraining health insurance premiums in the first few years after the reform (Douven et al., 2007).