外文翻译 瑞士社会健康保险共同支付.docx

1、外文翻译 瑞士社会健康保险共同支付外文文献翻译材料（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

2、 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 sp

3、eak 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

4、 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

5、 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 eq

6、uivalence 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

7、 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,Switzerl

8、and 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.E

9、very 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 h

10、ealth 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-i

11、nsurance.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

12、 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 1

13、0 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

14、, 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 th

15、ough 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 minima

16、l 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 e

17、xpenditure 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 pa

18、tientsco-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

19、 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

20、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 sponso

21、red 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 t

22、heir 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 cho

23、ice 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

24、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 th

25、e 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 expenditu

26、re 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

27、 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 result

28、s 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

29、 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 rea

30、son, 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 contra

31、ct. 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 v

32、ariables 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 t