A critical review of the use of R in risk equalization research.

Nearly all empirical studies that estimate the coefficients of a risk equalization formula present the value of the statistical measure R. The R-value is often (implicitly) interpreted as a measure of the extent to which the risk equalization payments remove the regulation-induced predictable profits and losses on the insured, with a higher R-value indicating a better performance. In many cases, however, we do not know whether a model with R = 0.

A framework for ex-ante evaluation of the potential effects of risk equalization and risk sharing in health insurance markets with regulated competition.

Many health insurance markets are organized by principles of regulated competition. Regulators of these markets typically apply risk equalization (aka risk adjustment) and risk sharing to mitigate risk selection. Risk equalization and risk sharing can have various positive and negative effects on efficiency and fairness.

Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland? Ten years later.

From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later.

Supplementary physicians' fees: a sustainable system?

In Belgium and France, physicians can charge a supplementary fee on top of the tariff set by the mandatory basic health insurance scheme. In both countries, the supplementary fee system is under pressure because of financial sustainability concerns and a lack of added value for the patient. Expenditure on supplementary fees is increasing much faster than total health expenditure.

Supplementary insurance as a switching cost for basic health insurance: Empirical results from the Netherlands.

Nearly everyone with a supplementary insurance (SI) in the Netherlands takes out the voluntary SI and the mandatory basic insurance (BI) from the same health insurer. Previous studies show that many high-risks perceive SI as a switching cost for BI. Because consumers' current insurer provides them with a guaranteed renewability, SI is a switching cost if insurers apply selective underwriting to new applicants.

Should new health technology be available only for patients able and willing to pay?

New health technology comes on the market at a rapid pace and - sometimes - at a huge cost. Providing access to new health technology is a serious challenge for many countries with mandatory health insurance. This article analyses access to new health technology in Belgium and the Netherlands, using eight concrete examples as a starting point for comparing the two - neighbouring - countries.

Improving access to essential health care services: the case of Israel.

In a recent article in this journal Simon-Tuval, Horev and Kaplan argue that in order to improve the protection of consumers there might be a need to impose a threshold on the medical loss ratio (MLR) for voluntary health insurance (VHI) in Israel [1]. Their argument is that VHI in Israel covers several essential services that are not covered by the mandatory benefits package due to budget constraints, while there are market failures in the VHI market that justify regulation to assure consumer protection such as high accessibility to high quality coverage. In this commentary it will be argued that in addition to market failures there are also government failures.

How can the regulator show evidence of (no) risk selection in health insurance markets? Conceptual framework and empirical evidence.

If consumers have a choice of health plan, risk selection is often a serious problem (e.g., as in Germany, Israel, the Netherlands, the United States of America, and Switzerland).

Risk Selection Threatens Quality Of Care For Certain Patients: Lessons From Europe's Health Insurance Exchanges.

Experience in European health insurance exchanges indicates that even with the best risk-adjustment formulas, insurers have substantial incentives to engage in risk selection. The potentially most worrisome form of risk selection is skimping on the quality of care for underpriced high-cost patients--that is, patients for whom insurers are compensated at a rate lower than the predicted health care expenses of these patients. In this article we draw lessons for the United States from twenty years of experience with health insurance exchanges in Europe, where risk selection is a serious problem.

Switching rates in health insurance markets decrease with age: empirical evidence and policy implications from the Netherlands.

All consumer groups with specific preferences must feel free to easily switch insurer in order to discipline insurers to be responsive to consumers' heterogeneous preferences. This paper provides insight into the switching behaviour of low-risks (i.e.

Switching benefits and costs in competitive health insurance markets: A conceptual framework and empirical evidence from the Netherlands.

Competitive health insurance markets will only enhance cost-containment, efficiency, quality, and consumer responsiveness if all consumers feel free to easily switch insurer. Consumers will switch insurer if their perceived switching benefits outweigh their perceived switching costs. We developed a conceptual framework with potential switching benefits and costs in competitive health insurance markets.

Improved estimates of Belgian private health expenditure can give important lessons to other OECD countries.

OECD Health Data are a well-known source for detailed information about health expenditure. These data enable us to analyze health policy issues over time and in comparison with other countries. However, current official Belgian estimates of private expenditure (as published in the OECD Health Data) have proven not to be reliable.

Risk selection in a regulated health insurance market: a review of the concept, possibilities and effects.

The Dutch basic health insurance is based on the principles of regulated competition. This implies that insurers and providers compete on price and quality while the regulator sets certain rules to achieve public objectives such as solidarity. Two regulatory aspects of this scheme are that insurers are not allowed to risk rate their premiums and are compensated for predictable variation in individual medical expenses (i.

Risk equalization in The Netherlands: an empirical evaluation.

The Netherlands relies on risk equalization to compensate competing health insurers for predictable variation in individual medical expenses. Without accurate risk equalization insurers are confronted with incentives for risk selection. The goal of this study is to evaluate the improvement in predictive accuracy of the Dutch risk equalization model since its introduction in 1993.

Choice of insurer for basic health insurance restricted by supplementary insurance.

Choice of insurer is an essential precondition for efficiency in healthcare systems based on regulated competition. However, supplementary insurance (SI) may restrict choice of insurer for basic health insurance (BI) due to a joint purchase of BI and SI. Roos and Schut (Eur J Health Econ 13(1):51-62, 2012) found that the belief in not being accepted by another insurer for SI was an important reason for not switching insurer for BI for 4% of the non-switching Dutch population in 2006.

Preconditions for efficiency and affordability in competitive healthcare markets: are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland?

Context: From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.

Consumer choice among Mutual Healthcare Purchasers: a feasible option for China?

In its 2009 blue print of healthcare reform, the Chinese government aimed to create a competitive health insurance market in order to increase efficiency in the health insurance sector. A major advantage of a competitive health insurance market is that insurers are stimulated to act as well-motivated prudent purchasers of healthcare on behalf of their enrolees, and that consumers can choose among these purchasers. To emphasize the insurers' role of purchasers of care we denote them, as well as other entities that can fulfil this role (e.

The level of consumer information about health insurance in Nanjing, China.

The Chinese government is considering a (regulated) competitive healthcare system. Sufficient consumer information is a crucial pre-condition to benefit from such a change. We conducted a survey on the level of consumer information regarding health insurance among the insured population in Nanjing, China in 2009.

Risk adjustment and risk equalization: what needs to be done?

In this paper, we first deal with the rationale of risk adjustment and risk equalization in health insurance markets. Then we discuss the state of the art concerning the application of risk adjustment and risk equalization in practice. Finally, we focus on: What needs to be done?

Effects of purchaser competition in the Dutch health system: is the glass half full or half empty?

In 2006, the Dutch health insurance system was radically reformed to strengthen competition among health insurers as purchasers of health services. This article considers whether purchaser competition has improved efficiency in health-care provision. Although supply and price regulation still dominates the allocation of health services, purchaser competition has already significantly affected the provision of hospital care, pharmaceuticals and primary care, as well as efforts to gather and disseminate information about quality of care.

Risk-adjusting the doughnut hole to improve efficiency and equity.

An important goal of consumer cost-sharing in health insurance is to increase incentives for cost containment. A relatively new cost-sharing phenomenon is the "doughnut hole": a gap in coverage starting at a predefined level of medical expenses. An important question is where to locate the starting point to achieve the strongest incentives for cost containment.

Prospects for regulated competition in the health care system: what can China learn from Russia's experience?

As China explores new directions to reform its health care system, regulated competition among both insurers and providers of care might be one potential model. The Russian Federation in 1993 implemented legislation intended to stimulate such regulated competition in the health care sector. The subsequent progress and lessons learned over these 17 years can shed light on and inform the future evolution of the Chinese system.

Risk equalisation in voluntary health insurance markets: A three country comparison.

The paper summarises the conclusions for health policy from the experience of three countries who have introduced risk equalisation subsidies, in their voluntary health insurance (VHI) markets. The countries chosen are Australia, Ireland and South Africa. All of these countries have developed VHI markets and have progressed towards introducing risk equalisation.