World Bank: "Prices in Crises – What We Are Learning from Twenty Years of Health Insurance in Low-& Middle-Income Countries"

WASHINGTON, Feb. 23 (TNSrep)(TNScapv) -- The World Bank issued the following policy research working paper (No. 10313) in February 2023 entitled "The Prices in the Crises - What We Are Learning from Twenty Years of Health Insurance in Low- and Middle-Income Countries."

The policy research working paper was written by Jishnu Das and Quy-Toan Do.

Here are excerpts:

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Abstract

Governments in many low- and middle-income countries are developing health insurance products as a complement to tax-funded, subsidized provision of health care through publicly operated facilities. This paper discusses two rationales for this transition. First, health insurance would boost fiscal revenues for health care, as post-treatment out-of-pocket payments to providers would be replaced by pre-treatment insurance premia to health ministries. Second, increased patient choice and carefully designed physician reimbursements would increase quality in the health care sector. This essay shows that, at best, these objectives have only been partially met. Despite evidence that health insurance has provided financial protection, consumers are not willing to pay for unsubsidized premia. Health outcomes have not improved despite an increase in utilization. The authors argue that this is not because there was no room to improve the quality of care but because behavioral responses among health care providers have systematically undermined the objectives of these insurance schemes.

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Discussion and Conclusion

A considerable literature from LMICs over the last two decades highlights several noteworthy features of health insurance schemes. In terms of the structure, governments have converged on using public subsidies for health insurance premia, which are now nominally priced or free in most countries. On the other hand, governments have diverged in how they reimburse providers for services, using a wide range of payment mechanisms that are frequently revised and overhauled. In terms of outcomes, the schemes have provided financial protection with a decline in out-of-pocket expenditures, but these gains have not translated into demand for unsubsidized health insurance. Furthermore, these schemes tend to increase utilization without a concomitant improvement in health outcomes. Finally, the lack of consistent improvements in outcomes is not because of supply constraints in terms of workload, equipment, or knowledge but instead due to behavioral responses on the part of providers. Health insurance does not systematically improve the quality of existing providers, and often, it seems to make it worse. There is also little evidence to show that health insurance allows patients to visit higher quality providers.

The phenomena of low demand, poor health outcomes and adverse behavioral responses, while seemingly disparate, are consistent with an underlying framework that recognizes the special features of health care as a commodity. While adverse selection is traditionally regarded as the defining unique feature of health insurance, once premia are tax funded, it is less of a concern. What is instead germane here is the credence good aspect of health care, whereby physicians know what patients need but patients (and health insurance companies) do not. This informational asymmetry leads to over-treatment if patients are treated for serious problems when their condition is mild, and under-treatment or incorrect treatment if patients are treated for a mild condition when their condition is serious. Both are inefficient, as insurance pays for unnecessary treatment in the case of over-treatment and patients lose the surplus from good health in the case of under-treatment. Since physicians enjoy considerable latitude in choosing the treatment, they may distort treatment decisions in a manner that is beneficial to themselves rather than to the patient.

Theoretically, the dual inefficiencies of over- and under-treatment can be alleviated through a combination of price and non-price incentives. The latter include enhancing altruistic motives, professionalism, peer reviews and a host of norms and principles. Interestingly, even in the absence of non-price mechanisms, price incentives alone can deliver efficient outcomes in markets with credence goods under certain conditions (Dulleck and Kerschbamer 2006)./15 In practice however, accurate price setting requires a high degree of transaction and physician-specific information, which is unlikely to be available for administrators in any insurance scheme. Consequently, we see countries adjusting their pricing mechanisms as providers exploit deficiencies in existing purchasing agreements, we see little improvement in health outcomes despite increased utilization because of increasing unnecessary care (cataracts, hysterectomies) and a possible decline in the quality of each interaction and we see systematic changes in provider behavior that undermine the stated objectives of the insurance scheme.

This idea--that health insurance affects both demand for and supply of quality health care is not new: for example, Arrow's 1963 article on health care dealt with the doctor-patient relationship and the problem of trust or credence (Arrow 1963). More recently, Newhouse (2014) considers the role of provider moral hazard in explaining why the US-based Rand Health Insurance experiment showed that more insurance led to increased utilization, but not improved health outcomes--a result similar to what we have documented here. Newhouse wrote: "[T]he odds that a service at the margin helped them were probably offset by the odds that it hurt them. I have felt more confidence in this explanation over time as evidence of medical error and poor quality of care has piled up (...)." Indeed, our review uncovered multiple papers that sought to explain why insurance does not improve health outcomes by pointing to the poor administration of the scheme or unexpected departures from what the scheme was supposed to do.

Moving forward, in terms of the research, future studies using demand-side data can still be insightful for several open questions. Does financial protection alone provide sufficient justification for expanding health insurance (Finkelstein, Hendren, and Luttmer 2019)? Does low demand reflect an actuarial calculation or administrative burdens or other costs, perhaps linked to behavioral issues? Does health...

15 What disciplines doctors in this case is physician-specific pricing that equalizes the markups from different treatments. This is because posted prices reveal information about the doctors' strategy: if costs are known, patients correctly infer that a physician will always choose the treatment plan that offers a higher profit. This predictability in turn implies that there is no further information asymmetry and therefore no incentive for the doctor to distort her behavior in order to extract surplus from the patient.

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...insurance lead to improved health outcomes in studies with sufficiently large sample sizes and a broad set of indicators?

While these are important questions, where we desperately need new evidence is instead on the supply side of the market where the major failures are concentrated. If our diagnosis of the problems of health insurance in low- and middle-income countries is correct, the key questions are (a) whether the arrival of health insurance allows households to visit higher-quality facilities and (b) whether the arrival of health insurance increases the quality of clinical interactions among existing providers. We have not found any studies that causally link health insurance to objectively measured higher quality choices (as opposed to proxy measures, such as private or public) or documented supply responses to the arrival of health insurance. Providing this evidence is admittedly not easy: for example, data on post-hospitalization outcomes requires teams to track hospital users to their homes months after their procedure. Yet, this is where we will likely see the largest gains in our understanding of how (and whether) health insurance can improve the health of populations in LMICs.

We cannot separate health insurance from the quality of care, nor can we separate quality of care from specific reimbursement mechanisms. Consequently, the issue at heart is not whether government subsidies should be channeled through health insurance premiums or direct subsidies to public facilities. Instead, the question is what specific payment structures and non-price mechanisms can alter provider behavior and patient choice to improve quality under any administrative regime.

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Table 1: Health insurance coverage across countries and over time

Figure 1: Correct management proportions across standardized patient studies

Figure 2: Outpatient capacity utilization in 12 low- and middle-income countries

Figure 3: Know-do gaps between medical vignettes and standardized patients

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The policy research working paper is posted at: https://documents1.worldbank.org/curated/en/099646102222328569/pdf/IDU09939e0140545c040490b24d0db206215ee67.pdf