Health insurance and the tragedy of the common risk pool (Doc Holliday) 1:58 AM

In my earlier posting (8 October 2009) I discussed the adverse effects of community rating on the efficiency of health insurance markets, and put forward a case for a modified voucher system for health care (which in the Australian context, I will call Medicare Savings Accounts or MSAs). In this posting I examine the tensions between health insurers and medical care, and propose some policy solutions.

A heated point of discussion in the health insurance debate is how to reimburse (that is, pay) doctors and hospitals. The traditional method of payment is the ‘fee for service’ – in which a doctor and a hospital is paid for the services they render. To an economist, this model appears to be fairly obvious – as a fee for service is basically the price of providing a service. Yet in the context of health care it has created all sorts of strange notions and policy prescriptions which are ultimately ill-conceived and self defeating.

The case against fee for service is that, put simply, doctors have an incentive to over-service their patients. The economics of this incentive is rarely put forward with any clarity by its proponents. They generally appeal to notions of ‘information asymmetries’ and ‘market power’. But none of these are adequate explanations. For example, market power assumes that doctors reduce their supply of services - but this is the opposite of what has been observed. Similarly, information asymmetries lead to adverse selection (Akerlof’s lemons problem), something which the medical colleges seem to adequately addressed.

The only explanation that makes sense to me is that over servicing is part of the wider problem of contractual enforcement - doctors have an incentive to charge and serve ‘that little bit more’ because insurers are unable to closely monitor doctors’ actions. Another way of looking at it is to think of pooled insurance being a 'tragedy of the commons'. The insurance pool is a common resource which doctors do not have any incentive in preserving. Rather, they have an incentive to encourage consultations and prescriptions believing that they are acting in the interest of their patient.

This problem is not unique to health insurance and examples can be found in other insurance markets. Consider the analogy of an automotive panel beater. I have lost count of how many times I’ve approached a panel beater and asked him to give me two quotes for the same job – a cash job and an insurance job. The quote for the insurance job is always more costly and extensive (in terms of work undertaken). The same logic applies in medicine. This phenomenon is analogous to moral hazard, but whereas moral hazard is normally associated as the patient's response to imperfect contractual arrrangements, this squarely puts it in the lap of suppliers.

One obvious implication is that free-riding on the insurance pool will give each patient additional care, but it is not clear whether the additional services necessarily lead to valuye-for-money. Another implication is that the logic of the tragedy of the commons applies to both private health insurance and to single-payer government fund insurance schemes.

My observations are not in any way new. Commentators have long observed the expansion in supply, and it has been dubbed as 'supplier-induced demand'. However, this explanation seems to have the best ring of truth to it.

But if fee for service in a pooled insurance setting leads to free-riding / supplier-induced demand (these terms should be used interchangeably), what have been the policy responses? In Europe, the United Kingdom and the United States, supplier-induced demand has led to the changes in the reimbursement of doctors and an increased monitoring of doctors' practices. In the United States where fee for service arrangements are commonplace, health management organisations (HMOs) have emerged. HMOs enter into contractual relationships with patients and doctors alike, and set limits on the practices of doctors. They can, for example, refuse to fund a course of treatment if it believes is not fiscally responsible. In the UK, the National Health Service has long salaried doctors in hospitals and has recently been changing the reimbursement of GPs. Now, doctors are reimbursed in terms of the number of patients on their books not how frequently they see their patients. In Europe, mutual sick funds have long operated their own hospitals and salaried doctors, and have closely monitored the prescribing behaviour of doctors.

There are similar pressures in Australia. Public hospitals in Australia have traditionally been funded on a capped budget basis, and doctors in public hospitals are salaried. Though some jurisdictions have increasingly adopted casemix funding of hospitals (such as Victoria) (which is essentially a fee for service arrangement) to improve productivity, in NSW at least, a public hospital is now funded according to how many people there are in its catchment area.

However, these policy prescriptions have two obvious deleterious effects. First, the close monitoring of the practices of doctors is in effect equivalent to regulating doctor behaviour. While it might be argued that it is welfare enhancing (relative to free-riding) it is not a first-best policy solution. Telling a doctor he can not give medicine x to a patient with condition y is a blunt (inefficient) instrument and misses the point that patients are highly individual and what might be an appropriate course of treatment for one patient may not be effective for another.

Second, paying doctors and hospitals fixed amounts reduces their productivity. As a community, you want doctors and hospitals to be as productive as possible (technically efficient) as they are very scarce and valuable resources. Yet paying a doctor on an hourly-basis will yield lower levels of productivity than if you were to pay them on a piece-work basis. Consider for example asking two house painters to give you a quote to paint the house: the one that gives you a fixed price quote will get the job done quicker than the one that quotes you an hourly rate. If doctors in public hospitals work long hours, it may not be because of the excessive workload they face, but because of the internal inefficiencies of the hospital caused by the financial incentives the hospital and doctors face.

This is not to say that regulating doctor behaviour and paying doctors on a salaried basis (or funding hospitals with fixed budgets) has no role in the community. But these are at best second-best solutions.

What then is the first-best policy solution? If it is the case that supplier-induced demand is simply free riding by another name, the answer is to ensure that the financial implications (market failure) of doctor behaviour are fully internalised. There are two complementary solutions to this. The first is to empower patients to resist over servicing. In my previous posting I put forward the case of governments creating Medicare Savings Accounts, abolishing community rating and making governments pay the actuarial risk premia to patients into MSAs. Under these reforms, patients will directly directly face the costs of their own health insurance, and will have a strong incentive in protecting their portion of the insurance pool. Doctors will not over service if the patient believes that the additional activity will not yield any additional benefits.

The second approach is not to employ and salary doctors but for them to own the health insurance business. Once doctors own the health insurance arm, they in effect internalise the costs of their own tendency to over service. Indeed, not only do patients have an incentive to look after their own health, but doctors will change their own behaviour away from simply disease treatment to disease prevention.

There is nothing in legislation or regulation that prevents doctors from starting their insurance fund, so in principle, it is possible. In Australia, however, there are a number of financial disincentives that inhibit such an institutional arrangement from arising. Two come to mind. First, there is little incentive for new businesses to enter into the health insurance industry. The presence of Medicare alone has severely curtailed the profitability (and degree of competition) among health insurers. When was the last time you read in the news of the start up of a new health insurer in Australia?

Second, since Medicare arrangements provide doctors with a nice little earner there is no incentive for them to champion a new world order of competition. You can bet your pretty penny that the Australian Medical Association will resist any attempts to reform Medicare. Replacing Medicare with MSAs implies greater competition for health insurance, which of course, doctors will not necessarily support.

This is not to say that doctor-owned insurance businesses do not exist. One standout example is the famous Kaiser Permanente of California. But a case study of Kaiser Permanente is for another posting.

regards

Doc Holliday

Insurance, the Market and those pesky wowsers (Doc Holliday) 3:19 AM

Now that my work has lightened up, I too will part a few shots at government and wowsers.

Health care puts forward a number of dilemmas for economists and policy makers. In this posting, I will consider the incentives and distortions that have arisen from government intervention in the provision of health insurance. I will also put forward a solution.

In any laissez faire insurance market, insurers charge insurance premiums that reflect the risk that people impose on the pool of insurance premiums. This is true for all insurance markets that I can think of - cars, houses, luxury boats, personal property. If you are 18 years old and park your Subaru WRX in Broadmeadows overnight, you pay the price!

Unfortunately, this doesn't occur in health. Instead, in every developed country that I can think of, everyone pays the average (pool) price - not the marginal cost. This is not because of a decision by health insurances but because of government regulation. The objective of community rating regulation as it is called, is to ensure that even the poorest can access affordable health care. Its effect is to smear insurance costs so that the rich and healthy subsidise the poor and the sick.

Community rating regulation appeared first in countries where private health insurance was the norm. But it also operates in the government-run single payer schemes (consider the National Health Service in the UK, Medicare in Australia and Canada). In these schemes, the costs of health insurance are smeared across tax-payers, not those seeking insurance. (The medicare levy surcharge is an exception, but this is only effective when we consider the role of Australia's Lifetime health cover rating system).

However, this has some rather unintended consequences (hello hello!). One is that it removes any incentive for individuals to adopt healthy life-styles. Why drink green tea and ride a bike to work if you know that someone else is paying for your healthcare?

In a laissez faire market, there would be a variety of insurance companies each offering slightly different products. Some might offer health-management organisation type contracts: you agree to change your behaviours (eg give up smoking) in return for discount insurance. (Funnily enough, the earliest health insurance schemes (organised by many religious and charitable organisations) at the turn of the 20th century did offer just that.)

But under community regulation, no one has an incentive to change their behaviour. This is a problem for both private health insurance schemes (as in US, Switzerland and Greece) and single-payer schemes (UK, Canada and Australia). In bid to protect the insurance pool against the threat of smoking and drinking geriatrics, wowsers step up to the plate to start issuing edicts: that shalt stop drinking, smoking, and growing old etc. The number of regulations that Roy posted are indeed scary. But in a dysfunctional market without marginal prices, the number of regulations can not but grow as bureaucrats scramble to change behaviour. Any market in which there are no prices will grow increasingly dysfunctional as successive layers of regulation are introduced to control it.

Is there a role for the market? I believe there is, and Australia already gives us an example. Some years ago (in 2000 I think), Australia introduced Lifetime health cover (LHC). It was introduced by the Howard Government in response to the adverse selection taking place as healthy people opted out of private health insurance to be covered by Medicare. LHC in effect penalises people incrementally the longer they remain privately uninsured. It acts like a second-best market price for private health insurance (PHI). The older and more likely you are to get sick, the more private health insurance will cost, so join up when

you're young. It doesn't give you the same incentive to change your lifestyles as an actuarially fair premium but its close. But it did influence PHI membership dramatically. It also demonstrates that people are sensitive to market prices - even for health insurance.

Back to my dilemmas for economists and policy makers. How do we get a healthcare system that is offers all the economic efficiencies that is currently lacking yet addresses the equity concerns of providing care for the poorest in the community? The obvious response is to introduce a voucher-type system. Governments provide individuals a voucher (it may be means-tested) to be spent on health insurance. The amount given to the individual reflects their risk-rating (so high risk individuals get paid more). Individuals can get to keep some of that voucher if they can demonstrate a reduction in their risk-rating (credited back to a Medicare Savings Account for use on a rainy, sick day). Individuals can use that voucher money to purchase private health insurance from any number of competing health insurers on the market.

There is another dilemma in health care that needs addressing - market power of medical professionals (doctors and surgeons). But that is for another posting.

regards

Doc Holliday.

2020 Health Overview (Doc Holliday) 6:44 AM

Australians are living longer than ever before. In 2004-05, the average life expectancy (at birth) of Australian men and women were 79 and 83 years. This makes Australian among the longest lived people in the world. The cost of health care is, for the moment, quite modest by international standards.

Yet there is quite a clear agreement that Australia’s health care system is stuffed, that somehow it is failing to deliver the sort of results that we would like. We have too many fat kids, kids that don’t exercise enough, kids that eat too much, kids with bad teeth, kids that smoke too much, kids that drink too much, kids that pop too many pills. It was so much better in our days – when all we could eat were lard sandwiches, smoke cigarettes behind the shed, and play football barefoot on the street, while our mothers were in the kitchen quietly dealing with an unwanted pregnancy. But no, our kids are too soft and we know what’s best for them.

But don’t just pick on the littlies. Why not the oldies? They’re too demented to know what’s good for them. Why, if only they exercised more and ate properly, they wouldn’t fall over and hurt themselves or clog up our hospitals with renal dialysis.

Then you’ve got the old (ho-hum) rugby scrum between the stern-looking guys in white coats and the witch-doctors promoting alternative therapies: ‘You can’t trust them holistic types, there’s no science in them’. And finally, there’s always that big bogey-man everyone loves to hate: big fat rich corporations (health insurance, pharmaceutical and, wait for it, oil companies) and professional associations (greedy doctors and dentists) all seeking for ways to rip you off.

There is one personality type that permeates the baying crowd: the one who knows the Truth. In his view all Australians should hike before breakfast, ride a bike to work, eat sushi for lunch, and have a cup of green tea after work. This one wants to ‘educate’ you, regulate you, provide you with all the infrastructure and incentives you would need, and then tax you to finance it all.

There is no doubt that Australia’s health-care industry can be improved. The problems almost always arise from the strange horse-trading that masquerades as government policy. There is, for a start, a rather odd relationship between Medicare and private health insurance (PHI): why should anyone take out PHI if Medicare is available for free? But Medicare is a major of problems because taxpayers are shielded from the effects that their lifestyle behaviours have upon the cost of the system. Fixing health insurance should be our first priority.

2020 Health Submission 4313 (Doc Holliday) 6:37 AM

I believe the Private Health Fund system is inefficient as there are too many funds which leads to much duplication of services. At the least the government should reduce the number of funds offering private insurance. This could be done by only allowing them. a reduced premium increase and letting market factors take their course. Those collapsed fund's members should be able to move to another fund without losing their accumulated benefits.

Better to put the several billions spent on private health insurance annually into public hospitals.

One of the great myths of the health insurance debate is that there is merit in having a single health insurer — that competition somehow leads to duplication.

The obvious extension of this logic is that all the clothes shops in Chapel St should be closed down, except one, since there is duplication. And while we’re at it, let’s close down all the souvlaki shops because, you know, there is duplication.

Where duplication does exist in health insurance, say in the number of actuaries employed, competition makes up for it through the innovation of new insurance products. Moreover, it is competition, not government mandate, that will eventually lead to lower insurance premiums — although the extent that this will occur will depend on how health care costs are controlled.

So if we have a single health insurer, why not make it publicly owned? And if we have a single clothes shop why not make it publicly owned too? Hell, why not combine clothes shops and souvlaki shops into Fur and Meat Emporiums and have the waif-thin fashionistas (‘That looks great on you’) teeter on high heels slicing lamb off the gyro.

Real reform to private health insurance can only be achieved by getting the right balance between private and public health insurance, and then deregulating health insurance to permit real competition. But we don’t like competition in health insurance.

‘Would you like yoghurt or sauce on your insurance policy, sir?’

Back of the envelope

• Cost --- Many billions
• Expected impact on average earnings --- Soviet era style living standards
• Expected impact on economic growth --- Big cut in GDP from reduced competition
• Impact on incentives --- Crappy customer service, poor health outcomes
• Impact on government spending --- big increase
• Impact on taxation --- big increase
• Winners --- Party officials
• Losers --- Everyone

2020 Health Submission 2015 (Doc Holliday) 6:23 AM

Dear reader, I have discovered on my hard drive a couple more health submissions from the book that never was. I will post them and the health over view over the forthcoming week. For those that are confused I suggest you reference the very earliest posts on this blogsite. Doc

Major medical problems in Australia due to obesity, smoking and alcohol need greater preventive campaigns and free behaviour change assistance for all people at risk.

This statement single handedly captures the ridiculousness of Australia’s Medicare system. What does ‘free behavioural change assistance’ really mean?

Medicare is compulsory national insurance: everyone contributes to it and is covered by it. However, contribution is based upon not the risk one poses to the national insurance pool, but by how much one can contribute. Thus a person’s lifestyle choice (how much they exercise, how much they eat, drink and smoke) has no bearing upon his or her financial contributions. Instead, he or she is covered, no matter what they do.

So unable to influence behaviour through the insurance system, governments instead focus on other ways to change behaviour. Government tend to lecture you (say, a multi-million dollar television campaign telling you that a glass of vino after work is the work of the devil). Governments can even get tough: ‘if we catch you drinking, or not exercising or smoking, then you are in really big trouble …’. But incentives are still important, so of course, there are many examples of governments turning to their own citizens to enforce is dictates.

So if you, Tim, plan to head off to the race track tomorrow to place a few bets, tug on a few ciggies, you better watch out. Somewhere there is a little boy scout ready to dob you into the re-education camp Stasi. Instead, treat the problem at its source, by fixing health insurance.

Back of the envelope

• Cost --- Multi millions
• Expected impact on average earnings --- Unchanged average weekly earnings except for public servants enforcing the law
• Expected impact on economic growth --- Big decrease in GDP as everyone lives in fear of little boy scouts
• Impact on incentives --- Don't do anything remotely fun, in case your neighbour thinks you're behaving suspiciously
• Impact on government spending --- big increase
• Impact on taxation --- big increase
• Winners --- re education camp managers, stasi officials and scouts
• Losers --- TAB Tim at the races