Contributions published at Applied Microeconomics (Peter Zweifel)

Regulation fostering Managed Care alternatives in health insurance is spreading. This work reports on an experiment designed to measure the amounts of compensation asked by the Swiss population (in terms of reduced premiums) for Managed-Care type restrictions in the provision of health care. It finds that restrictions on the freedom of physician choice would require an average compensation of more than one-third of the premium, while generic substitution even meets with a small willingness to pay. Marked preference heterogeneity is an argument against regulation imposing uniformity of contract in Swiss social health insurance.

This study applies financial portfolio theory to determine efficient electricity-generating technology mixes for Switzerland and the United States. Expected returns are given by the (negative of the) rate of increase of power generation cost. Volatility of returns relates to the standard deviation of the cost increase associated with the portfolio, which contains Nuclear, Run of river, Storage hydro and Solar in the case of Switzerland, and Coal, Nuclear, Gas, Oil, and Wind in the case of the United States. Since shocks in generation costs are found to be correlated, the seemingly unrelated regression estimation (SURE) method is applied for filtering out the systematic component of the covariance matrix of the cost changes. Results suggest that at observed generation costs in 2003, the maximum expected return (MER) portfolio for Switzerland would call for a shift towards Nuclear and Solar, and therefore away from Run of river and Storage hydro. By way of contrast, the minimum variance (MV) portfolio mainly contains Nuclear power and Storage hydro. The 2003 MER portfolio for the United States contains Coal generated electricity and Wind, while the MV alternative combines Coal, Nuclear, Oil and Wind. Interestingly, Gas does not play any role in the determination of efficient electricity portfolios in the United States.

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The aim of The Elgar Companion to Health Economics is to take an audience of advanced undergraduates, postgraduates and researchers to the frontier of research in health economics, by providing them with short and easily readable introductions to key topics. The volume brings together 50 chapters written by more than 90 leading international contributors. The contributions to the Companion are concise and focus on specific concepts, methods and key evidence.

A joint Wharton School–World Bank conference called attention to the high proportions of medical care spending paid out of pocket in most developing countries. One of the reasons for this, attendees said, is the problem in such economies of generating high tax revenues in a nondistortive way. Since people are paying out of pocket, they should be able to afford some private insurance that can spread the risk of above-average out-of-pocket payments. The potential efficiency gains from greater use of voluntary private insurance seem large, but there are a number of possible impediments to the emergence of such insurance.

Si stanno sempre più diffondendo forme di regolamentazione che promuovono alternative di managed care nell’ambito delle assicurazioni sanitarie. In questo lavoro viene riportato un esperimento che mira a determinare l’ammontare della compensazione richiesta dalla popolazione svizzera (in termini di riduzione del premio) quale indennizzo per l’introduzione di restrizioni di tipo managed care nell’offerta di assistenza sanitaria. L’esperimento evidenzia come restrizioni concernenti la scelta del medico richiederebbero un indennizzo medio superiore a un terzo del premio, mentre la sostituzione di farmaci di marca con generici richiederebbe un indennizzo piuttosto contenuto. La marcata eterogeneità delle preferenze costituisce un argomento a sfavore di una regolamentazione che punti a imporre contratti assicurativi uniformi nell’ambito del sistema sanitario svizzero di assicurazione sociale.

In the present allocation of resources in healthcare, preferences of consumers as the ultimate financiers of healthcare services are judged to be of little relevance. This state of affairs is being challenged because the past decade has seen great progress in the measurement of preferences, or more precisely, willingness-to-pay (WTP) as applied to healthcare services. This article reports evidence on WTP of the Swiss population with regard to three hypothetical modifications of the drug benefit to be covered by social health insurance: delaying access to the most recent therapeutic innovations (among them, drugs) by two years in exchange for a reduction of the monthly premium; substituting original preparations by generics, again in return for a lowered premium; and the exclusion of preparations for the treatment of minor complaints from the drug benefit. Using discrete-choice experiments, WTP and its determinants are estimated. Average WTP for avoiding such a delay (which acts across the board) is much higher than for eschewing the exclusive use of generics (which are claimed to be largely equivalent to the original) or the retention of 'unimportant' drugs in the list of benefits – a rating predicted by economic theory. In addition, a great deal of preference heterogeneity between the French-speaking minority and the German-speaking majority was found, pointing to considerable efficiency losses caused by uniformity of social health insurance.

Health insurance is potentially subject to risk selection, i.e. adverse selection on the part of consumers and cream skimming on the part of insurers. Adverse selection models predict that competitive health insurers can eschew high-risk individuals by offering contracts with low deductibles or co-payment rates, while attracting low-risk individuals with higher copayments, resulting in a separating equilibrium. This contribution seeks to determine whether in competitive Swiss social health insurance policies with deductibles in excess of the legal minimum do indeed serve as an instrument of risk selection. In a discrete choice experiment, effected in 2003, some 1,000 individuals were given the hypothetical choice of alternative insurance contracts that differed both in terms of deductibles and copayments and in bene.ts covered. Results suggest that healthy individuals, i.e. those not having consulted medical services during the past six months, were more likely to select a policy with a high deductible. Compensation demanded for voluntarily accepting an increase in the annual deductible also varies with socioeconomic characteristics and increases with the current level of deductible, as predicted by theory and constituting evidence in favor of the risk selection hypothesis. The experiment allows to compute necessary premium reductions and provides guidance for the pricing policy of insurers when offering differentiated products.

This contribution seeks to answer two related questions. First, what is the purpose of social health insurance? Or put in slightly different terms, what are the reasons for social (or public) health insurance to exist, even to dominate private health insurance in most developed countries? And second, what are the limits of social health insurance? Can one say that there is "too much" social health insurance in the following two senses: Should the balance be shifted towards the private alternative? And is the degree of coverage excessive?

Die Wirksamkeit und Sicherheit der beiden in der Schweiz zur Behandlung der Hepatitis C zugelassenen Kombinationstherapien (Pegasys®/Copegus®, PAC; PegIntron®/Rebetol®, PIR) ist sehr ähnlich. Das Ziel dieser Arbeit ist, die Kosten der beiden Therapien zu vergleichen und ihren kostengünstigsten Einsatz zu definieren. Die Durchschnittskosten für Genotyp-1-Patienten liegen zwischen CHF 21700.- (PAC) und CHF 19700.- (PIR), bzw. CHF 15600.- (PAC) und CHF 15000.- (PIR) für Genotyp-2/3-Patienten. Ein konsequenter Einsatz von PIR ist 9 bis 12% kostengünstiger als PAC. Weitere Kosteneinsparungen von 3% könnten bei einem Einsatz von PIR bei allen Patienten unter 85 kg (Genotyp 1) bzw. unter 75 kg (Genotyp 2/3) und von PAC bei solchen über 85 kg (Genotyp 1) bzw. über 75 kg (Genotyp 2/3) erreicht werden.

Health care may be similar to Sisyphus work: When the task is about to be completed, work has to start all over again. To see the analogy, consider an initial decision to allocate more resources to health. The likely consequence is an increased number of survivors, who will exert additional demand for health care. With more resources allocated to health, the cycle starts over again. The objective of this paper is to improve on earlier research that failed to find evidence of a Sisyphus syndrome in industrialized countries. This time, there are signs of such a cycle, which however seems to have faded away recently.

There is growing interest in discrete-choice experiments (DCE) as a method to elicit consumers' preferences in the health care sector. Increasingly this method is used to determine willingness-to-pay (WTP) for health-related goods. However, its external validity in the health care domain has not been investigated until today. This paper examines the external validity of DCE concerning the reduction of a health risk. Convergent validity is examined by comparing the value of a statistical life with other preference elicitation techniques, such as revealed preference. Criterion validity is shown by comparing WTP values derived from stated choices in the experiment with those derived from actual choices made by the same individuals. Both tests provide strong evidence in favor of external validity of the DCE method.

Regulation fostering Managed Care alternatives in health insurance is spreading. This work reports on an experiment designed to measure the amounts of compensation asked by the Swiss population (in terms of reduced premiums) for Managed-Care type restrictions in the provision of health care. It finds that restrictions on the freedom of physician choice would require an average compensation of more than one-third of the premium, while generic substitution even meets with a small willingness to pay. Marked preference heterogeneity is an argument against regulation imposing uniformity of contract in Swiss social health insurance.

This article evaluates three measures introduced by the Australian Federal Government in 1999 and 2000 that were designed to encourage private health insurance and relieve financial pressure on the public healthcare sector. These policy changes were (i) a 30% premium rebate, (ii) health insurers offering lifetime enrolment on existing terms and the future relaxation of premium regulation by permitting premiums to increase with age, and (iii) a mandate for insurers to offer complementary coverage for bridging the gap between actual hospital billings and benefits paid. These measures were first evaluated in terms of expected benefits and costs at the individual level. In terms of the first criteria, the policy changes as a whole may have been efficiency-increasing. The Australian Government mandate to launch gap policies may well have created a spillover moral hazard effect to the extent that full insurance coverage encouraged policy holders to also use more public hospital services, thus undermining the government's stated objective to relieve public hospitals from demand pressure. Without this spillover moral hazard effect, there might have been a reduction in waiting times in the public sector. Secondly, the measures were evaluated in terms of additional benchmarks of the cost to the public purse, access and equity, and dynamic efficiency. Although public policy changes were found to be largely justifiable on the first set of criteria, they do not appear to be justifiable based on the second set. Uncertainties and doubts remain about the effect of the policy changes in terms of overall cost, access and equity, and dynamic efficiency. This is a common experience in countries that have considered shifts of their healthcare systems between the private and public sectors.