Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana
Tóm tắt
Utilization of healthcare in Ghana’s novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme’s financial sustainability. This paper investigates the presence of adverse selection by assessing the effect of healthcare utilization and frequency of use on NHIS renewal. Routine enrolment and utilization data from 2008 to 2013 in two regions in Ghana was analyzed. Pearson Chi-square test was performed to test if the proportion of insured who utilize healthcare in a particular year and renew membership the following year is significantly different from those who utilize healthcare and drop-out. Logistic regressions were estimated to examine the relationship between healthcare utilization and frequency of use in previous year and NHIS renewal in current year. We found evidence suggestive of the presence of adverse selection in the NHIS. Majority of insured who utilized healthcare renewed their membership whiles most of those who did not utilize healthcare dropped out. The likelihood of renewal was significantly higher for those who utilize healthcare than those who did not and also higher for those who make more health facility visits. The NHIS claims bill is high because high risk individuals who self-select into the scheme makes more health facility visits and creates financial sustainability problems. Policy makers should adopt pragmatic ways of enforcing mandatory enrolment so that low risk individuals remain enrolled; and sustainable ways of increasing revenue whiles ensuring that the societal objectives of the scheme are not compromised.
Tài liệu tham khảo
WHO. Fifty-eighth World Health Assembly - Resolutions and Decisions. Switzerland, Geneva: WHO; 2005.
Chankova S, Sulzbach S, Diop F. Impact of mutual health organizations: evidence from West Africa. Health Policy and Planning. 2008;23:264–76.
Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy and Planning. 2004;19:249–70.
NHIA. National health insurance authority 2012 annual report. Accra-Ghana: NHIA; 2013. http://www.nhis.gov.gh/files/2012%20NHIA%20ANNUAL%20REPORT.pdf. Accessed on 10 May 2015.
Xu K, Evans D, Kawabata K, Zeramdini R, Klavus J, Murray C. Household catastrophic health expenditure: a multicountry analysis. Lancet. 2003;362:111–7.
Sulzbach S. Evaluating the Impact of National Health Insurance in Ghana. Accra: Health Systems 20/20; 2008.
Mensah J, Oppong J, Schmidt C. An evaluation of the Ghana national health insurance scheme in the context of the health MDGs. Health Econ. 2010;19(S1):95–106.
GOG. The National Health Insurance Act: Act 650. Accra: Government of Ghana; 2003. http://d1020125.u42.pws-servers.com/UploadFiles/Publications/National%20Health%20Insurance%20Act090407134319.pdf. Accessed 11 May 2015.
Keane M, Stavrunova O. Adverse selection, moral hazard and the demand for Medigap insurance. 2014. https://www.nuffield.ox.ac.uk/economics/papers/2014/PaperApril2014_3.pdf. Accessed 21 May 2015.
Arrow K. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53(5):941–73.
Blanchet NJ, Fink G, Osei-Akoto I. The effects of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Medical Journal. 2012;46(2):76–84. 2012.
Cutler DM, Zackhauser RJ. Adverse selection in health insurance; in frontiers in Health. Policy Research. 1998;1:1–32.
Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica. 1979;47(2):263–92.
Anderson M, Dobin C, Gross T. The effect of health insurance coverage on the use of medical services. Am Econ J Econ Pol. 2012;4(1):1–27.
Card D, Dobkin C, Maestas N. The impact of nearly universal insurance coverage on health care utilization: evidence from Medicare. Am Econ Rev. 2008;98:2242–58.
Meer J, Rosen HS. Insurance and the utilization of medical services. Soc Sci Med. 2004;58(9):1623–632.
Johnson RW, Crystal S. Uninsured status and Out-of-pocket costs at midlife. Health Serv Res. 2000;35(5):911–32.
Preker AS, Carrin G, Dror D, Jakab M, Hsiao W, Arhin-Tenkorang D. Effectiveness of community health financing in meeting the cost of illness. Bull World Health Organ. 2002;80:143–50.
Robyn PJ, Barnighausen T, Souares A, Savadog G, Bicaba B, Sie A, Sauerborn R. Does enrolment status in community-based insurance lead to poorer quality of Care? Evidence from Burkina Faso. Int J Equity Health. 2013;12:31–44.
Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC International Health & Human Rights. 2009;9(1):20.
Neudeck W, Podczeck K. Adverse selection and regulation in health insurance markets. J Health Econ. 1996;15(4):387–408.
Pauly MV. Overinsurance and public provision of insurance: the roles of moral hazard and adverse selection. Q J Econ. 1974;88(1):44–62.
Sapelli C, Vial B. Self-selection and moral hazard in Chilean health insurance. J Health Econ. 2003;22(3):459–76.
Savage E, Wright DJ. Moral hazard and adverse selection in Australian private hospitals: 1989–1990. J Health Econ. 2003;22(3):331–59.
Parmar D, De Allegri M, Savadogo G, Sauerborn R. Adverse selection in a community-based health insurance scheme in rural Africa: implications for introducing targeted subsidies. BMC Health Serv Res. 2012;12:181–8.
Simon KI. Adverse selection in health insurance markets? Evidence from state small-group health insurance reforms. J Public Econ. 2005;89(9–10):1865–77.
Wang H, Zhang L, Yip W, Hsiao W. Adverse selection in a voluntary rural mutual health care health insurance scheme in China. Soc Sci Med. 2006;63(5):1236–45.
Noterman JP, Criel B, Kegels G, Isu K. A prepayment scheme for hospital care in the Masisi district in Zaire: a critical evaluation. Soc Sci Med. 1995;40(7):919–30.
Dror DM, Soriano ES, Lorenzo ME, Sarol Jr JN, Azcuna RS, Koren R. Field based evidence of enhanced healthcare utilization among persons insured by micro health insurance units in Philippines. Health Policy. 2005;73(3):263–71.
De Allegri M, Kouyate B, Becher H, Gbangou A, Pokhrel S, Sanon M, Sauerborn R. Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case–control study in rural Burkina Faso. Bulletin of World Health Organization. 2006;84(11):852–8.
Resende M, Zeidan R. Adverse selection in the health insurance market: some empirical evidence. European Journal of Health Economics. 2010;11(4):413–8.
Rajkotia Y, Frick K. Does household enrolment reduce adverse selection in a voluntary health insurance system? Evidence from the Ghanaian health insurance system. Health Policy and Planning. 2012;27(5):429–37.
Amponsah S. Adverse selection, moral hazard and income effect: the case of Ghana. Bulletin of Political Economy, Tokyo International University. 2013;14:1–20.
GSS. 2010 Population and Housing Census. Accra, Ghana: Ghana Statistical Service; 2011. http://www.statsghana.gov.gh/docfiles/2010phc/Census2010_Summary_report_of_final_results.pdf. Accessed on 11 May 2015.
NHIA. National health insurance authority 2009 annual report. Accra-Ghana: NHIA; 2010. http://www.nhis.gov.gh/files/1(1).pdf.
NHIA. National health insurance authority 2011 annual report. Accra-Ghana: NHIA; 2012. http://www.nhis.gov.gh/files/annualreport2011.pdf. Accessed on 10 May 2015.
NHIA. National health insurance authority 2013 annual report. Accra-Ghana: NHIA; 2014. http://www.nhis.gov.gh/files/2013%20Annual%20Report-Final%20ver%2029.09.14.pdf. Accessed on 10 May 2015.
Cutler DM. Public policy for health care. NBER Working Paper no. 5591. Cambridge: National Bureau of Economic Research, Inc.; 1996. http://www.nber.org/papers/w5591.pdf. Accessed 21 Nov 2015.
Atim C. Contribution of mutual health organizations to financing, delivery, and access to health care: Synthesis of research in nine West and Central African countries. PHR Technical Report No. 18. Bethesda, MD: Partnerships for Health Reform, Abt Associates Inc.; 1998.
Diop F. Determinants of financial stability of mutual health organizations in the Thies region of Senegal: Household survey component. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc.; 2005.