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136 Maximum Billing Supplement KCE reports 80S 7 FINDINGS IN THE LITERATURE 7.1 SEARCH STRATEGY In order to find the relevant empirical articles, we performed a search in the Econlitdatabase looking for the search terms in the frame in the abstracts and the titles, with no language or time restrictions (search performed on November 6, 2007). We restricted the search to peer-reviewed journals. Limitation of the search to peerreviewed articles in the Econlit-database was done in order to obtain high quality articles with a focus on the economic impact of deductibles. The term deductible or its synonym had to be present in the abstract or title, because a more general review of the impact of price on medical care consumption had already been done in a previous research. 1 ("health care" OR "medical care" OR "health service*" OR "hospital care" OR "physician service*" OR "physician utili*ation" OR "GP care" OR "drug*" OR "specialist*" OR "medical service*" OR pharmaceutical* OR doctor* OR hospitalisation* OR hospitalization* OR treatment) AND ("deductible*" OR "cap" OR ceiling OR “annual limit*” OR “annual maxim*”) The search procedure resulted in 49 articles. 39 articles were irrelevant; they did not relate to health care (13), did not contain empirical results (2) or did not contain results on the impact of deductibles (24). We retained 10 articles (Contoyannis et al., 2005; Gerfin and Schellhorn, 2006; Keeler and Rolph, 1988; Newhouse et al., 1980; Schellhorn, 2001; Sule et al., 2002; Sule et al., 2005; van Vliet, 2001; van Vliet, 2004; Werblow and Felder, 2003). On the basis of the references and citations of the retained articles we found 10 additional papers (Eichner, 1989; Ellis, 1986; Ellis and McGuire, 1986; Keeler et al., 1988; Kephart et al., 2007; Kephart et al., 2003; Li et al., 2007; Lundin, 2000; Manning and Marquis, 1996; Werblow, 2002). Three of these however did not contain any new empirical results. The next paragraph summarizes the results of these articles. 7.2 SUMMARY OF EMPIRICAL RESULTS Table AX.1 gives an overview of the country of analysis and type of medical care in the 17 articles that were retained. 11 studies were published in the last 10 years (1997- 2007); the oldest dates back to 1980. All data relate to developed countries: USA (6 studies), Canada (5 studies), Switzerland (3 studies), the Netherlands (2 studies) and Sweden (1 study). Most studies (7) consider all medical care (sometimes with additional results for disaggregated categories); 6 studies focus on drugs, 2 on physician visits and 2 on ambulatory mental health care. Table AX.1 : Articles retained in the literature review Authors and publication year Country of analysis Type of medical care Contoyannis et al., 2005 Eichner, 1989 Ellis and McGuire, 1986 Gerfin and Schellhorn, 2006 Keeler and Rolph, 1988 Keeler et al., 1988 Kephart et al., 2007 Li X et al., 2007 Lundin, 2000 Manning and Marquis, 1996 Newhouse et al., 1980 Schellhorn, 2001 Sule et al., 2002 Sule et al., 2005 van Vliet, 2001 van Vliet, 2004 Werblow and Felder, 2003 Canada USA USA Switzerland USA USA Canada Canada Sweden USA USA Switzerland Canada Canada The Netherlands The Netherlands Switzerland Drugs All Mental health care Physician visits All (5 types; not mental) Mental health care Drugs Drugs Drugs All All Physician visits Drugs Drugs All (in 6 types) All (in 6 types) All
KCE Reports 80S Maximum Billing Supplement 137 7.2.1 Price elasticity and adverse selection All studies consider the impact of deductibles; the principal research question is the behavioural reaction of individuals to price. jj However, measurement of these effects is fraught with difficulties. A first difficulty relates to self selection: individuals in bad health have a tendency to buy more health insurance. If they have the choice, they will for instance choose smaller deductibles. When looking at expenditures of individuals with different deductibles, differences can be due to behavioural reaction to the coverage itself (which is usually indicated as moral hazard) but also to differences in health (selfselection or adverse selection). Three studies explicitly address this issue. 7,8,9 They all relate to Switzerland; the problem of self-selection is very pertinent in this country since a choice of deductible was introduced in the mandatory basic health insurance in 1996. All people face a small deductible below which they have to pay the full price and above which there is a co-payment. People can however choose a higher deductible, and will then receive a premium reduction. Schellhorn (2001) 8 estimates the impact of the deductible on the number of physician visits, taking into account the endogeneity of the choice of the deductible, with data from the Swiss Health Survey 1997 (one year after the reform). He observes that the probability of taking a higher deductible is positively affected by the existence of supplemental insurance cover and that a higher deductible is associated with a lower number of doctor visits. However, this seems to be the result of self-selection rather than a change in utilization behaviour. These results diverge from those of the two other studies that both find a significant moral hazard effect. Werblow and Felder (2003) 9 use a much larger claims dataset from a longer time period (1997-1999) and with richer information. They estimate the decision to consume and the amount of (all) expenditures, taking into account the endogeneity of the deductible chosen. Higher deductibles reduce the probability of consumption and the amount of consumption. For the smallest two deductibles, about 30% of reduced consumption is due to moral hazard and 70% to self-selection. For the highest two deductibles, these shares are reversed. In a third study, Gerfin and Schellhorn (2006) 7 use more recent data from the Health Interview Survey (year 2002) and a different model to estimate the impact of the deductible on the probability to go to the physician. The significant moral hazard effect is in line with Werblow and Felder (2003). 9 All other studies do not consider the endogeneity of the deductible. This is evident for Keeler and Rolph (1988) 2 , Keeler et al. (1988) 10 , Keeler et al. (1977) 11 and Manning and Marquis (1996) 12 since they use data from the Rand Health Insurance Experiment (HIE). This is an large experiment in the USA, which was designed to investigate the effects of cost-sharing without the problem of adverse selection. Families were randomly assigned to 14 different insurance plans, varying in coinsurance rate and cap on maximum spending. These insurance plans had a specified cap on cumulative OOP-spending (the Maximum Dollar Expenditure or MDE), after which the price for the patients is zero. Other studies do not consider the endogeneity because individuals are compared through time. 13,14,15,16,17,18 van Vliet (2001) 19 and van Vliet (2004) 20 do not control for endogeneity of deductibles, but their estimates control for health status. Moreover, they argue that self-selection is less of an issue in the Netherlands because the choice of a deductible tends to be permanent kk . Newhouse et al. (1980) 21 do not control for endogeneity but give no motivation. jj There are two exceptions that focus on the redistributional impact of drug subsidy programs on respectively the elderly 5 and the general population 6 in Canada. The empirical results indicate that for the elderly, a fixed transfer per household is to be preferred to drug subsidies on income distribution grounds. For the general non-senior population drug subsidies provide a greater reduction in the prescription drug budget shares of the low-income households; high deductibles however reduce redistribution. These articles are not further discussed in this paragraph. kk When people change the deductible this is regarded as a change in contract and premiums will then be adapted to people’s current health status (and such adaptations are not done in other circumstances). Since people know this, according to the authors, there will also be less self selection.
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