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Insurance reimbursement

In: Handbook of Health Economics

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  • Pauly, Mark V.
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    Abstract

    This paper discusses theoretical and empirical findings concerning insurance reimbursement of patients or providers by insurers operating in private markets or in mixed public and private systems. Most insurances other than health insurance do not "reimburse"; instead they pay cash to insureds conditional on the occurrence of a prespecified event. In contrast, health insurance ties the payment to medical expenditures or costs incurred in some fashion, often making payments directly to medical providers. These differences are caused by a much higher degree of moral hazard and the dominant effect of insurer demand on provider prices. Health insurances also often prohibit "balance billing," provider charges in excess of some prespecified amount. Such prohibitions are related to patient inability to shop or bargain, and to insurer market power.Empirical evidence suggests that some versions of physician and hospital reimbursement have increased the level of medical spending relative to the level that would be experienced under prospective payment. In particular, cost-based reimbursement raises total spending. Optimal reimbursement, with balance billing prohibited, may also be chosen to control moral hazard; payment will generally involve a mix of fee-for-service and predetermined (salary or capitation) payment, and may well involve positive patient cost sharing. Monopsony behavior by dominant insurers is possible, and may improve consumer welfare but not total welfare.

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    This chapter was published in:

  • A. J. Culyer & J. P. Newhouse (ed.), 2000. "Handbook of Health Economics," Handbook of Health Economics, Elsevier, edition 1, volume 1, number 1, 00.
    This item is provided by Elsevier in its series Handbook of Health Economics with number 1-10.

    Handle: RePEc:eee:heachp:1-10

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    Web page: http://www.elsevier.com/wps/find/bookseriesdescription.cws_home/BS_HE/description

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    Cited by:
    1. Karen Eggleston & Anupa Bir, 2009. "Measuring Selection Incentives in Managed Care: Evidence From the Massachusetts State Employee Insurance Program," Journal of Risk & Insurance, The American Risk and Insurance Association, vol. 76(1), pages 159-175.
    2. Eggleston, Karen, 2005. "Multitasking and mixed systems for provider payment," Journal of Health Economics, Elsevier, vol. 24(1), pages 211-223, January.
    3. Richard Watt & Francisco Vázquez, 2009. "Optimal accident compensation schemes," Spanish Economic Review, Springer, vol. 11(1), pages 75-82, March.
    4. Liliana Chicaíza & Fredy Rodríguez & Mario García, 2006. "La equidad del mecanismo de pago por uso de servicios en el sistema de aseguramiento en salud de Colombia," Revista de Economía Institucional, Universidad Externado de Colombia - Facultad de Economía, vol. 8(15), pages 269-289, July-Dece.
    5. Lecluyse, Ann & Van de Voorde, Carine & De Graeve, Diana & Schokkaert, Erik & Van Ourti, Tom, 2009. "Hospital supplements in Belgium: Price variation and regulation," Health Policy, Elsevier, vol. 92(2-3), pages 276-287, October.
    6. Powell-Jackson, Timothy & Hanson, Kara & Whitty, Christopher J.M. & Ansah, Evelyn K., 2014. "Who benefits from free healthcare? Evidence from a randomized experiment in Ghana," Journal of Development Economics, Elsevier, vol. 107(C), pages 305-319.

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