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Prioritisation, risk selection, and illness severity in a mixed healthcare system

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  • Olivella, Pau
  • Vera-Hernández, Marcos

Abstract

We study the link between illness severity and the use of public health care services by the privately insured under a mixed healthcare system. Our theoretical model shows that this relationship depends on (1) the prioritisation implemented by public healthcare providers, (2) the stringency of the gatekeeping system, (3) the skewness of the patients’ severity distribution, and (4) the private sector’s risk selection behaviour. Our empirical analysis reveals that the relationship between illness severity and public healthcare use is U-shaped. As our theoretical model points out, the increasing part of the U-shape is not necessarily a consequence of risk selection by private healthcare providers, but could instead reflect prioritisation within the public sector. According to our analysis, individuals in both extremes of the illness severity distribution will benefit from additional resources to shorten public sector waiting times.

Suggested Citation

  • Olivella, Pau & Vera-Hernández, Marcos, 2025. "Prioritisation, risk selection, and illness severity in a mixed healthcare system," Journal of Health Economics, Elsevier, vol. 104(C).
    • Handle: RePEc:eee:jhecon:v:104:y:2025:i:c:s0167629625001079
    DOI: 10.1016/j.jhealeco.2025.103072
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    1. Sofia Dimakou & Ourania Dimakou & Henrique Basso, 2015. "Waiting time distribution in public health care: empirics and theory," Health Economics Review, Springer, vol. 5(1), pages 1-27, December.
    2. Kaveh Danesh & Jonathan T. Kolstad & William D. Parker & Johannes Spinnewijn, 2024. "The Chronic Disease Index: Analyzing Health Inequalities Over the Lifecycle," NBER Working Papers 32577, National Bureau of Economic Research, Inc.
    3. Michael Rothschild & Joseph Stiglitz, 1976. "Equilibrium in Competitive Insurance Markets: An Essay on the Economics of Imperfect Information," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 90(4), pages 629-649.
    4. Pita Barros, Pedro & Siciliani, Luigi, 2011. "Public and Private Sector Interface," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 927-1001, Elsevier.
    5. Propper, Carol, 1993. "Constrained choice sets in the U.K. demand for private medical insurance," Journal of Public Economics, Elsevier, vol. 51(3), pages 287-307, July.
    6. Fabbri, Daniele & Monfardini, Chiara, 2009. "Rationing the public provision of healthcare in the presence of private supplements: Evidence from the Italian NHS," Journal of Health Economics, Elsevier, vol. 28(2), pages 290-304, March.
    7. Randall P. Ellis & Timothy J. Layton, 2014. "Risk Selection and Risk Adjustment," Boston University - Department of Economics - Working Papers Series wp2014-011, Boston University - Department of Economics.
    8. Pedro Pita Barros & Pau Olivella, 2005. "Waiting Lists and Patient Selection," Journal of Economics & Management Strategy, Wiley Blackwell, vol. 14(3), pages 623-646, September.
    9. Barros, Pedro Pita & Machado, Matilde P. & Sanz-de-Galdeano, Anna, 2008. "Moral hazard and the demand for health services: A matching estimator approach," Journal of Health Economics, Elsevier, vol. 27(4), pages 1006-1025, July.
    10. Søgaard, Rikke & Pedersen, Morten Saaby & Bech, Mickael, 2013. "To what extent does employer-paid health insurance reduce the use of public hospitals?," Health Policy, Elsevier, vol. 113(1), pages 61-68.
    11. Iversen, Tor, 1997. "The effect of a private sector on the waiting time in a national health service," Journal of Health Economics, Elsevier, vol. 16(4), pages 381-396, August.
    12. Grassi, Simona & Ma, Ching-to Albert, 2011. "Optimal public rationing and price response," Journal of Health Economics, Elsevier, vol. 30(6), pages 1197-1206.
    13. Mireia Jofre-Bonet, 2000. "Public health care and private insurance demand: The waiting time as a link," Health Care Management Science, Springer, vol. 3(1), pages 51-71, January.
    14. Chiara Canta, 2021. "Efficiency, access, and the mixed delivery of health care services," Journal of Public Economic Theory, Association for Public Economic Theory, vol. 23(3), pages 510-533, June.
    15. Neil J. Buckley & Katherine Cuff & Jeremiah Hurley & Logan McLeod & Robert Nuscheler & David Cameron, 2012. "Willingness‐to‐pay for parallel private health insurance: evidence from a laboratory experiment," Canadian Journal of Economics/Revue canadienne d'économique, John Wiley & Sons, vol. 45(1), pages 137-166, February.
    16. Brenna, Elenka & Giammanco, Maria Daniela, 2024. "The use of voluntary health insurance in the access to specialist care: Evidence from the Italian NHS," Socio-Economic Planning Sciences, Elsevier, vol. 93(C).
    17. Cristina Pardo-Garcia & Jose J. Sempere-Monerris, 2018. "Mixed provision of health care services with double coverage," Journal of Economics, Springer, vol. 123(1), pages 49-70, January.
    18. Chai Cheng, T & Vahid, F, 2010. "Demand for hospital care and private health insurance in a mixed publicprivate system: empirical evidence using a simultaneous equation modeling approach," Health, Econometrics and Data Group (HEDG) Working Papers 10/25, HEDG, c/o Department of Economics, University of York.
    19. Denise Doiron & Nathan Kettlewell, 2018. "The Effect of Health Insurance on the Substitution between Public and Private Hospital Care," The Economic Record, The Economic Society of Australia, vol. 94(305), pages 135-154, June.
    20. Marisol Rodríguez & Alexandrina Stoyanova, 2004. "The effect of private insurance access on the choice of GP/specialist and public/private provider in Spain," Health Economics, John Wiley & Sons, Ltd., vol. 13(7), pages 689-703, July.
    21. Propper, Carol, 2000. "The demand for private health care in the UK," Journal of Health Economics, Elsevier, vol. 19(6), pages 855-876, November.
    22. Erik Schokkaert & Tom Van Ourti & Diana De Graeve & Ann Lecluyse & Carine Van de Voorde, 2010. "Supplemental health insurance and equality of access in Belgium," Health Economics, John Wiley & Sons, Ltd., vol. 19(4), pages 377-395, April.
    23. Simona Grassi & Ching‐To Albert Ma, 2012. "Public Sector Rationing and Private Sector Selection," Journal of Public Economic Theory, Association for Public Economic Theory, vol. 14(1), pages 1-34, February.
    24. Martinussen, Pål E. & Magnussen, Jon, 2019. "Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS," Health Policy, Elsevier, vol. 123(7), pages 675-680.
    25. Ellis, Randall P., 1998. "Creaming, skimping and dumping: provider competition on the intensive and extensive margins1," Journal of Health Economics, Elsevier, vol. 17(5), pages 537-555, October.
    26. Propper, Carol & Rees, Hedley & Green, Katherine, 2001. "The Demand for Private Medical Insurance in the UK: A Cohort Analysis," Economic Journal, Royal Economic Society, vol. 111(471), pages 180-200, May.
    27. Sara Moreira & Pedro Pita Barros, 2010. "Double health insurance coverage and health care utilisation: evidence from quantile regression," Health Economics, John Wiley & Sons, Ltd., vol. 19(9), pages 1075-1092, September.
    28. Besley, Timothy & Hall, John & Preston, Ian, 1999. "The demand for private health insurance: do waiting lists matter?," Journal of Public Economics, Elsevier, vol. 72(2), pages 155-181, May.
    29. A. C. Cameron & P. K. Trivedi & Frank Milne & J. Piggott, 1988. "A Microeconometric Model of the Demand for Health Care and Health Insurance in Australia," The Review of Economic Studies, Review of Economic Studies Ltd, vol. 55(1), pages 85-106.
    30. Ross Abram & Margherita Borella & Mariacristina De Nardi & Rory McGee & Nicolò Russo, 2024. "Health inequality and economic disparities by race, ethnicity, and gender," IFS Working Papers W24/41, Institute for Fiscal Studies.
    31. Anikó Bíró, 2014. "Supplementary private health insurance and health care utilization of people aged 50+," Empirical Economics, Springer, vol. 46(2), pages 501-524, March.
    32. Wynand P. M. M. Ven & René C. J. A. Vliet & Richard C. Kleef, 2017. "How can the regulator show evidence of (no) risk selection in health insurance markets? Conceptual framework and empirical evidence," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 18(2), pages 167-180, March.
    33. Kullberg, Linn & Blomqvist, Paula & Winblad, Ulrika, 2022. "Does voluntary health insurance reduce the use of and the willingness to finance public health care in Sweden?," Health Economics, Policy and Law, Cambridge University Press, vol. 17(4), pages 380-397, October.
    34. Gutacker, Nils & Siciliani, Luigi & Cookson, Richard, 2016. "Waiting time prioritisation: Evidence from England," Social Science & Medicine, Elsevier, vol. 159(C), pages 140-151.
    35. Doiron, Denise & Fiebig, Denzil G. & Suziedelyte, Agne, 2014. "Hips and hearts: The variation in incentive effects of insurance across hospital procedures," Journal of Health Economics, Elsevier, vol. 37(C), pages 81-97.
    36. Pau Olivella & Marcos Vera‐Hernández, 2013. "Testing for Asymmetric Information in Private Health Insurance-super-," Economic Journal, Royal Economic Society, vol. 123(567), pages 96-130, March.
    37. Cheng, Terence Chai, 2014. "Measuring the effects of reducing subsidies for private insurance on public expenditure for health care," Journal of Health Economics, Elsevier, vol. 33(C), pages 159-179.
    38. Hugh Gravelle & Luigi Siciliani, 2008. "Is waiting‐time prioritisation welfare improving?," Health Economics, John Wiley & Sons, Ltd., vol. 17(2), pages 167-184, February.
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