CAN WE DESIGN A MARKET FOR COMPETITIVE HEALTH INSURANCE?
The most important evidence on this issue to Australia comes from a number of demonstration
projects, the Co-ordinated Care Trials, which were established in the mid 1990s. The Trials combined
the funds from medical benefits (for which the Commonwealth is the source), pharmaceutical
benefits (Commonwealth), public hospitals (States and Territories), and the community health
program (also States and Territories) for a defined group of individuals with some form of chronic
condition under an agency which was responsible for co-ordinating and managing their care
(Duckett 2000). The demonstration and evaluation is the largest health services research project
yet mounted in Australia. Evaluation results were equivocal in terms of whether outcomes
were improved and costs were reduced, but a number of the trials were not financially viable
(Commonwealth Department of Health and Aged Care 2001). The budgets were notional rather
than real, and the care co-ordinator was not at any financial risk, so the incentives were muted.
This is not conclusive evidence that there is no benefit to be gained from funds pooling in Australia,
but it certainly does demonstrate that greater efficiency or lower costs are not simply attained by
combining funds from different sources under one case manager.
Cross-country comparisons of health care expenditure also throw some light on how the
organisation of health care services might affect levels of health care expenditure. Overall spending
control has been achieved best in those countries with a strong, ie single, public funder responsible
for both funding and provision of health care (Gerdtham, Jonsson 2000). Insurance systems with
multiple contracting arrangements have higher administrative costs. Strong funder organisations
are also able to exert pressure on provider prices; the extreme example is the US where much
of the higher spending on health care is due to higher provider incomes rather than increased
consumption of services (OECD 2000; Anderson, Reinhardt et al. 2003).
THE EVIDENCE ON CONSUMER CHOICE AND SATISFACTION
US style managed care has a poor popular image that has extended to Australia. The impression
is one of unsympathetic, untrained and unknown persons denying useful care to those unfortunate
enough to be severely ill or disabled (Harris, Ripperger et al. 2000; Robinson 2000; Gold 2003). The
evidence from systematic attempts to measure consumer satisfaction from the US, as for other
aspects of managed care, is mixed, both in general, and for low income groups and those with
chronic care (Miller, Luft 1997).
There has been substantial research into the factors affecting consumer decisions on insurance,
using qualitative approaches, and choice modelling using both revealed and stated preference data
(Scanlon, Chernew et al. 1997; Chernew, Scanlon 1998). The factors that have been consistently
shown to influence choice are the cost of insurance, the extent of services covered, the choice of
doctors, and quality (Chakraborty, Ettenson et al. 1994; Isaacs 1996; Scanlon, Chernew et al. 1997;
Tumlinson, Bottigheimer et al. 1997). While insurers have responded by providing more information
on plan performance, consumers report difficulties in understanding the information presented
to them (Gibbs, Sangl et al. 1996; Jewett, Hibbard 1996; Tumlinson, Bottigheimer et al. 1997).
Consumers also report that choosing an insurer is difficult and frustrating (Sainfort, Booske 1996). In
one study, only 30% of respondents were able to accurately report the main features of their health
insurance plans (Cunningham, Denk et al. 2001); and in another 67% of enrollees in a Preferred
Provider Organisation (PPO) did not understand the difference between that form of insurance and
fee for service coverage (Isaacs 1996).
If many consumers find it difficult to understand the features of the health insurance system, and
the information presented to them on individual insurance packages, do they nonetheless change
insurers? Davis and Schoen found in a large study of US working age adults that most changes
of insurer were initiated by changes in employment or eligibility, or by the employers’ decisions to
change insurers rather than individual decisions (Davis, Schoen 1997). Further, these authors report
that half the respondents said that changing insurance plans involved changing doctors and that this
would discourage switching. The relationship between insurance and employment that is a feature
of the US system is not proposed in Scotton’s Australian model, and so caution must be exercised in
extending these results. Nonetheless, the body of evidence suggests that consumers find it difficult
to understand health insurance and information on insurance plan performance, and as a result
may be reluctant to change insurers