外文翻譯 瑞士社會健康保險：共同支付

1、外文文獻(xiàn)翻譯材料（2010屆） 瑞士社會健康保險：共同支付學(xué)生姓名 學(xué) 號 院 系 醫(yī) 學(xué) 院 專 業(yè) 公共事業(yè)管理(衛(wèi)生事業(yè)管理) 指導(dǎo)教師 填寫日期 swiss social healthinsurance: co-paymentsworkstefan felder andandreas werblowfrom the perspective of an insurance community,co-payments are only interesting if they affect total expenditure by a decrease in the probability

2、or the size of damages. if the insured take preventiveactions to reduce the risk or change their behavior when damages occur, their expenditure will decrease. if insurance coverage is comprehensive,important incentives for prevention and restricting damages are absent. economists speak of moral haza

3、rd, referring to the effect of the extent of insurance coverage on the behavior of the insured.in health insurance, the insured have a particularly large influence on the amount of services they demand. healthy food, sufficient physical motion, prevention of stress, all these reduce the probability

4、of an illness. moreover, the behavior in case of an illness, i.e.the choice of therapy or the patientscompliance with the physiciansprescriptions will substantially affect health care expenditure. do copayments reduce moral hazard in health insurance?swiss social health insurance is an ideal candida

5、te for studying this issue, as co-payments have a long tradition there.characteristics of the swiss health insurance systemin switzerland, 100 percent of the population is enrolled in the statutory (basic) health insurance system. in the complementary private insurancesector, the equivalence princip

6、le holds the insured pay risk equivalent premiums. by comparison,community rating applies in social health insurance, i.e. every person within a sickness fund pays the same premium irrespective of his/her risk.this implies that the so-called good risks (persons whose payments exceed their expected e

7、xpendisubsidize the bad risks (persons with payments below the expected expenditure). with thegiven health care expenditure profiles, community rating means for instance that the young subsidize the old and that men subsidize women.in contrast to germany and other countries,switzerland does not impo

8、se any substantial interregional redistribution in financing health care.premiums are differentiated according to regional differences in health care expenditure. furthermore,contributions to health insurance are not paid from the payroll but function as in other insurance sectors.every individual a

9、dult, adolescent or child therefore pays his/her own premium. nevertheless, lowincome persons receive a subsidy from the local government as well as from the federal state to pay for health insurance. the average health insurance premium is around170 per month.co-payments in swiss health insurance i

10、nclude a minimal160 deductible per year. expenditure that exceeds this threshold is subject to a 10 percent co-insurance rate. the system is capped: the maximum co-payment for a person is560. this implies that medical bills up to4,160 ( 160 plus4,000) are subject to demand-side co-insurance.90 perce

11、nt of the insured have expenditure below this threshold. exemptions for chronically ill or low-income persons from the compulsory copaymentrules do no exist. this consistent employment of coinsurance is directed at moral hazard.the adverse equity implication is seen as the pricethat the community mu

12、st pay for achieving a more efficient use of health care services.in switzerland, the insured can opt for a deductible above160. the optional deductibles amount to270, 400, 800 and1,000.they come with(maximal) premium rebates of 8 percent, 15 percent,30 percent and 40 percent. the 10 percent coinsur

13、ance rate for expenditure above the deductible does not change. this is also valid for the cap, which is only adjusted by the chosen deductible.the goal of the optional deductibles is to influence the demand for health care services by the insured,i.e. to fight moral hazard. however, there is a disa

14、dvantage to these options. they allow the insured to choose the insurance contract that suits their expected health care expenditure best. in other words, good risks will opt for a high deductible, whereas bad risks will stay put with the compulsory minimal deductible.still, even though individuals

15、will rationally choose the size of the deductible, the incentives of the measure remain.yet, they are reinforced since the extentof co-payments has been enlarged by these options.moral hazard or self-selection? that is the question!while 60 percent of the insured stick to the minimal deductible, 40

16、percent choose one of the higher deductibles (see fig. 1 that summarizes the shares for a representative sample of 60,000 persons in the canton of zurich). of these individuals,three fourths opted for the270 deductible. the figure reveals a substantial decrease in gross healthcare expenditure with a

17、n increasing deductible. a person with the minimal deductible (160) on average incurred2,150 health care expenditureper year; the average in the highest deductible(1,000) only amounted to510.the second bar in each category of figure 1 represents health care expenditure net of the patientsco-payments

18、. the third bar illustrates the average premium per deductible. a comparison with the expenditures shows that despite large rebates, a substantially financial redistribution from low- to high-risk individuals occurs.these observations do not tell whether the lower expenditure in the higher deductibl

19、e classes is inthe first place a consequence of the contract selection by the insured, expecting different future health care expenditure, or whether it is a reflection of a change in the behavior of the insured.one would expect that both self-selection and moral hazard matter. the separation of the

20、 two effects is methodologically challenging, as the two simultaneously show up in the health care expenditure data.while one observes lower expenditure of the insured who have opted for a high deductible, one does not know the reason for it.in the 1980s, the rand corporation sponsored an extensive

21、study designed to detect the price effect of deductibles on the demand for health care. in a controlled randomized experiment, persons were allocated with health insurance contracts that differed with respect to the co-insurance rate. since the persons had no possibility to choose their contract,a s

22、election effect could be excluded. on average,the rand researchers detected a reduction of 20-30 percent in the demand for health care dueto co-insurance (see manning et al. 1987).in the swiss system, persons have the choice between different deductibles. if one expects that the choice reflects the

23、expectation of future health care expenditure, the problem of self-selection can be solved by explicitly incorporating the choice of contracts.this, indeed, was the approach we took in the swissstudy. in the first step, we estimated the choice of the individuals with respect to the size of the deduc

24、tible. in the second step, taking into account the results of the first step, we estimated the influence of thedeductibles on the demand for health care services.three months prior to the end of one year, an insured has to choose the deductible in hishealth insurance contract for the next year. in t

25、his decision,he/she will take into account the health-care expenditure he/she expects for the following year. if the premium rebate exceeds the expected additionalco-payments, he/she will likely opt for a high deductible.why should a person who expects very low health-care expenditure not go for the

26、 highest deductible? a chronically ill person, by comparison,will likely adhere to the minimal deductible.in the swiss study we modeled the contract choice using individualhealth care expenditure data of the following three years, 19971999. the expenditure in 1997 and 1998 were used to form the expe

27、ctation offuture expenditure, as they indicate the health status of an individual. additional explanatory variables for the choice of the contract for 1999 are the individuals age, sex,income as well as his/her premium (for details, see werblow and felder 2003).the estimation results confirm the hyp

28、otheses:the higher health care expenditure in the past, the higher the probability that an individual distances himself from choosing an optional (higher)deductible. low-income individuals likewise prefer the compulsory minimal deductible. individuals with a low income fear the risk of high co-payme

29、nts more than high-income persons. individuals living in high-premium regions more likely choose a higher deductible. this has to do with the regulationof proportional rebates. for any deductible,the rebate in absolute terms, therefore, increases with the premium level. for this reason, in highpremi

30、um regions, it is more profitable to restrict insurance coverage by means of a high deductible.does moral hazard exist in swiss health-care insurance?in the second step of the estimation, we dealt with the explanation of the demand for health-care services,given the choice of contract. by taking int

31、o account the endogeneity of the choice, it is possible to net-out the effect of selection from the change in demand. in the second estimation, age, sex and income, but also supply-side factors such as thedensity of physicians in the neighborhood of an insured serve as explanatory variables for the

32、demand for health-care services. the estimation results confirm to a large extent the existence of moral hazard. despite self-selection, health-care expenditure for high-deductible individuals is significantly lower compared to individuals with a minimal deductible.figure 2 summarizes the results fo

33、r an average male person. the first bar in each category shows the observed reduction of health-care expenditure for the four optional deductibles compared to the level of the minimal deductible (corresponds to the bars in fig. 1). the next two bars present the division of this change between self-s

34、election andmoral hazard.a forty-year-old man who opted for a deductible of270 on average incurs 30 percent lower health care expenditure than a man of the same age and a minimal deductible of 160. two thirds of this reduction are according to our estimations due to self-selection. the remaining one

35、 third is caused by a change in behavior. the same divisionbetween self-selection and moral hazard occurs at the deductible level of 400.for the two highest deductibles, moral hazard is more prone. of the observed change in health care expenditure 70 percent is due to moral hazard.with a higher redu

36、ction of health-care expenditure in total, self-selection makes up 30 percent.deductibles in switzerland reduce health-care demandthe swiss social health insurance system includes differentiated optional deductible schemes. the insured appear to deal rationally with these options, i.e. as in other i

37、nsurance sectors theychoose their coverage depending on the expected damages and the premiums. our study based on health-care expenditure data of 60,000 individuals shows that price signals from deductibles significantly affect behavior even when taking into account the endogeneity of the contract c

38、hoice.optional deductibles substantially reduce healthcare expenditure.even though part of the reduction of health care expenditure is due to the rational choice of contracts,co-insurance induces a change in demandthat significantly contributes to the reduction.depending on the size of the deductibl

39、e, between one third and 70 percent is due to moral hazard.furthermore, the higher the deductible, the higher the change in behavior of the insured.there is an efficiency-equity trade-off when the government goes for optional deductibles in social health insurance. however, it is noteworthy that the

40、re is an efficiency gain involved. if demand-side coinsurance in health care were only redistributive,no one would have to care about co-insurance.the efficiency-equity trade-off can be handled with restricting the rebate, which persons can attain whenever they choose a higher deductible. it is impo

41、rtant, however, that some incentives for the insured remain, taking into account the costs whenever they demand health care services.conclusionpatients co-payments are a suitable measure to reduce health care expenditure. they positively affect prevention and foster the expenditureawareness of the i

42、nsured. these effects can be identified in swiss social health insurance, a system that contains a compulsory deductible of 200 extended by optional deductibles up to 1,000.瑞士社會健康保險：共同支付stefan felder醫(yī)學(xué)博士.教授andreas werblow經(jīng)濟(jì)學(xué)博士.教授馬格德堡大學(xué)概要從保險的角度出發(fā)，共同付款唯一所關(guān)心的是它們是否影響總的支出或減少被保險人的損傷大小概率采取預(yù)防行動，以減少風(fēng)險或改變他們的行

43、為。當(dāng)損害發(fā)生時，他們的開支將會減少，如果保險覆蓋面是全面的話。重要誘因預(yù)防和限制賠償。經(jīng)濟(jì)學(xué)家談?wù)摰赖嘛L(fēng)險是指對被保險人行為的保險覆蓋范圍的影響。在醫(yī)療保險中，被保險人有一個特別大的影響，他們的服務(wù)量需求。健康的食物，足夠的物理運動，預(yù)防壓力，所有這些減少疾病的概率。還有，在生病時的行為，治療或即經(jīng)選擇的患者遵守醫(yī)師的處方會嚴(yán)重影響醫(yī)療支出費用。做共同支付可以減少健康保險的道德風(fēng)險嗎？瑞士社會醫(yī)療保險為研究這個問題提供了理想的方案，作為共同支付，是一個有悠久傳統(tǒng)。特色的瑞士醫(yī)療保險系統(tǒng)在瑞士，百分之百的人參加了法定（基本）醫(yī)療保險系統(tǒng).在私人保險的補(bǔ)充部門，等價原則認(rèn)為，在被保險人支付的風(fēng)險

44、等價保費。通過對照，社會評價適用于社會健康保險，每個人在生病基金支付同樣的保費，不論他/她的風(fēng)險。這意味著，所謂的良好的風(fēng)險（支付超過其預(yù)期支出）資助的不良風(fēng)險（低于預(yù)期的支出款項的人）。隨著提供健康服務(wù)的開支概況，社區(qū)等級代表了年輕的補(bǔ)貼，例如老人和婦女，男人補(bǔ)貼。相對于德國和其他國家，瑞士沒有施加任何實質(zhì)性區(qū)域間的再分配醫(yī)療融資。保費是根據(jù)區(qū)域差異在衛(wèi)生保健的差異開支。此外，醫(yī)療保險費不從工資支付，但在其他保險行業(yè)，每個人包括成人，青少年或兒童都有支付他/她自己的費用。還有，低收入者可以得到當(dāng)?shù)卣a(bǔ)貼以及從聯(lián)邦政府支付健康保險，平均健康醫(yī)療保險費大約在每月170歐元。共同支付在瑞士的醫(yī)療

45、保險金每年最少包括160歐元，開支超過這個閾值是要受百分之十的共同保險率，結(jié)果顯示：這最大共同支付為每人 560歐元。這意味著，醫(yī)療費用高達(dá)4160歐元（160歐元加4000歐元）受需求方面的共同保險。90%被保險人開支在這標(biāo)準(zhǔn)以下，長期病患者或低收入者強(qiáng)制豁免部分負(fù)擔(dān)的規(guī)則不復(fù)存在，這種一致共同保險是針對道德風(fēng)險的要求。不良資產(chǎn)的影響被認(rèn)為是價格的社會必須實現(xiàn)的衛(wèi)生保健服務(wù)的更有效的利用。在瑞士，被保險人可以選擇一個扣除160歐元以上，也可選免賠額金額為 270歐元、400歐元、歐元800和歐元1000的。他們提出（最大）的保險費回扣8%，15%、30%、40%，對于上述扣減開支百分之十共同

46、保險率不會改變。這也是有效的上限，這是唯一的選擇調(diào)整扣除?？蛇x免賠額的目標(biāo)是影響由被保險人的醫(yī)療服務(wù)需求，對抗道德風(fēng)險，然而，是對這些選項的缺點。他們允許被保險人選擇適合自己的保險合同，符合預(yù)期的最好的醫(yī)療開支，換句話說，良好的風(fēng)險會選擇一個高扣除，壞的風(fēng)險便會停滯不前的強(qiáng)制性最低扣除。不過，即使個人將理性地選擇該扣除的規(guī)模，鼓勵措施的多邊環(huán)境協(xié)定，然而，他們是因為共同支付的范圍已擴(kuò)大了強(qiáng)化這些選項。道德風(fēng)險或自我選擇？ - 這就是問題所在！雖然百分之六十被保險人堅持最小扣除，同時百分之四十選擇一個較高的免賠額（見圖1，概述了60000人的代表樣本在蘇黎世州）。這些人，四分之三選擇了了扣除27

47、0歐元。這個數(shù)字揭示了一個越來越扣減的毛醫(yī)療開支大幅下降。帶有最小扣除（平均160歐元）每年發(fā)生衛(wèi)生保健開支在2150歐元；其最高扣除（平均1000歐元）只達(dá)到510歐元。圖1第二條代表在每個類別中的健康照顧病人的共同支付支出凈額。第三欄顯示了平均每扣除保險費。與支出的比較表明，扣減數(shù)還是很大的，一個從低到高風(fēng)險的個人所發(fā)生重大財務(wù)再分配。人均開支的保費及被保險人的份額為免賠額蘇黎世州1999年藍(lán)色代表：總支出 灰色代表：總支出凈額共同付款 紅色代表：保險費用計量單位：歐元這些意見不知道較低的支出扣除是不是在高階層，首先合同的后果由被保險人的選擇，期待不同的未來醫(yī)療開支，或是否是一個在行為變化的中反映保險。人們期望雙方自我選擇和道德風(fēng)險問題這兩個效應(yīng)的分離在方法論上具有挑戰(zhàn)性，因為這兩個同時出現(xiàn)在醫(yī)療開支上升的數(shù)據(jù)，同時一個不知道什么原因，在一個低支出的人觀察下，被保險人選擇高扣除開支。在20世紀(jì)80年代，蘭德公司贊助了一項旨在檢測醫(yī)療保健需求的免賠額價格的影響廣泛研究。在受控制的隨機(jī)實驗中，人員分配與醫(yī)療保險合同有關(guān)的合作，保險費率各不相同。既然人已沒有可能選擇自己的合同，選擇效果可能被排除在外。平均而言，蘭德公司的研究人員發(fā)現(xiàn)了醫(yī)療合作保險需求減少了20%-30%（見曼寧等。1987年）。在瑞士醫(yī)療保險制度中，每個人有選擇不同的免賠額。如果人們期望的選擇反映了未來