2nd Conference of the Swiss Society of Health Economics

Session B: Demand and supply of healthcare

Choice of nursing home: The out-of-pocket price is pivotal

The Swiss long-term care market is heavily regulated with ongoing efforts to further expand market interventions to offset the alleged lack of competition. This paper evaluates the consumer response to prices of care and accommodation in the choice of a nursing home, taking advantage of the special conditions of the Swiss market.

Using data from the official administrative statistics for social-medical institutions (SOMED) of the Federal Statistical Office for the years 2014 to 2017, a conditional logit model is used to analyze to which extent prices, quality and distance influence the nursing home choice.

The findings suggest a negative relationship between the price of accommodation, which is not covered by social security contributions (out-of-pocket price), and the choice of the nursing home. By comparison, the price for medical care, which is almost entirely covered by insurance and public finances, appears to have no influence on the nursing home choice. The choice is also significantly associated with shorter distance from the client’s prior residence, higher total staffing ratio and larger facility size.

Individuals in need of care and about to move to a nursing home do not only consider location but also compare prices and the quality of providers. Measures for the promotion of competition can therefore enhance efficiency. However, demand is only affected by out-of-pocket expenditures and easy-to-assess quality measures.

Rachel Straumann, University of Basel

Cost-Sharing or Rebate What Drives Patients’ Treatment Decisions?

Economists have long stressed the importance of designing appropriate incentives in health insurance plans in order to reduce moral hazard. Cost-sharing, for example, splits the cost of treatment between the health insurer and the patient. Alternative instrument are rebates. Rebates substitute the negative incentives of cost-sharing with a positive incentive scheme. Theoretical research suggests that, due to loss aversion, reduction in costs of utilization may be higher under cost-sharing than rebates. Previous literature supports the theoretical results. In contrast to previous literature we can directly account for loss aversion, and can also preclude alternative confounds such as liquidity constraints and discounting.

We employ a lab experiment in which subjects take the role of patients. Each week, patients face the risk to have a mild, a severe disease or no disease at all. Patients are health-insured but covered with either a cost-sharing or a rebate scheme. Whereas treating the major disease is efficient, treating the minor disease is not. Patients decide whether or not to receive treatment in each period.

Results & Discussion:
We find that efficient treatment is not reduces under either health insurance scheme. Rebates show to be more effective in reducing inefficient care. We find no evidence that loss aversion drives patients utilization decision. Our results thus suggest a rebate plan might be promising in reducing inefficient care.

Christian Waibel, ETH Zurich

Decomposition of Outpatient Health Care Spending by Disease: A Novel Approach Using Insurance Claims Data

Decomposing total health care spending by disease, type of care, age, and sex can lead to a better understanding of the structure of health care spending. The lack of diagnostic coding in outpatient care poses a challenge to such an exercise in Switzerland. However, health insurance claims data hold a broad variety of diagnostic clues that may be used to identify diseases even in the absence of diagnostic coding.

We use claims data from a large health insurer to identify 42 diseases of the exhaustive Global Burden of Disease classification. We combine information on medication, inpatient treatments, physician specialization and disease-specific treatment and examination codes from the different tariff catalogues to identify diseases. We determine disease-specific spending by direct (clues-based) and indirect (regression-based) spending assignment.

Our results show a high precision of disease identification for most diseases. Overall, 76% of outpatient spending can be assigned to diseases, mostly based on indirect assignment. Preliminary results show that outpatient spending is highest for musculoskeletal diseases (28.7%), followed by mental disorders (10.5%) and cardiovascular diseases (8.6%).
Discussion: Our study shows the potential of health insurance claims data in identifying diseases when no diagnostic coding is available. The disease-specific spending estimates may inform Swiss health policies in cost containment and priority setting.

Michael Stucki, Zurich University of Applied Sciences

Impact of a diabetes disease management program on guideline-concordant care and health care costs: A propensity score matching study using claims data

Structured treatment programs have been recommended for patients with chronic conditions to improve quality of care. We evaluated the impact of a disease management program (DMP) for patients with diabetes on guideline-concordant care and health care costs in Swiss primary care.

We performed a prospective observational study and compared patients with diabetes enrolled in a DMP (N=538) with patients receiving usual care (N=5127) using propensity score kernel matching with entropy balancing. We used a difference-in-difference (DiD) approach and compared changes in outcomes from baseline to one-year-follow-up between the DMP (intervention) and the usual care group (control). Outcomes included measures of guideline-concordant diabetes care, use of health care services and direct medical costs (health insurer perspective).

We identified a positive impact of the DMP on various measures of guideline-concordant care: the number of fulfilled guideline criteria (DiD: +0.19, 95%-CI 0.04;0.34) as well as the patient share fulfilling all considered criteria (DiD: +7%-points, 95%-CI 3%;12%). Health care services use and costs showed no significant DiD with the exception of the hospitalization rate with an absolute and relatively stronger decrease in the DMP group (DiD: -0.06, 95%-CI -0.11; -0.01).

After one-year-follow-up, the DMP under evaluation seems to exert a positive impact on the quality of diabetes care of the enrolled patients.

Marc Höglinger, Zurich University of Applied Sciences

The costs of celiac disease: a contingent valuation in Switzerland

Celiac disease (CD) is an autoimmune disease damaging the intestine when patients ingest gluten. The only treatment available is a gluten-free diet (GFD), which implies great nutritional constraints and can cause social and psychological burden, in addition to the physical discomfort arising in case of gluten absorption. These inconveniences are part of the intangible costs of CD. This paper proposes a first monetary measure of these costs in Switzerland.

We used a contingent valuation provided via an online questionnaire. The scenario suggested to celiac patients the possibility of purchasing a daily pill, which would allow them eating normally and avoid any physical pain from gluten absorption.

Mean WTP is found to be around CHF 87 per month. Individuals, who spend more on gluten-free food and those facing more constraints on the labour market or find that CD imposes logistical constraints are willing to pay more than others. On the other hand, those who find the GFD healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current frequency or intensity of symptoms are found to be insignificant. Since individuals facing stronger symptoms are more likely to strictly adhere to the GFD, the frequency and strength of symptoms is likely to decrease.

The results confirm that CD imposes substantial costs, mainly composed of an impaired social life, a more stressful organisation and indirect costs on the labour market.

Laia Soler, University of Lausanne