Health Insurance System Research Articles

Workshop on s-claim application system for BPJS claim officers at Grandmed Lubuk Pakam Hospital

BPJS Health is a public legal entity that is directly responsible to the President and functions to organize health insurance programs for all Indonesian residents, including foreigners who work for a minimum of six months in Indonesia. The BPJS Health claim procedure can be quite complicated and requires a lot of supporting documents. Unclearness in the guidance or instructions provided can make participants confused and not prepare the complete documents required, one of which is incomplete data files. This is a problem that slows down the claim process. This activity aims to provide health education on the application of the S-National Health Insurance (JKN) system, namely health protection program in Indonesia designed to provide basic health care and protection benefits for all Indonesian citizens. The main goal of JKN is to ensure that everyone in Indonesia has access to adequate basic health services, either through contributions paid by participants themselves or contributions paid by the government for certain groups. With the existence of JKN, it is hoped that the entire population of Indonesia can feel the benefits of equitable and quality health services, thereby improving the health status of the community as a whole. Claims to BPJS officers. The method of implementing activities is using observation sheets and questionnaires regarding the application of the S-Claim system to BPJS officers. Through this activity, it is hoped that the knowledge of BPJS claims officers can increase and change attitudes so that they can apply the BPJS E-Claim system correctly. Socialization to BPJS claims officers can be concluded that the knowledge of BPJS claims officers at Grandmed Lubuk Pakam Hospital has increased by 60% after conducting socialization using discussion, lecture and question and answer methods as well as holding quizzes or tests to evaluate participants' understanding of the S application.

Navigating Health Insurance Economics: A Data-Driven Approach to Enhanced Pricing in the United States

This study delves into the dynamics of healthcare spending in the United States, revealing a considerable financial commitment that hasn't translated into commensurate health outcomes. With healthcare costs reaching $4.3 trillion in 2021, driven by factors such as an aging population and escalating service prices, the nation confronts challenges to its fiscal health. The analysis extends to the intricacies of U.S. health insurance pricing, critiquing the existing system's complexity and opacity while drawing comparisons with approaches in other developed countries. Amid criticisms of profit-centric motives in the private sector, the study prompts discussions on potential reforms, learning from international experiences. Additionally, the study explores the transformative potential of data analytics in health insurance pricing, emphasizing its role in enhancing fairness and competitiveness. However, ethical considerations, including privacy, data security, and potential biases, underscore the need for a delicate balance between leveraging data-driven insights and responsible practices. The results of the study may be of great interest to specialists from the point of view of the further development of the compulsory social health insurance system in the Republic of Kazakhstan.

Analysis of the DPR'S Policy in Rejecting BPJS Health's Inclusion in the Health Law

The House of Representatives (DPR) as a legislative institution in Indonesia has a very important role in drafting and formulating laws, including approval of laws. In this article, an in-depth analysis will be carried out regarding the DPR's policy in rejecting the inclusion of BPJS Health in the Health Law in Indonesia. The DPR can consider alternative policies or improvements to the health insurance system to make it more effective and sustainable in providing health services to the community. The research aims to provide an insight into the legislative process, policy-making dynamics, and the potential consequences for public health administration and policy. The study will be conducted by combining primary, secondary, and tertiary legal materials (which are secondary data) with primary data obtained in the field, namely DPR Policy Analysis.

A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. A conceptual framework to provide additional ethical guardrails for health systems. Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Impact of modifications to antidementia drug reimbursement in France: Analysis of the FRA-DEM cohort.

Alzheimer's disease and related diseases (ADRD) is a progressive and inexorable disease. In France, acetylcholinesterase inhibitors and memantine were reimbursed for subjects with ADRD, until 2 modifications of their reimbursement rate (2012, 2018). We aimed to study the consequences of these measures on ADRD subjects' healthcare use. We analysed data from the FRA-DEM cohort, including subjects with presumed incident ADRD identified since 2011 in the French health insurance system. We studied the healthcare use of subjects identified with incident ADRD in 2011, 2013, 2015, 2017 and 2019, notably the annual number of defined daily doses of various psychotropic groups. We performed 2 multivariate multinomial logistic regressions with the subcohort year as the dependent variable. In total, 165 120 subjects were included. A progressive decrease in exposure to antidementia drugs was observed between 2011 and 2019. Consultations with private neurologists or psychiatrists, and exposure to risperidone, antidepressants and benzodiazepines increased in the 2019 subcohort, following the 2018 reimbursement withdrawal. Meanwhile, the use of nursing/allied healthcare and emergency care increased over the subcohort years, whereas we observed a decrease in general practitioner consultations. These results suggest increases in private neurologist or psychiatrist consultations and exposure to recommended drugs after the reimbursement withdrawal, contrary to the fears expressed. However, antidementia drug exposure decreased long before the reimbursement modifications, probably due to the growing evidence of the modest effect of these drugs, and exposure to benzodiazepines increased after the reimbursement withdrawal.

A case study of lean digital transformation through robotic process automation in healthcare

Under Taiwan's National Health Insurance (NHI) system, it's crucial for all healthcare providers to accurately submit medical expense claims to the National Health Insurance Administration (NHIA) to avoid incorrect deductions. With changes in healthcare policies and adjustments in hospital management strategies, the complexity of claiming rules has resulted in hospitals expending significant manpower and time on the medical expense claims process. Therefore, this study utilizes the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) management approach to identify wasteful and non-value-added steps in the process. Simultaneously, it introduces Robotic Process Automation (RPA) tools to replace manual operations. After implementation, the study effectively reduces the process time by 380 min and enhances Process Cycle Efficiency (PCE) from 69.07 to 95.54%. This research validates a real-world case of Lean digital transformation in healthcare institutions. It enables human resources to be allocated to more valuable and creative tasks while assisting hospitals in providing more comprehensive and patient-centric services.

Application of cultured epidermal autograft, JACE®, improves survival rate in extensive burns: A propensity score matching study using Tokyo registry data.

Cultured epidermal autograft, JACE®, was introduced into the Japanese national health insurance system in 2009 and has been used in more than 1000 cases of extensive burns. The aim of this study was to investigate whether the use of JACE® contributes to survival rate in extensive burns. In this study, 119 cases were selected from 3990 cases in Tokyo Burn Unit Association registry data from 2009 to 2023, excluding cases with less than 40% total body surface area, cases of deaths within 4 weeks and cases with unknown length of hospital stay. In total, 25 patients treated with JACE® were selected and matched with another 25 patients who did not receive JACE® using propensity score matching. The results showed that patients treated with JACE® had a significantly higher survival rate than did those who were not treated with JACE® at all time points between 6 and 9 weeks post-injury. In addition, there was no significant difference in length of hospital stay between the groups. These results suggest that the use of JACE® in patients with extensive burns contributes to patient survival and does not prolong hospital stay.

The impact of the expanded health insurance coverage policy on healthcare spending: evidence from Korea

BackgroundSouth Korea’s National Health Insurance (NHI) system pursues universal health coverage, but it has not been able to alleviate patients’ financial burden owing to limited coverage and a high proportion of out-of-pocket expenses. In 2017, the government announced a plan to strengthen universality by providing coverage for all unincluded services, expanding coverage, and alleviating household financial burden. We aimed to evaluate the effect of “Moon Care” with a focus on changes in health expenditures following policy implementation, and to provide empirical evidence for future policies to strengthen the NHI system’s universality.MethodsUsing data from the 2016 and 2018 Korea Health Panel (KHP), we established a treatment group affected by the policy and an unaffected control group; we ensured homogeneity between the groups using propensity score matching (PSM). Subsequently, we examined changes in NHI payments, non-payments, and out-of-pocket payments (OOP); we performed difference-in-differences (DID) analysis to evaluate the policy’s effect.ResultsFollowing policy implementation, the control group had a higher increase than the treatment group in all categories of health expenditures, including NHI payments, non-payments, and OOP. We noted significant decreases in all three categories of health expenditures when comparing the differences before and after policy implementation, as well as between the treatment and control groups. However, we witnessed a significant decrease in the interaction term, which confirms the policy’s effect, but only for non-payments.ConclusionsWe observed the policy’s intervention effect over time as a decrease in non-payments, on the effectivity of remunerating covered medical services. However, the policy did not work for NHI payments and OOP, suggesting that it failed to control the creation of new non-covered services as noncovered services were converted into covered ones. Thus, it is crucial to discuss the financial spending of health insurance regarding the inclusion of non-covered services in the NHI benefits package.

Childcare needs as a barrier to healthcare among women in a safety-net health system

BackgroundChildcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population.MethodsWe conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers.ResultsAmong the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs.ConclusionsChildcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Disparities in cause-specific mortality by health insurance type and premium: evidence from Korean NHIS-HEALS cohort study, 2002–2019

BackgroundAlthough one’s socioeconomic status affects health outcomes, limited research explored how South Korea’s National Health Insurance (NHI) system affects mortality rates. This study investigated whether health insurance type and insurance premiums are associated with mortality.MethodsBased on the National Health Insurance Service-Health Screening cohort, 246,172 men and 206,534 women aged ≥ 40 years at baseline (2002–2003) were included and followed until 2019. Health insurance type was categorized as employee-insured (EI) or self-employed-insured (SI). To define low, medium, and high economic status groups, we used insurance premiums at baseline. Death was determined using the date and cause of death included in the cohort. Cox proportional hazard models were used to analyze the association between insurance factors and the overall and cause-specific mortality.ResultsThe SI group had a significantly higher risk of overall death compared to the EI group (adjusted hazard ratio (HR) [95% confidence interval]: 1.13 [1.10–1.15] for men and 1.18 [1.15–1.22] for women), after adjusting for various factors. This trend extended to death from the five major causes of death in South Korea (cancer, cardiovascular disease, cerebrovascular disease, pneumonia, and intentional self-harm) and from external causes, with a higher risk of death in the SI group (vs. the EI group). Further analysis stratified by economic status revealed that individuals with lower economic status faced higher risk of overall death and cause-specific mortality in both sexes, compared to those with high economic status for both health insurance types.ConclusionThis nationwide study found that the SI group and those with lower economic status faced higher risk of overall mortality and death from the five major causes in South Korea. These findings highlight the potential disparities in health outcomes within the NHI system. To address these gaps, strategies should target risk factors for death at the individual level and governments should incorporate such strategies into public health policy development at the population level.Trial registrationThis study was approved by the Institutional Review Board of Chungbuk National University Hospital (CBNUH-202211-HR-0236) and adhered to the principles of the Declaration of Helsinki (1975).

Technology Acceptance for Machine Learning Decision Model in the Health Insurance System

Technology Acceptance for Machine Learning Decision Model in the Health Insurance System

Understanding barriers to well-child visit attendance among racial and ethnic minority parents

ObjectivesTo assess racial and ethnic minority parents’ perceptions about barriers to well-child visit attendance.MethodsFor this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes.ResultsTwenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers.ConclusionsRacial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Evaluation of the Effect of Educational Intervention on the Error of Insurance Documents on Deductions in Hospitalization Records

Background: This study aims to consider the effect of an educational intervention on the error rate of insurance documents in the deducting of hospitalization records of COVID-19 patients' health insurance among hospital staff. Methods: The target population of this semi-experimental study was all personnel involved in the management of patients with Covid-19. Among the hospitals of the COVID-19 site in Chaharmahal and Bakhtiari provinces, one hospital was selected as the educational target group (24 individuals) and one hospital was considered as the control group (16 individuals) by lottery. To measure the effectiveness of education, the sample size of all cases of 19 patients with health insurance in two hospitals during two periods of October and March 2016 was determined. Data collection was performed by checklists and direct reviews of files, the health insurance system, and the hospital HIS system. Data analysis was performed using SPSS21 software. Results: The number of deductions in the case of "Covid 19 hospitalized patients" of the health insurance decreased significantly in the intervention hospital from 1833 to 933 (p < .005) and increased in the control hospital from 447 to 2712 (p < .005). In the intervention hospital, the highest decrease in deductions in the hoteling service was from 235 (12.8%) to 2 (0.2%) cases (p < .001), and for medicines from 335 (18.2%) to 56 (6%) cases (p < .001). Conclusion: The results demonstrated that staff training on the error in COVID-19 insurance documents during the coronavirus pandemic outbreak has reduced the number of insurance deductions in COVID-19 patients' records.

Life expectancy of patients with early gastric cancer who underwent curative gastrectomy: Comparison with the general population using the Korean Statistical Information Service database.

e16077 Background: Although clinical trials have reported the long-term survival of patients with early gastric cancer, data comparing their life expectancy with that of the general population is scarce. Our study estimated these patients’ life expectancy and analyzed the differences in life expectancy between patients with early gastric cancer and the general population. Methods: We enrolled patients who underwent curative gastrectomy and were diagnosed with pathologic stage 1 gastric cancer at Asan Medical Center from the gastric cancer registry. We determined patients’ survival status through the national health insurance system. Their life expectancy was analyzed and compared with that of the general population, utilizing data from the Korean Statistical Information Service database. Results: This cohort comprised 8,637 patients and 64.7% were men. Approximately 17.3% of participants were aged 70 years and older. Approximately 20% of patients underwent total gastrectomy. Life expectancy was favorable among women. Across all age groups, women’s life expectancy generally exceeded 80 years. Male patients showed a reduced life expectancy, typically 4-10 years shorter than their female counterparts. The average life expectancy of male patients aged over 80 years who underwent total gastrectomy was about 5 years, whereas that of their female counterparts was approximately 7 years. Female patients undergoing distal gastrectomy did not demonstrate a statistically significant variance in life expectancy compared to the general population. Conclusions: This study provided comprehensive life expectancy data, organized by age, sex, and type of gastrectomy in a large stage 1 gastric cancer cohort. Elderly patients undergoing total gastrectomy with limited life expectancy may benefit from considering alternative treatment options instead of total gastrectomy.

Prospective monitoring for immunotherapy by liquid biopsy and signal pathway alterations in head and neck cancers.

e18000 Background: Clinical biomarkers that predict response or prognosis to immune checkpoint inhibitors (ICIs) are unclear in head and neck squamous cell carcinoma (HNSCC). Comprehensive genome profiling (CGP) testing including liquid biopsy using cell-free DNA (cfDNA) has become clinically available; however, CGP testing is approved only once per patient under the Japanese health insurance system. Therefore, whether liquid biopsy is useful for detecting sequential genetic change and disease progression as a real-time monitoring tool is still unknown. This study aims to analyze the cfDNA in the plasm of recurrent or metastatic (R/M) HNSCC patients during ICI therapy. This study was prospectively conducted to examine the relationship between sequential genetic changes and treatment response. Methods: In this prospective study, we examined ten evaluable R/M HNSCC cases treated with ICI monotherapy (nivolumab or pembrolizumab) from October 2020 to December 2023. Blood samples were collected and analyzed using Guardant360 at differing three-time points (0, 4, and 24 weeks or at progressive disease, PD). Results: The ten cases consisted of 5 males and 5 females, with a median age of 71 years old (52-92 years old). Seven patients received pembrolizumab as a first line and three received nivolumab as the second line treatment. The best response to ICI was partial response (PR) in 3 cases , stable disease (SD) in 1 and PD in 6. Three cases discontinued the study at the second point because of the rapid disease progression. Microsatellite status is stable in all cases. Eight of the ten cases had at least one pathogenic mutation, one case had only variants of unknown significance, and one case that had target lesions at lung metastases had none of them through a series of liquid biopsies. The most frequent gene alterations observed were TP53 (60%), TERT promoter (20%), GNAS (20%), and EGFR amplification (20%). In particular, EGFR amplification had emerged at the second point in two PD cases and these patients showed the sensitivity to cetuximab-based therapy at the following treatment line. In all PD cases, the highest variant allele fraction (VAF) was increased at the second point, which might help predict the response to ICI therapy. In one case achieving PR, BRAF mutation had emerged at the second point. Then it was undetectable at the third point with PD, and GNAS mutation was newly detected. In another case, APC inactivation had disappeared at the second point with PR, even though GNAS mutation emerged, and this case maintained the response to ICI. These results suggest that switching the signals in the MAPK or Wnt pathway could impact the response to ICI therapy. Conclusions: The findings of this prospective study demonstrated that the highest VAF alterations and genetic mutations detected by cfDNA analysis could reflect and predict the response to ICI.

Preliminary outcomes of boron neutron capture therapy for head and neck cancers as a treatment covered by public health insurance system in Japan: Real-world experiences over a 2-year period.

Since June 2020, boron neutron capture therapy (BNCT) has been a health care service covered by health insurance in Japan to treat locally advanced or recurrent unresectable head and neck cancers. Therefore, we aimed to assess the clinical outcomes of BNCT as a health insurance treatment and explore its role among the standard treatment modalities for head and neck cancers. We retrospectively analyzed data from patients who were treated using BNCT at Kansai BNCT Medical Center, Osaka Medical and Pharmaceutical University, between June 2020 and May 2022. We assessed objective response rates based on the Response Evaluation Criteria in Solid Tumors version 1.1, and adverse events based on the Common Terminology Criteria for Adverse Events, version 5.0. Additionally, we conducted a survival analysis and explored the factors that contributed to the treatment results. Sixty-nine patients (72 treatments) were included in the study, with a median observation period of 15 months. The objective response rate was 80.5%, and the 1-year locoregional control, progression-free survival, and overall survival rates were 57.1% (95% confidence interval [CI]: 43.9%-68.3%), 42.2% (95% CI: 30.1%-53.8%), and 75.4% (95% CI: 62.5%-84.5%), respectively. Locoregional control was significantly longer in patients with earlier TNM staging and no history of chemotherapy. BNCT may be an effective treatment option for locally advanced or recurrent unresectable head and neck cancers with no other definitive therapies. If definitive surgery or radiation therapy are not feasible, BNCT should be considered at early disease stages.

한국의 의료 공공성에 대한 인식 격차*

Medical care is an essential social service that supports other valued goods, such as life, health, safety, and the guarantee of social opportunities. In many countries, access to medical care is provided through public health insurance systems. South Korea’s medical insurance system, which has expanded at an unprecedented rate in recent decades, performs very well by several internationally recognized indicators. However, excessive government regulations, a private-centered supply of medical resources, and overuse of the system by patients have led to a misallocation of medical resources. This article examines the supply and use of medical care by the Korean government, the medical community, patients, and citizens, highlighting awareness gaps in the public value and nature of medical care. Recognizing this issue is the first step in building a sustainable medical system that ensures that medical resources are appropriately allocated and utilized.

Teen pregnancy involvement among African, Caribbean and Black adolescent boys and girls: A scoping review

ObjectivesThis study aims to investigate the incidence, associated factors and interventions to address teen pregnancy involvement (TPI) among African, Caribbean and Black (ACB) adolescents in North America.DesignWe conducted a scoping...

#2414 Hypertension resolution after kidney transplantation is associated with better kidney transplant outcomes in patients with pre-transplant hypertension

Abstract Background and Aims Hypertension is prevalent in patients with advanced chronic kidney disease (CKD), and kidney transplantation (KT) can potentially improve hypertension. Although hypertension is expected to be resolved after KT in many recipients with pre-transplant hypertension, little is known about the hypertension resolution rate and its prognostic role in KT outcomes. Method We retrospectively identified KT recipients (between 2006 and 2015) who had pre-transplant hypertension using Health Insurance Review & Assessment Service and Korea National Health Insurance System. The recipients were categorized into two groups based on their post-KT hypertension status: “persistent hypertension” and “resolved hypertension”. Cox proportional hazard analyses were performed to assess the risk of death-censored graft failure and all-cause mortality with adjusting various clinical, immunological risk factors, and socioeconomic status. Results Among 11,342 KT recipients with pre-transplant hypertension, 8,233 (73%) remained hypertensive, while 3,109 (27%) experienced hypertension resolution after KT. Recipients with resolved hypertension had lower rates of delayed graft function and major comorbidities, including diabetes mellitus, ischemic heart disease, and stroke compared to recipients who remained hypertensive. After adjusting for multiple covariates, the resolved hypertension group had 0.59-fold (95% confidence interval [CI] 0.49–0.73) lower risk for graft failure and 0.59-fold (95% CI 0.48–0.73) lower risk for all-cause mortality compared to the persistent hypertension group. Subgroup analyses revealed that the protective effect of resolved hypertension on graft survival was more pronounced in females (P for interaction = 0.045), and on overall survival was weaker in recipients with diabetes (P for interaction = 0.033). Conclusion A significant proportion of patients experienced hypertension resolution after KT, which is associated with improved graft survival and overall patient survival. The post-KT hypertension status can be used as a prognostic indicator for predicting better outcomes in KT recipients with pre-transplant hypertension.

Financing universal health care: Premiums or payroll taxes?

This paper presents a stochastic overlapping generations model with endogenous health investment to study the transition from the existing hybrid health insurance system in Germany towards a uniform system, financed by either funded or unfunded premiums or payroll taxes.Our simulation results highlight the insurance properties of payroll taxes, but also their cost in terms of labor supply distortions and moral hazard. We find that compulsory deductibles decrease aggregate welfare in Germany, although they reduce moral hazard and increase private health investment. Reform models with premiums also induce precautionary behavior and increase labor supply, but at the same time increase exposure to productivity risk. Since the introduction of a funded system is costly for transitional cohorts, unfunded premiums provide the highest efficiency gains in our framework.