Price Of Health Insurance Research Articles

Health Insurance Factor Analysis

This paper explores the intricacies of health insurance costs in the United States, emphasizing the Affordable Care Act's (ACA) role in reform. Employing a "health insurance factor analysis" approach, the study identifies key determinants using data visualization and regression models. Factors such as age, BMI, family size, gender, smoking status, and geographic region significantly influence insurance prices. The research evaluates various regression models and neural networks, with linear regression standing out for its high accuracy. The findings underscore the impact of smoking, medical history, and coverage level on insurance costs. Despite dataset limitations and sample size considerations, this study contributes to a nuanced understanding of health insurance pricing, aiding insurers, policymakers, and individuals in decision-making. By integrating data insights and predictive models, the research advances comprehension of the complex relationships shaping health insurance costs. The ultimate goal is to optimize insurance programs and promote accessible and affordable health insurance for all.

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.

Multimarket Contact in Health Insurance: Evidence from Medicare Advantage*

Many industries consist of large firms that compete in multiple geographic markets. Such overlap, defined as multimarket contact (MMC), may facilitate tacit collusion and soften competition. We examine the effects of MMC on health insurance prices and quality using comprehensive data on the Medicare Advantage (MA) market from 2008 through 2015. Our identification strategy exploits two plausibly exogenous changes to MMC: (1) out‐of‐market mergers; and (2) policy‐driven changes in the benchmark rates of other markets. Our results consistently support the mutual forbearance hypothesis, where we find that prices are significantly higher and high‐quality plans less pervasive as MMC increases.

Correlation of Anticancer Drug Prices with Outcomes of Overall Survival and Progression-Free Survival in Clinical Trials in Japan.

Drug pricing methods vary extensively across countries. Japan calculates drug prices using cost accounting and based on the efficacy of similar drugs. This study investigated the relationship between drug prices and their clinical efficacy and usefulness using public information on anticancer drugs reimbursed by the National Health Insurance price listing between January 2009 and March 2020. We investigated drug characteristics, prices, and clinical benefits based on overall survival (OS) and progression-free survival (PFS). Eighty anticancer drugs were approved in Japan during the study period. The largest number (28 drugs, 35.0%) was approved based on PFS, 18 (22.5%) were approved based on OS, and 13 (16.3%) based on the response rate. The mean (±SD) drug price was JPY 88,416.2 (±148,974.7), while the median drug price (with quartiles) was JPY 21,694 (JPY 4855.0-JPY 93,396.8). Drug prices were significantly higher for PFS than for OS, while cost index-the drug price to extend PFS or OS by one day-did not differ significantly between PFS and OS. The relationship between the 46 drugs approved based on OS or PFS and their prices was examined. A correlation was found between drug prices and their clinical usefulness in terms of OS but not PFS.

Prevalence of hypertensive diseases and treated hypertensive patients in Japan: A nationwide administrative claims database study

We investigated the prevalence of hypertensive patients and treated hypertensive patients using a Japanese nationwide administrative claims database. We analyzed national database data from 2014, including all claims data, provided by the Ministry of Health, Labour and Welfare of Japan. Hypertensive diseases were identified using Japanese standardized disease codes. Among hypertensive patients, treated hypertensive patients were defined by the prescription of any antihypertensive medication, identified using national health insurance price listing codes. We calculated and compared the number and age-adjusted prevalence of hypertensive patients and treated hypertensive patients by prefecture and the proportion of these patients by the size of medical facilities. In 2014, approximately 27 million Japanese people were identified as hypertensive, among which 89.6% were treated. The age-adjusted prevalence of hypertensive patients (per 100,000 persons) among women and men was 21,414 and 21,084, respectively. The age-adjusted prevalence of treated hypertensive patients (per 100,000 persons) among women and men was 19,118 and 18,974, respectively. While the prevalence of hypertensive and treated hypertensive patients varied geographically, the prevalence remained similar between the sexes. Approximately 59% of hypertensive patients visited clinics (0 to 19 beds) in Japan. In Japan, 27 million people were diagnosed with hypertensive diseases, and approximately 90% of these patients were treated with any antihypertensive medication in 2014. The distribution of hypertensive patients varied geographically throughout Japan.

The financials of cybercrime: a health insurance pricing approach

The financials of cybercrime: a health insurance pricing approach

Consumption and cost trends of EGFR TKIs: influences of reimbursement and national price negotiation

BackgroundEpidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have been widely used in the treatment of EGFR mutation non-small-cell lung cancer. The Chinese government has made great efforts to improve the availability and affordability of these drugs. The aim of this study was to investigate the trends in the consumption and cost of EGFR TKIs in Nanjing, a developed city in China, and evaluate the influence of health insurance coverage and national price negotiation on drug consumption.MethodsData about EGFR TKIs applications in 2010–2019 were extracted from Jiangsu Medicine Information Institute. Five types of EGFR TKIs were included. Consumption was expressed in defined daily doses (DDDs) and expenditure. The correlation between defined daily cost (DDC) and DDDs was analyzed by Pearson's correlation test.ResultsThe DDC, number of DDDs and expenditure of EGFR TKIs changed little from 2010 to 2015. National price negotiation was initiated as a policy and low-price generic gefitinib came into the market in 2016. Three types of EGFR TKIs moved into the coverage of the national health insurance since 2017. Hence, the DDC decreased, and the number of DDDs increased significantly year by year since 2016. The first generation TKIs always made up of comprised the majority of the total consumption. The predominantly prescribed TKIs were gefitinib and icotinib. DDC was negatively correlated with the number of DDDs. The number of DDDs increased significantly after health insurance enrollment, price negotiation and generic drug replacement.ConclusionThe consumption of EGFT TKIs has increased and the DDC of EGFR TKIs has decreased since 2016. These trends may be attributed to drug reimbursement, price negotiation and generic drug replacement. Further efforts are needed to translate the high consumption of EGFR TKIs into clinical benefits.

Policyholder cluster divergence based differential premium in diabetes insurance

Traditional health insurance pricing, which is based on experience rates, cannot correctly estimate the risk types of policyholders, can lead to serious adverse selection. Due to massive data volumes and developments in data analysis technology, the underwriting process can more accurately reflect the insured's risk type. Therefore, this paper based on policyholder cluster divergence proposes a differential premium approach by employing fuzzy c‐means algorithm (FCM) with an extended initial multistate Markov model to formulate the differential premium that matches the policyholder's risk category. Our results confirm that the proposed differential premium approach better reveals the policyholder's risk type as compared with unified pricing and effectively counteracts adverse selection.

Multi-criteria and medical diagnosis for application to health insurance systems: a general approach through non-additive measures

In this contribution, we propose a healthcare decision support system. Nowadays, it is commonly recognized that quantitative tools and decision support can increase the benefits and the performances of healthcare systems, and for this, different multiple criteria methods were proposed in many branches of medicine. The approach we propose is based on non-additive measures and the Choquet integral. This methodology has been intensively applied in many real-world applications, given its capability to represent interactions among criteria, and thus to model a wide range of preference structures. Considering that the diagnosis procedure needs also to take the clinical expertise into account, this method appears particularly tailored for a diagnosis support, mainly when statistical models cannot be applied and/or available data are scarce and knowledge can be inferred by physicians’ opinions. In particular, we propose a disease risk evaluation and compute some associated indicators. Furthermore, an error estimation is performed. As an application, a cardiovascular risk diagnosis model is presented. The proposed methodology, that allows to quantify the disease risk taking into account individual’s medical conditions, can be used for improving healthcare service quality or for pricing and reserving health insurance policies. An application to health insurance pricing is provided.

The Affordable Care Act and Tax Policy

The Affordable Care Act fails to coordinate the impact of tax burdens on individuals with the global aim of extending the availability of health care insurance. The price of private health insurance depends in this country on who buys it; large employers pay less than small employees and individuals for the same level of coverage. Because the ACA does not eliminate these and related artefactual cost differences, the Act’s pricebased adjustments of the post-tax cost of health care to individuals simply perpetuate or worsen central problems of tax fairness and neutrality.

Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study

BackgroundRecent studies that compared patient spending in hospital-owned physician practices versus physician-owned groups did not compare quality of care. Past studies had incomplete measures of physician-hospital integration, or lacked patient-level data.ObjectiveTo measure the association between physician-hospital integration and both spending and quality using patient-level data and explicit physician-hospital contracting information.DesignRetrospective review of claims data from 2014 through 2016. Adjustments were made for patient, physician, and regional characteristics.PatientsPatients aged 19 to 64 enrolled in a Blue Cross Blue Shield Texas Preferred Provider Organization in the four largest metropolitan areas in Texas who could be attributed to a physician practice based on claims.Main Outcomes and MeasuresAnnual spending per patient was compared for patients treated by a physician practice that is billing through a hospital, versus billing through an independent physician practice; spending was also subdivided by BETOS category, by site and type of care, and percent of patients with positive spending by subcategory. Quality measures included readmission within 30 days of discharge for hospitalized patients, appropriate care for diabetic patients, and screening mammography for women ages 50–64.ResultsEstimates suggest that patients in a preferred provider organization incur spending which is 5.8 percentage points higher when treated by doctors in hospital-owned versus physician-owned practices (95% CI 1.7 to 9.9; p = 0.006). Spending is significantly higher for durable medical equipment, imaging, unclassified services, and outpatient care. The spending difference appears attributable to greater service utilization rather than higher prices. There was no consistent difference in care quality for hospital-owned versus physician-owned practices.Conclusions and RelevanceWe find that financial integration between physicians and hospitals raises patient spending, but not care quality. Given that higher spending raises the price of health insurance, policy makers should carefully consider policies that limit consolidation of hospitals and physicians.

Personalizing solidarity? The role of self-tracking in health insurance pricing

Can data-driven innovations, working across an internet of connected things, personalize health insurance prices? The emergence of self-tracking technologies and their adoption and promotion in health insurance products has been characterized as a threat to solidaristic models of healthcare provision. If individual behaviour rather than group membership were to become the basis of risk assessment, the social, economic and political consequences would be far-reaching. It would disrupt the distributive, solidaristic character that is expressed within all health insurance schemes, even in those nominally designated as private or commercial. Personalized risk pricing is at odds with the infrastructures that presently define, regulate and deliver health insurance. Self-tracking can be readily imagined as an element in an ongoing bio-political redistribution of the burden of responsibility from the state to citizens but it is not clear that such a scenario could be delivered within existing individual private health insurance operational and regulatory infrastructures. In what can be gleaned from publicly available sources discussing pricing experience in the individual markets established by the Patient Protection and Affordable Care Act 2010 (ACA), widely known as ‘Obamacare’, it appears unlikely that it can provide the means to personalize price. Using the case of Oscar Health, a technology driven start-up trading in the ACA marketplaces, I explore the concepts, politics and infrastructures at work in health insurance markets.

Envelhecimento populacional e gastos com saúde: uma análise das transferências intergeracionais e intrageracionais na saúde suplementar brasileira

O modelo de precificação de planos de saúde no Brasil prevê a imposição de limites de variação das mensalidades por faixa etária, possibilitando a transferência de recursos dos mais jovens, que têm menor risco de utilização, para aqueles em idades mais avançadas. O aumento da proporção de idosos nas carteiras dos planos de saúde poderá inviabilizar as transferências intergeracionais e a atual estrutura de precificação. O objetivo deste artigo é estimar a magnitude das transferências intergeracionais (entre diferentes grupos de idade) e intrageracionais (em um mesmo grupo de idade) na saúde suplementar brasileira, por meio da análise de dados de uma amostra representativa de operadoras de planos de saúde. Segundo os resultados encontrados, os saldos das transferências intergeracionais foram positivos e ocorrem dos mais jovens para beneficiários de 66 anos ou mais. Os resultados mostram ainda a ocorrência de transferências intrageracionais em duas das faixas etárias definidas pela legislação vigente: 0 a 18 anos e 59 anos ou mais. Finalmente, o exercício de retroprojeção demonstrou que nos últimos 15 anos a sinistralidade nos planos individuais apresentou constante aumento, indicando risco crescente de insuficiência das mensalidades para fins de custeio das despesas no médio prazo, em razão do envelhecimento populacional.

Regulated Medicare Advantage And Marketplace Individual Health Insurance Markets Rely On Insurer Competition.

Two important individual health insurance markets-Medicare Advantage and the Marketplaces-are tightly regulated but rely on competition among insurers to supply and price health insurance products. Many local health insurance markets have little competition, which increases prices to consumers. Furthermore, both markets are highly subsidized in ways that can exacerbate the impact of market power-that is, the ability to set price above cost-on health insurance prices. Policy makers need to foster robust competition in both sectors and avoid designing subsidies that make the market-power problem worse.

Marketing Approval of Ethical Kampo Medicines.

Kampo medicine is an original traditional medicine in Japan. Currently, 148 ethical Kampo formulations (Kampo prescription drugs) are registered in the National Health Insurance Price List. Kampo medicines can be prescribed under the national insurance system, which shows that they are part of conventional medicine in Japan. Japan has a unified drug approval system that does not distinguish between Western and Kampo medicines, and both are subject to the same regulations. The application for the market approval of ethical Kampo medicines is based on the general notification for drugs, i.e., "Handling of Ethical Combination Drugs" in "Precautions Necessary When Applying for Drug Marketing Approval" (Yakushokushinsa Notification No. 1121-12 of November 21, 2014). Furthermore, applications for the market approval of ethical Kampo medicines should follow the Kampo-specific notification of "Handling of Ethical Kampo Medicines" (Yakushin Notification No. 804 of June 25, 1980). Data from comparative studies with standard decoctions must be submitted with approval applications according to Yakushin 2 Notification No. 120 of May 31, 1985. The safety, efficacy, and quality of Kampo medicines are comprehensively assured by the Japanese Pharmacopoeia, Good Manufacturing Practice, Good Agricultural and Collection Practices, marketing approval certificate, approval standard, and pharmacovigilance. I believe that the basic framework for the market approval of ethical Kampo medicines has been established as described above. The key factors for the practical application of superior manufacturing technology and research achievements and the promotion of drug development are the specific guidelines for the approval of drugs of herbal origin.

Emergency care usage and longevity have opposite effects on health insurance rates

PurposeThis paper aimed to study the price of health insurance for individuals aged 65 years and over.Design/methodology/approachA sample of private health policyholders in Spain is analysed. Joint models are estimated for men and women, separately. A log-linear model of the transformed cumulated number of claims associated with emergency room occupation, ambulance use and hospitalization is estimated, together with a proportional hazard survival model.FindingsThe association between the longitudinal process of severe medical care and the survival time process is positive and highly significant for both men and women. An increase in the price of health insurance because of the effect of a larger number of emergency care demand events is slightly offset by the decrease in expected longevity.Research limitations/implicationsThe effect of an increase in the number of claims is small compared to the reduction in survival, so age still plays a central role in ratemaking.Practical implicationsHigh rates of health insurance for elderly insureds should be compensated with younger insureds in the portfolio.Social implicationsAffordable health insurance premiums for elderly people are difficult to obtain only with strict actuarial principles.Originality/valueThe proposed methodology allows dynamic rates to be designed, so that the price of health insurance can change as new usage information becomes available.

A Cost-Effectiveness Analysis of Gemcitabine plus Cisplatin Versus Gemcitabine Alone for Treatment of Advanced Biliary Tract Cancer in Japan

ObjectivesThis study assessed the cost-effectiveness of combination treatment with gemcitabine and cisplatin compared to treatment with gemcitabine alone for advanced biliary tract cancer (BTC) in Japan.MethodsA monthly transmitted Markov model of three states was constructed based on the Japan BT-22 trial. Transition probabilities among the health states were derived from a trial conducted in Japan and converted to appropriate parameters for our model. The associated cost components, obtained from a receipt-based survey undertaken at the Aichi Medical University Hospital, were those related to inpatient care, outpatient care, and treatment for BTC. Costs for palliative care and treatment of adverse events were obtained from the National Health Insurance price list. We estimated cost-effectiveness per quality-adjusted life year (QALY) at a time horizon of 36 months. An annual discount of 3 % for both cost and outcome was considered.ResultsThe base case outcomes indicated that combination therapy was less cost-effective than monotherapy when the incremental cost-effectiveness ratio (ICER) was approximately 14 million yen per QALY gained. The deterministic sensitivity analysis of the ICER revealed that the ICER of the base case was robust. A probabilistic analysis conducted with 10,000-time Monte Carlo simulations demonstrated efficacy at the willingness to pay threshold of 6 million yen per QALY gained for approximately 33 % of the population.ConclusionIn Japan, combination therapy is less cost-effective than monotherapy for treating advanced BTC, regardless of the statistical significance of the two therapies. Useful information on the cost-effectiveness of chemotherapy is much needed for the treatment of advanced BTC in Japan.

Cost-effectiveness of amlodipine compared with valsartan in preventing stroke and myocardial infarction among hypertensive patients in Taiwan.

Hypertension is a major risk factor for strokes and myocardial infarction (MI). Given its effectiveness and safety profile, the calcium channel blocker amlodipine is among the most frequently prescribed antihypertensive drugs. This analysis was conducted to determine the costs and quality-adjusted life years (QALYs) associated with the use of amlodipine and valsartan, an angiotensin II receptor blocker, in preventing stroke and MI in Taiwanese hypertensive patients. A state transition (Markov) model was developed to compare the 5-year costs and QALYs for amlodipine and valsartan. Effectiveness data were based on the NAGOYA HEART Study, local studies, and a published meta-analysis. Utility data and costs of MI and stroke were retrieved from the published literature. Medical costs were based on the literature and inflated to 2011 prices; drug costs were based on National Health Insurance prices in 2014. A 3% discount rate was used for costs and QALYs and a third-party payer perspective adopted. One-way sensitivity and scenario analyses were conducted. Compared with valsartan, amlodipine was associated with cost savings of New Taiwan Dollars (NTD) 2,251 per patient per year: costs were NTD 4,296 and NTD 6,547 per patient per year for amlodipine and valsartan users, respectively. Fewer cardiovascular events were reported in patients receiving amlodipine versus valsartan (342 vs 413 per 10,000 patients over 5 years, respectively). Amlodipine had a net gain of 58 QALYs versus valsartan per 10,000 patients over 5 years. Sensitivity analyses showed that the discount rate and cohort age had a larger effect on total cost and cost difference than on QALYs. However, amlodipine results were more favorable than valsartan irrespective of discount rate or cohort age. When administered to Taiwanese patients for hypertension control, amlodipine was associated with lower cost and more QALYs compared with valsartan due to a lower risk of stroke and MI events.

A health insurance pricing model based on prevalence rates: Application to critical illness insurance

The Italian health insurance market is currently undersized. The paucity of assured data and the discontinuous statistical surveys carried out by the National Institute of Statistics (ISTAT) represent one of the main obstacles to the insurance market development. The paper sets forth a parametric model to estimate technical basis for health insurance policies when data are limited and only aggregated information on mortality and morbidity is available. The probabilistic framework is based on a multiple state continuous and time inhomogeneous Markov model. We provide an estimate of transition intensities from the healthy state to the sickness state when only prevalence rates of sickness are available, according to an extension and modification of the methodology proposed in Olivieri (1996) for Long Term Care insurance. We assume that mortality intensity of both healthy and sick lives is modelled by two independent Gompertz–Makeham models.

The role of the Pharmaceuticals and Medical Devices Agency and healthcare professionals in post-marketing safety.

The development of drugs and medical devices is necessary for medical progress; however, safety measures need to be put in place to protect the health of the population. In order to ensure the safety of drugs and medical devices, it is important to determine measures for appropriate management of risks at any time during the development phase, the regulatory review and the post-marketing phase. Adverse events detected in clinical trials are limited due to the restricted numbers of patients enrolled in the trials. Therefore, it is almost impossible to predict rare serious adverse events during the post-marketing phase. The revised Pharmaceutical Affairs Act was established in Japan in November 20, 2013. The new act focuses on increased safety of drugs and medical devices. The Pharmaceuticals and Medical Devices Agency (PMDA) is the regulatory authority in Japan that promotes safety measures from the development phase through to the post-marketing phase. In the post-marketing phase, the PMDA collects information from the medical product companies and healthcare professionals, as well as instructing and advising them with regard to post-marketing safety measures for each drug and medical device. Since Japan has a national health insurance system, a new drug or a medical device is available throughout the country when the drug price or medical fee is listed in the National Health Insurance price list. Healthcare professionals in medical institutions must learn about the drugs and medical devices they handle, and should make an effort to maintain patient safety. The PMDA medi-navi is a very useful electronic mail delivery service that provides critical information for protecting patients from health hazards caused by adverse events. The 'risk management plan' is also important as it contains important information about safety profile and post-marketing measures of a new drug.