eco question
MORAL HAZARD
Adapted from Bhattacharya, Hyde and Tu – Health Economics
1
What is moral hazard?
Definition: Moral hazard is the tendency for insurance against loss to reduce incentives to prevent or minimize the cost of loss.1
Moral hazard with health insurance
Insured people take risks with their health that similar uninsured people would not take, and demand more expensive treatment from their doctors when they get sick.
Moral hazard is the downside of health insurance because it raises society’s level of health care expenditures.
The moral hazard pattern
An individual faces some risk of a bad event X, and his actions can increase or decrease its likelihood
He holds an insurance contract that will help pay some or all of the costs of X, if it occurs. Thus his price of X is now lower.
In response to the price distortion, he changes his behavior in a way that increases the chance of X or increases the costs of recovering from X.
The insurance company cannot observe this behavior change – there is an information asymmetry. Otherwise the contract would have been written to discourage the riskier behavior.
The individual’s riskier behavior creates a social loss, because the costly event X occurs more than it would have without insurance.
Ex ante vs. Ex post
Ex ante moral hazard: behavior changes that occur before an insured event happens and make that event more likely.
leaving the stove on
skipping the flu vaccine
Ex post moral hazard: behavior changes that occur after an insured event happens and make recovering from that event more expensive.
using expensive drugs instead of generics
knee replacement surgery instead of painkillers
5
How does moral hazard lead to social loss?
Consider an individual who loves cheeseburgers but is at risk for a heart attack.
Without health insurance: his cost for each cheeseburger includes both the price of the burger and the increased chance of a heart attack
With health insurance: the cost of each cheeseburger declines, since the insurer picks up the costs of heart attack care.
In this case, social loss takes the form of extra money, labor, time, and effort that others expend on caring for heart attacks caused by cheeseburger overconsumption
Responses to changes in price
Counterfactual:
Bob has insurance. How many cheeseburgers would Bob eat if he didn’t have insurance?
Price
Pu
PI
Quantity
QI
Qu
Demand
Social loss caused by moral hazard
Point A is the socially efficient equilibrium.
Point B is the outcome with partial insurance.
Varying price distortion and price sensitivity
What determines the level of price distortion and price sensitivity?
Completeness of insurance
The fuller the insurance, the greater the price distortion
Price sensitivity: how controllable is the disease?
Consider Parkinson’s disease vs heart attacks
Moral hazard occurs if and only if three conditions hold:
The cost of a risky or wasteful action to an individual is reduced, usually as a consequence of insurance.
Asymmetric information prevents an insurer from adequately pricing the action.
That individual responds to the price distortion by changing his behavior—either by taking more risks or demanding more covered goods and services.
HOW TO LIMIT MORAL HAZARD
12
How do health insurers limit moral hazard?
The extent of moral hazard depends on both how sensitive demand is to price and the amount of price distortion caused by insurance.
Insurers cannot alter customers’ price sensitivity (which is a property of their demand functions), but they do have ways to reduce the price distortion due to insurance
Coinsurance
Copayments
Deductibles
Monitoring
Cost-sharing: coinsurance and copayment
Coinsurance: enrollees pay a percentage of each medical bill, and the insurer covers the remaining portion.
Copayment: insurance provision in which enrollees pay only a fixed amount, called a copay
Without insurance, the individual would consume at point QU.
Every unit of medical care he consumes would provide at least as much marginal benefit as marginal cost.
But with full insurance, his marginal costs of medical care (from his perspective) fall to zero.
His effective demand curve is DF and he consumes at point QA
Cost-sharing: coinsurance and copayment
Cost-sharing: coinsurance
Imagine the consumer starts at 0% coinsurance (full insurance from the previous slide).
His insurer then increases the level of coinsurance.
As coinsurance rises, out-of-pocket prices move closer to actual prices, and the demand curve rotates back toward the uninsured demand curve DU.
At the extreme, coinsurance of 100% is equivalent to no insurance.
Effect of coinsurance
Cost-sharing: copayment
Alternatively, imagine his insurer institutes a copay of PC , which becomes the effective price for each episode of care.
This reduces his demand from QA to QB.
Deductibles
In addition to coinsurance and copayment, many insurers also include deductibles as part of their offered plans.
Deductibles set minimal levels of expenses below which the insurer does not help reimburse medical expenses.
Example: A person insured with a deductible of $1,000 pays for his first thousand dollars of health care expenditures out-of-pocket. His insurance policy then helps pay for expenses beyond the thousandth dollar.
Deductibles
Monitoring
Some insurance companies try to observe and guide the preventative measures their customers take, while others choose to supervise the medical care that customers receive.
Motivation
Employee incentive programs with payouts if you:
see a nutritionist
do yoga once a week
get a fitness test
Gatekeeping
EVIDENCE OF MORAL HAZARD IN HEALTH INSURANCE
21
Empirical evidence of moral hazard
Moral hazard is quite difficult to study empirically.
Researchers suffer from the same information asymmetry that prevents insurers from eliminating moral hazard: behavior changes are very hard to observe.
But a few careful studies do find credible evidence of moral hazard.
Ex ante moral hazard
RAND HIE: people on the free plan more likely to show up at the hospital with broken bones or drug abuse
Ghana: insured households less likely to use mosquito nets, key for preventing malaria
Seguro Popular: low-income Mexicans assigned to receive free insurance were less likely to get a flu shot and cancer screenings
Ex ante moral hazard
Ex post moral hazard
Stanford employees: after a 1967 change that required a new 25% copay, visits to the doctor declined by 24%
RAND HIE: those on the free plan more likely to visit hospital
Germany: introducing deductibles leads to greatly decreased health expenditures
Canada: people with prescription drug coverage visit doctor more often
The End
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282 | Modern Health Economics
Figure 11.1: The basic analysis of social loss caused by moral hazard.
C
$
PU
PI
QU QI
Extent of price distortion
DC
Extent of price sensitivity
social loss
A
B
elastic demand for cheeseburgers would imply a large angle and major moral hazard.
Varying price distortion and price sensitivity
Figure 11.2: Varying the extent of price distortion and price sensitivity affects the social loss from moral hazard.
(a)
C
$
PU
PI
Greater price distortion
DC
Greater price sensitivity
huge social loss
A
B
(b)
C
$
PT
PI
Less price distortion
DC
Less price sensitivity
tiny social loss
A
B
In Figure 11.2, we vary the extent of price distortion and the degree of price sensitivity to
282 | Modern Health Economics
Figure 11.1: The basic analysis of social loss caused by moral hazard.
C
$
PU
PI
QU QI
Extent of price distortion
DC
Extent of price sensitivity
social loss
A
B
elastic demand for cheeseburgers would imply a large angle and major moral hazard.
Varying price distortion and price sensitivity
Figure 11.2: Varying the extent of price distortion and price sensitivity affects the social loss from moral hazard.
(a)
C
$
PU
PI
Greater price distortion
DC
Greater price sensitivity
huge social loss
A
B
(b)
C
$
PT
PI
Less price distortion
DC
Less price sensitivity
tiny social loss
A
B
In Figure 11.2, we vary the extent of price distortion and the degree of price sensitivity to
292 | Modern Health Economics
off his demand curve, we find that this reduces the consumer’s demand to QB.
Figure 11.7: Social loss from different insurance plans.
(a) Full insurance
social loss
Q
$
P
D A
QA
DF
U
QU
(b) Copayment plan
social loss
Q
$
P
PC
D
A
QA
U
QU
B
QB
(c) Coinsurance plan
social loss
Q
$
P
DU
DI
A
QA
Effect of coinsurance
U
C
By contrast, a coinsurance plan rotates the insured individual’s demand outward (Figure 11.7c). Imagine the consumer starts at full insurance – 0% coinsurance. His demand curve is then vertical since he faces no out-of-pocket costs for any services he consumes. The insurer pays 100% of the bill and graphically, the demand curve becomes a vertical line over Point A. As coinsurance rises, out-of-pocket prices become closer and closer to actual prices, and the demand curve rotates back toward the uninsured demand curve DU . At the extreme, coinsurance of 100% is equivalent to no insurance.
In Figures 11.7b and 11.7c, the imposition of either a copay or coinsurance increases the marginal cost of additional medical care to the consumer and lowers the quantity demanded. This reduces social loss at the expense of increasing uncertainty faced by consumers who are no longer fully insured.
Deductibles In addition to coinsurance and copayment, insurers also sometimes include deductibles as part of their offered plans. Deductibles set minimal levels of expenses below which the insurer does not help reimburse medical expenses. For example, a person insured with a deductible of $1,000 pays for his first thousand dollars of health care expenditures out-of-pocket. His insurance policy then helps pay for expenses beyond the thousandth dollar. Depending on the policy, deductibles may apply to an individual episode of care or over an entire year of expenditures.
Deductibles may be paired with coinsurance or copayments in the same policy. Figure 11.8 shows the relationship between total medical care expenses and out-of-pocket expenditures for a health insurance policy with 33% coinsurance, a deductible of ⌦, and full insurance for catastrophic care expenses above . For the first ⌦ dollars of medical care, the insured individual pays the whole price, so the slope m in this region equals 1. However, each dollar of medical care above ⌦ only costs the customer $0.33 because his coinsurance has now taken effect. The slope in this region is therefore only 0.33. Lastly, this hypothetical policy provides full insurance for catastrophic care,
292 | Modern Health Economics
off his demand curve, we find that this reduces the consumer’s demand to QB.
Figure 11.7: Social loss from different insurance plans.
(a) Full insurance
social loss
Q
$
P
D A
QA
DF
U
QU
(b) Copayment plan
social loss
Q
$
P
PC
D
A
QA
U
QU
B
QB
(c) Coinsurance plan
social loss
Q
$
P
DU
DI
A
QA
Effect of coinsurance
U
C
By contrast, a coinsurance plan rotates the insured individual’s demand outward (Figure 11.7c). Imagine the consumer starts at full insurance – 0% coinsurance. His demand curve is then vertical since he faces no out-of-pocket costs for any services he consumes. The insurer pays 100% of the bill and graphically, the demand curve becomes a vertical line over Point A. As coinsurance rises, out-of-pocket prices become closer and closer to actual prices, and the demand curve rotates back toward the uninsured demand curve DU . At the extreme, coinsurance of 100% is equivalent to no insurance.
In Figures 11.7b and 11.7c, the imposition of either a copay or coinsurance increases the marginal cost of additional medical care to the consumer and lowers the quantity demanded. This reduces social loss at the expense of increasing uncertainty faced by consumers who are no longer fully insured.
Deductibles In addition to coinsurance and copayment, insurers also sometimes include deductibles as part of their offered plans. Deductibles set minimal levels of expenses below which the insurer does not help reimburse medical expenses. For example, a person insured with a deductible of $1,000 pays for his first thousand dollars of health care expenditures out-of-pocket. His insurance policy then helps pay for expenses beyond the thousandth dollar. Depending on the policy, deductibles may apply to an individual episode of care or over an entire year of expenditures.
Deductibles may be paired with coinsurance or copayments in the same policy. Figure 11.8 shows the relationship between total medical care expenses and out-of-pocket expenditures for a health insurance policy with 33% coinsurance, a deductible of ⌦, and full insurance for catastrophic care expenses above . For the first ⌦ dollars of medical care, the insured individual pays the whole price, so the slope m in this region equals 1. However, each dollar of medical care above ⌦ only costs the customer $0.33 because his coinsurance has now taken effect. The slope in this region is therefore only 0.33. Lastly, this hypothetical policy provides full insurance for catastrophic care,
292 | Modern Health Economics
off his demand curve, we find that this reduces the consumer’s demand to QB.
Figure 11.7: Social loss from different insurance plans.
(a) Full insurance
social loss
Q
$
P
D A
QA
DF
U
QU
(b) Copayment plan
social loss
Q
$
P
PC
D
A
QA
U
QU
B
QB
(c) Coinsurance plan
social loss
Q
$
P
DU
DI
A
QA
Effect of coinsurance
U
C
By contrast, a coinsurance plan rotates the insured individual’s demand outward (Figure 11.7c). Imagine the consumer starts at full insurance – 0% coinsurance. His demand curve is then vertical since he faces no out-of-pocket costs for any services he consumes. The insurer pays 100% of the bill and graphically, the demand curve becomes a vertical line over Point A. As coinsurance rises, out-of-pocket prices become closer and closer to actual prices, and the demand curve rotates back toward the uninsured demand curve DU . At the extreme, coinsurance of 100% is equivalent to no insurance.
In Figures 11.7b and 11.7c, the imposition of either a copay or coinsurance increases the marginal cost of additional medical care to the consumer and lowers the quantity demanded. This reduces social loss at the expense of increasing uncertainty faced by consumers who are no longer fully insured.
Deductibles In addition to coinsurance and copayment, insurers also sometimes include deductibles as part of their offered plans. Deductibles set minimal levels of expenses below which the insurer does not help reimburse medical expenses. For example, a person insured with a deductible of $1,000 pays for his first thousand dollars of health care expenditures out-of-pocket. His insurance policy then helps pay for expenses beyond the thousandth dollar. Depending on the policy, deductibles may apply to an individual episode of care or over an entire year of expenditures.
Deductibles may be paired with coinsurance or copayments in the same policy. Figure 11.8 shows the relationship between total medical care expenses and out-of-pocket expenditures for a health insurance policy with 33% coinsurance, a deductible of ⌦, and full insurance for catastrophic care expenses above . For the first ⌦ dollars of medical care, the insured individual pays the whole price, so the slope m in this region equals 1. However, each dollar of medical care above ⌦ only costs the customer $0.33 because his coinsurance has now taken effect. The slope in this region is therefore only 0.33. Lastly, this hypothetical policy provides full insurance for catastrophic care,