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In most US health insurance markets, plans face strong incentives to upcode the patient diagnoses they report to the regulator, as these affect the risk-adjusted payments that plans receive. We show that enrollees in private Medicare plans generate 6%–16% higher diagnosisbased risk scores than they would under fee-for-service Medicare, where diagnoses do not affect most provider payments. Our estimates imply that upcoding generates billions in excess public spending and significant distortions to firm and consumer behavior. We show that coding intensity increases with vertical integration, suggesting a principal-agent problem faced by insurers, who desire more intense coding from the providers with whom they contract.

Healthcare reimbursements in the United States have been traditionally based on a fee-for-service (FFS) scheme, providing incentives for high volume of care, rather than efficient care. The new healthcare legislation tests new payment models that remove such incentives, such as the bundled payment (BP) system. We consider a population of patients (beneficiaries). The provider may reject patients based on the patient’s cost profile and selects the treatment intensity based on a risk-averse utility function. Treatment may result in success or failure, where failure means that unforeseen complications require further care. Our interest is in analyzing the effect of different payment schemes on outcomes such as the presence and extent of patient selection, the treatment intensity, the provider’s utility and financial risk, and the total system payoff. Our results confirm that FFS provides incentives for excessive treatment intensity and results in suboptimal system payoff. We show that BP could lead to suboptimal patient selection and treatment levels that may be lower or higher than desirable for the system, with a high level of financial risk for the provider. We also find that the performance of BP is extremely sensitive to the bundled payment value and to the provider’s risk aversion. The performance of both BP and FFS degrades when the provider becomes more risk averse. We design two payment systems, hybrid payment and stop-loss mechanisms, that alleviate the shortcomings of FFS and BP and may induce system optimum decisions in a complementary manner. This paper was accepted by Serguei Netessine, operations management .

A central question in the debate over privatized Medicare is whether increased government payments to private Medicare Advantage (MA) plans generate lower premiums for consumers or higher profits for producers. Using difference-in-differences variation brought about by a sharp legislative change, we find that MA insurers pass through 45 percent of increased payments in lower premiums and an additional 9 percent in more generous benefits. We show that advantageous selection into MA cannot explain this incomplete pass-through. Instead, our evidence suggests that market power is important, with premium pass-through rates of 13 percent in the least competitive markets and 74 percent in the most competitive.

We describe findings from the first large-scale cluster randomized controlled trial in a developing country that evaluates the uptake of a health-protecting technology, insecticide-treated bednets (ITNs), through micro-consumer loans, as compared to free distribution and control conditions. Despite a relatively high price, 52 percent of sample households purchased ITNs, highlighting the role of liquidity constraints in explaining earlier low adoption rates. We find mixed evidence of improvements in malaria indices. We interpret the results and their implications within the debate about cost sharing, sustainability and liquidity constraints in public health initiatives in developing countries.

Background: Health insurance is among the healthcare financing reforms proposed to increase the available healthcare resources and to decrease the risk of household financial crisis. Recently, Ethiopia has been implementing community-based health insurance which mainly targets the very large rural agricultural sector and small and informal sector in urban settings. Therefore, this study was aimed to assess the coverage of health insurance and its determinants in Ethiopia. Methods: Data were extracted from the 2019 mini Ethiopian Demographic and Health Survey (EDHS) to assess determinants of health insurance coverage in Ethiopia. The analysis included a weighted sample of 8663 respondents. Multivariable logistic regression analysis was conducted and the results were presented as adjusted odds ratio (AOR) at 95% confidence interval (CI), statistical significance was declared at a p-value < 0.05 in all analyses. Results: The health insurance coverage in Ethiopia was 28.1% (95%CI: 27.2%, 29%). Administration regions (Tigray: AOR = 16.9, 95%CI: 5.53, 51.59, Amhara: AOR = 25.8, 95%CI: 8.52, 78.02, Oromia, AOR = 4.27, 95%CI: 1.41, 12.92, Southern Nations, Nationalities and Peoples region, AOR = 4.06, 95%CI: 1.34, 12.32, Addis Ababa, AOR = 4.65, 95%CI: 1.46, 14.78), place of residence (rural, AOR = 1.38, 95%CI: 1.17, 1.63), sex of household head (male; AOR = 1.23, 95%CI: 1.07, 1.41), wealth index (middle, AOR = 1.75, 95%CI: 1.46, 2.09, richer, AOR = 1.86, 95%CI: 1.55, 2.24), family size (Ï 5 members, AOR = 1.17, 95%CI: 1.03, 1.33), having under-five children (AOR = 1.22, 95%CI: 1.076, 1.38), and age of household head (31-40 years, AOR = 1.71, 95%CI: 1.45, 2.01, 41-64 years, AOR = 2.49, 95%CI: 2.12, 2.92, 65 + years, AOR = 2.43, 95%CI: 2.01, 2.93) were factors associated with health insurance coverage. Conclusions: Less than one-third of Ethiopians were covered by health insurance. Socio-economic factors and demographic factors were found to associate with health insurance coverage in Ethiopia. Therefore, enhancing health insurance coverage through contextualized implementation strategies would be emphasized.

Medical crowdfunding is the practice of using websites to raise money from donors to pay for medicalcare or related expenses. While in terms of overall funding volume, medical crowdfunding should still be considered as a niche phenomenon, it is rapidly growing in many countries and is seen by many people as a way to cope with government cuts on public health financing. Examining the worldwide population of healthcare crowdfunding platforms, this study is the first to offer global and cross-platform evidence on healthcare crowdfunding by providing an assessment of how and where healthcare crowdfunding platforms emerge. We explore the relationship between healthcare crowdfunding and national health systems, finding evidence of a substitution effect when public health coverage is low. Moreover, our findings support the evidence that the number of successfully funded health projects is higher when the platform is not investment-based or dedicated only to healthcare projects.

The SARS-CoV-2 coronavirus that causes the COVID-19 disease led to the most significant change in the world order over the past century, destabilizing the global economy and financial stock markets, the world's economy, social development, business, risk, financial management and financial markets, among others. COVID-19 has generated great uncertainty, and dramatically affected tourism, travel, hospitality, supply chains, consumption, production, operations, valuations, security, financial stress and the prices of all products, including fossil fuel and renewable energy sources. This Editorial introduces a Special Issue of the Journal of Risk and Financial Management (JRFM) on the \"Risk and Financial Management of COVID-19 in Business, Economics and Finance\". This Special Issue will attract practical, state-of-the-art applications of mathematics, probability and statistical techniques on the topic, including empirical applications. This paper investigates important issues that have been discussed in tourism, global health security and risk management in business as well as the social and medical sciences.

Introduction Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. Methods We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. Results We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. Discussion Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

ABSTRACT Healthcare financing is attracting widespread interest due to the coronavirus pandemic. This study aims to assess federal public healthcare financing in Brazil in the light of a legal framework for minimum spending on health and the effects of economic cycles and crises. A literature review showed that public healthcare funding should increase during crises, which is contrary to what fiscal austerity policies postulate. Different formats of fiscal rules for minimum spending on health are analyzed based on the historical evolution of healthcare financing in Brazil. A simulation shows that linking this spending rule to GDP (and especially to current revenue) gives a pro-cyclical character to healthcare financing, which can make it difficult to guarantee health rights in times of crisis. Thus, a debate arises about the need to revise the rule set by the Constitutional Amendment 95/2016 (EC no. 95/2016) and to establish a parameter for growth in public healthcare expenditure that eliminates its pro-cyclical characteristic and enables the needs of the country to be met after the pandemic. RESUMO O financiamento de sistemas de saúde tem atraído amplo interesse devido à pandemia de coronavírus. Este artigo propõe uma avaliação do financiamento do sistema de saúde público no Brasil para o governo Federal à luz da legislação para gasto mínimo em saúde e dos efeitos de ciclos econômicos e crises. A partir de uma revisão da literatura, é indicado que, em momentos de crise, o financiamento do sistema público de saúde deva aumentar, contrário ao que as políticas de austeridade fiscal postulam. Diferentes formatos de regras fiscais para o gasto mínimo em saúde são analisados com base na evolução histórica do financiamento de saúde pública no Brasil. Uma simulação mostra que vincular essa regra de gasto ao PIB, e, principalmente, à receita corrente, atribui um caráter pró-cíclico ao financiamento do sistema público de saúde, o que dificulta a garantia do direito à saúde em momentos de crise. Assim, emerge o debate sobre a necessidade de revisar a regra estabelecida pela Emenda Constitucional nº 95/2016 e definir uma regra de crescimento para o gasto no sistema público de saúde que elimine o traço pró-cíclico e permita que as necessidades pós-pandemia do país sejam atendidas.