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The purpose of this paper is twofold: first, to present patient-level utilisation patterns of hospital-based mental health services funded by private health insurers; and second, to examine the implications of the findings for planning and delivering private mental health services in Australia.

Analysing private health insurance claims data, this study compares differences in demographic and hospital utilisation characteristics of 3,209 patients from 13 private health insurance funds with claims for mental health-related hospitalisations and 233,701 patients with claims for other types of hospitalisations for the period May 2014 to April 2016. Average number of overnight admissions, length of stay and per patient insurer costs are presented for each group, along with overnight admissions vs same-day visits and repeat services within a 28-day period following hospitalisation. Challenges in analysing and interpreting insurance claims data to better understand private mental health service utilisation are discussed.

Patients with claims for mental health-related hospitalisations are more likely to be female (62.0 per cent compared to 55.8 per cent), and are significantly younger than patients with claims for other types of hospitalisations (32.6 per cent of patients aged 55 years and over compared to 57.1 per cent). Patients with claims for mental health-related hospitalisations have significantly higher levels of service utilisation than the group with claims for other types of hospitalisations with a mean length of stay per overnight admission of 15.0 days (SD=14.1), a mean of 1.3 overnight admissions annually (SD=1.2) and mean hospital costs paid by the insurer of $13,192 per patient (SD=13,457) compared to 4.6 days (SD=7.3), 0.8 admissions (SD=0.6) and $2,065 per patient (SD=4,346), respectively, for patients with claims for other types of hospitalisations. More than half of patients with claims for mental health-related hospitalisations only claim for overnight admissions. However, the findings are difficult to interpret due to the limited information collected in insurance claims data.

This study shows the challenges of understanding utilisation patterns with one data source. Analysing insurance claims reveals information on mental health-related hospitalisations but information on community-based care is lacking due to the regulated role of the private health insurance sector in Australia. For mental health conditions, and other chronic health conditions, multiple data sources need to be integrated to build a comprehensive picture of health service use as care tends to be provided in multiple settings by different medical and allied health professionals.

This study contributes in two areas: patient-level trends in hospital-based mental health service utilisation claimed on private health insurance in Australia have not been previously reported. Additionally, as the amount of data routinely collected in health care settings increases, the study findings demonstrate that it is important to assess the quality of these data sources for understanding service utilisation.

The purpose of this paper is to explore the determinants of health insurance ownership of individuals in the Sri Lankan labor force and to examine how insurance ownership impacts healthcare utilization.

The authors first used logit model to explore determinants of health insurance ownership. The authors then employed propensity score matching method to estimate impact of insurance ownership on healthcare utilization. Data were obtained from national survey of self-reported health in Sri Lanka – 2014 (n=59,276). National survey of self-reported health in Sri Lanka – 2014 was conducted by the Department of Census and Statistics from January to December 2014.

Results showed that individuals with higher educational attainments, headed by literate-heads, based in urban sector, employed in formal sector, and with health adversities and higher degree of risk propensity are more inclined to have a health cover. Health insurance ownership reduces the likelihood of utilizing public facilities while increasing the likelihood of utilizing private facilities for non-communicable diseases (NCDs) and acute illnesses. Welfare consequences of expanding insurance ownership are doubtful due to oligopolistic private healthcare market and adverse selection issue faced by insurers in Sri Lanka.

This is the first study examining health insurance–healthcare utilization nexus based on Sri Lanka-wide microdata. Also, the study applies bias-corrected matching methods to establish causal links between two constructs. Without being so generalized, healthcare utilization is examined in terms of NCD care and Acute illnesses care, which improves robustness of results and leads to evidence-based healthcare policies.

The peer review history for this paper is available at: https//publons.com/publon/10.1108/IJSE-05-2019-0333.

We adopt a standard distributional impact methodology, based on Atkinson's cost of inequality approach, to estimate the degree of implicit redistribution created through public funding of health insurance in Canada. The first stage of the exercise is to determine the public health insurance benefits received by families of various age and composition and to add these to measured after-tax incomes. In our base case, which uses the Atkinson Mean Logarithmic Deviation as inequality index, we find that accounting for public health insurance benefits implies a reduction in inequality equivalent to 2.4% of per capita income. We then model the implications of moving to a hypothetical fully privatized system while proportionately refunding to individuals the tax revenues saved in doing so. This would give rise to a further 2.4% equivalent per capita income reduction resulting from increased inequality in the distribution of after-tax income. Thus, for this scenario, moving from public financing of health insurance in Canada to a fully privatized system implies an overall increase in inequality equivalent to a loss of 4.8% of per capita income. This corresponds to an increase of about 25% in existing inequality. Not surprisingly, the impact of publicly financed health insurance in reducing inequality is strongest for the elderly.

The central lesson to be learned from studying the case is to understand the challenges and constraints posed by contextual conditions in designing contracts in public–private partnerships (PPP) for financing and delivering health care in emerging economies such as India.

Perverse incentives, along with contextual conditions, led to extensive opportunistic behaviors among involved agencies, limiting the effectiveness of otherwise highly regarded innovative design of the program.

India’s “Rashtriya Swasthya Bima Yojana” or National Health Insurance Program, launched in 2007 provided free health insurance coverage to protect millions of low-income families from getting pushed into poverty due to catastrophic health-care expenditure. The program was implemented through a PPP using standardized contracts between multiple stakeholders from the public and private sector – insurance companies, hospitals, intermediaries, the provincial and federal government.

Teaching Notes are available for educators only.

CSS: 10 Public Sector Management.

The purpose of this article is to explore financial fraud in the private health insurance sector in Australia. Fraud in this sector has commonalities to other countries with similar health systems but in Australia it has garnered some unique characteristics. This article sheds light on these features, especially the fraught relationship between the private health funds and the public health insurance agency, Medicare and the problematic impact of the Privacy Act on fraud detection and financial recovery.

A qualitative methodological approach was used, and interviews were conducted with fraud managers from Australia’s largest private health insurance funds and experts in fields connected to health fraud detection.

All funds reported a need for more technological resources and higher staffing levels to manage fraud. Inadequate resourcing has the predictable outcome of a low detection and recovery rate. The fund managers had differing approaches to recovery action and this ranged from police action, the use of debt recovery agencies, to derecognition from the health fund. As for present and future harm to the industry, the funds found on-line claiming platforms a major threat to the integrity of their insurance system. In addition, they all viewed the Privacy Act as an impediment to managing fraud against their organizations and they desired that there be greater information sharing between themselves and Medicare.

This paper contributes to the knowledge of financial fraud in the private health insurance sector in Australia.

Health insurance in India has shown little development. It has not been able to evoke enthusiasm among Indian insurers. Consequently, several reports on Indian health care insurance have been produced. The purpose of this paper is to offer a review of this matter.

Critical review of related published and grey literature.

Almost 79 per cent of health expenditure is borne by private bodies and the rest by the public. Authors argue that to stimulate private health insurance growth, the Indian government should recognize health insurance as a separate line of business and distinguish it from other non‐life insurance. Particular emphasis is placed on the present health care scenario in India and international field generally. A global comparison of selected Asian countries, regarding their national incomes and health expenditure in public and private sectors, generates insights. Third party administrators (TPAs) facilitate a cashless health services for their customers and offer back‐up services to the insurance companies. Desired strategies and ways of furthering the role of the Insurance Regulatory and Development Authority in acting as a regulator for the purpose of ensuring the industry's smooth functioning is an issue for India's health services.

Information about the present complexities in the health insurance market has been gathered from various sources and summarized.

The purpose of this study is to understand how risk attitudes drive demand for different types of insurance amongst Ghanaians.

This study uses data from a nationally representative survey of Ghanaian households (Ghana Living Standards Survey Round 7). Risk aversion is measured following the approach of Holt and Laury (2002) in the use of hypothetical questions about investment. Probit regressions are used to estimate the effect of risk aversion on insurance outcomes.

The paper finds evidence that supports the theory that risk attitudes influence insurance demand. Specifically, risk aversion is positively related to the uptake of insurance in general and in particular, public health insurance. Unlike previous literature, the authors do not find the sex of the respondent to affect the relationship between risk aversion and insurance demand except for private health insurance. Socio-economic factors such as wealth, age and education were found to strongly predict insurance demand.

The findings confirm that risk attitude influence the demand for insurance in developing countries but socio-economic factors play a strong role in explaining low insurance penetration in such contexts.

Theoretically, attitudes towards risk have been strongly linked with insurance demand. Yet, empirical evidence on this relationship is limited in developing countries where insurance penetration is very low. This study is among the first to document the influence of risk attitude on the demand of a range of insurance products using a large nationally representative sample of individuals in a developing country.

This paper sets out to examine how private health insurance (PHI) supports the private interests of consumers of healthcare services. The focus is on how insurance companies promote PHI to consumers.

Using interviews with insurance company marketing managers and others, the paper is a case study on the introduction of PHI in Sweden.

The interviewed insurance company managers argue that PHI supports two types of consumers' private economic interests. One type is the employers' interest in managing their total health‐related costs for their employees and the promise of PHI to reduce these costs. The second type relates to the interests of employees, particularly sports professionals, in managing economic risks and the promise of PHI to limit such risks.

The paper focuses on how insurance companies promote PHI to consumers. There is no exploration of how PHI policyholders actually use their insurance. The study focuses on Sweden where private companies are the major PHI policyholders. In other European countries, PHI may be adapted to other consumer groups in order to develop other private interests. The paper points to the value of short waiting times in public healthcare.

The paper provides valuable insights for academics and practitioners who are interested in how the private interests of consumers may affect the healthcare sector.

Objective – The South African health system has long been characterised by extreme inequalities in the allocation of financial and human resources. Voluntary private health insurance, delivered through medical schemes, accounts for some 60% of total expenditure but serves only the 14.8% of the population with higher incomes. A plan was articulated in 1994 to move to a National Health Insurance system with risk-adjusted payments to competing health funds, income cross-subsidies and mandatory membership for all those in employment, leading over time to universal coverage. This chapter describes the core institutional mechanism envisaged for a National Health Insurance system, the Risk Equalisation Fund (REF). A key issue that has emerged is the appropriate sequencing of the reforms and the impact on workers of possible trajectories is considered.

Methodology – The design and functioning of the REF is described and the impact on competing health insurance funds is illustrated. Using a reference family earning at different income levels, the impact on workers of various trajectories of reform is demonstrated.

Findings – Risk equalization is a critical institutional component in moving towards a system of social or national health insurance in competitive markets, but the sequence of its implementation needs to be carefully considered. The adverse impact of risk equalization on low-income workers in the absence of income cross-subsidies and mandatory membership is considerable.

Implications for policy – The South African experience of risk equalization is of interest as it attempts to introduce more solidarity into a small but highly competitive private insurance market. The methodology for considering the impact of reforms provides policy-makers and politicians with a clearer understanding of the consequences of reform.

The objective of this study is to identify how risk and social variables are likely to be impacted by an increase in private sector participation in health insurance provision. The study focuses on the Chilean health insurance industry, traditionally dominated by the public sector.

Predictive risk modelling is conducted using a database containing over 250,000 health insurance policy records provided by the Superintendence of Health of Chile.

Although perceived with suspicion in some circles, risk segmentation serves as a rational approach to risk management from a resource perspective. The variables that have considerable impact on insurance claims include the number of dependents, gender, wages and the duration a claimant has been a customer.

As shown in the case study, to ensure that social benefits are realised, increased private sector participation in health insurance must be augmented by regulatory oversight and vigilance.

As it is clear that a “community-rated” health insurance provision philosophy impacts on insurance firm's ability to charge “market” prices for insurance provision, the authors explore whether risk segmentation is a feasible means of predicting insurance claim behaviour in Chile's private health insurance industry.