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Kajian Ekonomi Eropa 42 (1998) 513 522

Model ekonometrik pemanfaatan perawatan

kesehatan dan asuransi kesehatan di Swiss
Alberto Holly!,*, Lucien Gardiol,!
Gianfranco Domenighetti," Brigitte Bisig #
! Departement
&
d+ econometrie,
&
&
et d+ economie
&
politique, Uni versite& de Lausanne, Ecole des HEC,
1015-Lausanne, Swiss
" Bagian Sanitaria, Dipartimento delle opere sociali, Ticino, Swiss Institute for
v vUni ersity Zurich,
v Zrich, Swiss
# sosial dan pra enti e Kedokteran,

Abstrak
Makalah ini menyajikan analisis ekonometrik awal pada bagaimana different alternatif
rencana affect pemanfaatan pelayanan perawatan kesehatan di Swiss. Data yang datang dari
1992 1993 Swiss kesehatan survei (SHS). Kami briefly menggambarkan beberapa aspek

kelembagaan
sistem kesehatan Swiss yang berlaku pada saat SHS, dengan penekanan khusus pada rencana
asuransi kesehatan dan sistem pembayaran penyedia. Kami memperkirakan model dua
persamaan simultan yang mengandung laten variabel untuk membandingkan probabilitas
havingat setidaknya tinggal oneinpatient yang diberikan bahwa rencana diasuransikan hasused
somemedical perawatan bagi mereka yang telah membeli hanya basic insurance dan
orang-orang yang telah membeli asuransi tambahan.

( 1998 Elsevier ilmu BV Semua Hak, milik.

fikasi:
JEL Rahasia
USA. I111; C35
Kata kunci: Pemanfaatan perawatan kesehatan; Asuransi kesehatan; Survei kesehatan Swiss 1992/93; Simultan
dua persamaan probit

1. Pengenalan
Seperti diketahui, perawatan kesehatan pemanfaatan dikondisikan oleh
jenis rencana asuransi pengguna. Ada luas sastra ini subjek yang

* Sesuai penulis. E-mail: alberto.holly

@HEC.unil.ch.

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0014-2921/98/$19.00 hak cipta ( 1998 Elsevier ilmu BV Semua Hak, milik.
PII S 0 0 1 4 - 2 9 2 1 ( 9 8 ) 0 0 0 0 3 - 8

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514

A. Holly et al. / Iew Re ekonomi Eropa v42 (1998) 513 522

meneliti effect masalah moral hazard yang telah ditunjukkan lama yang lalu oleh
panah (1963). Hal ini terutama terjadi percobaan asuransi kesehatan RAND luar biasa
(RHIE) (Lihat Manning et al., 1987; Newhouse dan kelompok percobaan asuransi,
1993). Penelitian lain juga menunjukkan bahwa pemanfaatan perawatan kesehatan
mungkin dikondisikan oleh insentif ekonomi penyedia. Secara khusus, beberapa studi
menunjuk ke peran consumers informasi dan kemungkinan disebabkan permintaan
dalam rencana asuransi biaya-untuk-layanan.

Tujuan karya ini adalah untuk menyajikan sebuah penyelidikan awal effects
alternatif rencana asuransi pada pemanfaatan pelayanan perawatan kesehatan di
Swiss. Analisis ekonometrik didasarkan pada kesehatan Swiss 1992 1993

Survei (SHS) yang dilakukan oleh Swiss Federal Statistik Office (SFSO).

Umumnya, aspek kelembagaan memiliki implikasi penting untuk pemodelan hubungan antara
rencana asuransi kesehatan dan pemanfaatan perawatan kesehatan. SEC-tion
2describestherelevantaspectsoftheSHSdataandtheinstitutionaldetails mengenai rencana asuransi
pada waktu itu di Swiss. Namun, hal ini berguna untuk menunjukkan pada tahap ini bahwa
rencana ini terutama dipisah menjadi: basic insuranceconcerningthe disebut minimal
compulsory benefits; semi-private dan private asuransi, nama yang diberikan karena rawat
inap di kamar 2-tempat tidur dan sebuah ruang tempat tidur tunggal, masing-masing. Tapi ini
tiga jenis rencana asuransi juga bervariasi sepanjang beberapa dimensi lain: cakupan
kenyal-mentalinpatientandoutpatientservices, coverageofalliedhealthpersonneland sistem
pembayaran dari penyedia layanan untuk setiap prosedur atau layanan.

Dalam studi baru, Domenighettiet al. (1996) digunakan SHS data untuk
menganalisis variasi dalam konsumsi five specific prosedur bedah di
sub-kelompok dari penduduk Swiss.
2 Analisis di Domenighetti et al. (1996) menunjukkan
bahwa operasi harga jauh lebih rendah bagi mereka yang memiliki asuransi basic,

dan dengan demikian hanya berhak untuk rawat inap di bangsal umum, dan lebih tinggi bagi
mereka yang memiliki baik private atau semi-private asuransi.

Penyelidikan empiris awal disajikan dalam differs kertas ini dari Domenighetti et
al. (1996) di dua unsur utama. Pertama, kami menggunakan data pada pemanfaatan
pelayanan kesehatan oleh peserta selama 12 sebelumnya bulan insteadofthedata
ontheabove-mentionedsurgicalprocedures. Kedua, bukan multiple regresi logistik,
kami memperkirakan model persamaan simultan dengan laten variabel untuk
menganalisis data ini.
Sebagai sudah diamati oleh Cameron et al. (1988), antara lain, itu adalah difficult
untuk model penentuan bersama pilihan pemanfaatan dan asuransi kesehatan dengan
layanan kesehatan melalui model persamaan simultan struktural tractable. Khusus,
ekonometrik pelaksanaan model struktural untuk asuransi

1 Sebuah penyelidikan lebih lengkap dilakukan oleh Holly et al. (1997).

2 five bedah prosedur: histerektomi, amandel, usus buntu, dan operasi thehip dan kandung
empedu. Model yang digunakan dalam analisa mereka termasuk covariates untuk jenis kelamin,
usia, linguistik, Kanton, tingkat pendidikan dan jenis rencana asuransi.

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A. Holly et al. / Iew Re ekonomi Eropa v42 (1998) 513 522

515

permintaan cukup kompleks. Dalam tulisan ini, kita mengikuti pendekatan yang sama seperti
Cameron et al. (1988) dan mempertimbangkan model dua persamaan simultan yang hanya
berkaitan dengan penggunaan per orang selama 12 bulan sebelumnya
yang mungkin, kita telah dikelompokkan bersama dua jenis rencana asuransi
kesehatan

tambahan
(semi-private
danpenggunaan
private),tahunan
dan persamaan first adalah bentuk dikurangi persamaan
entah bagaimana,
ditafsirkan sebagai
3
rencana
asuransi.
pilihan asuransi. Persamaan kedua adalah persamaan
struktural
untuk kecenderungan bahwa
seseorang akan memiliki setidaknya satu rawat inap yang menginap mengingat bahwa ia telah
menggunakan beberapa pengobatan, bergantung pada jenis rencana asuransi yang dia telah dipilih.
Dengan demikian, ini persamaan containsendogenouslatent variabel serta merupakan-ous dummy
variabel.

4
Sisa kertas diatur sebagai berikut: Bagian 2 berisi deskripsi singkat dari
1992 1993 Swiss surveikesehatan dan asuransi kesehatan
pengaturan di Swiss pada waktu itu. Bagian 3 menyajikan model dua-persamaan simultan
dengan laten variabel dan variabel endogen dummy. Ini juga menampilkan perkiraan dari sistem
ini. Kesimpulan utama kami adalah sebagai berikut: jika kita mengendalikan untuk variabel lain,
fakta bahwa orang yang diasuransikan memiliki asuransi kesehatan tambahan memiliki effect
positif pada kemungkinan bahwa ia akan memiliki setidaknya satu rawat inap yang menginap
mengingat bahwa ia telah menggunakan beberapa pengobatan.

Dengan demikian,

menunjukkan

yang

The kesimpulan
Domenighetti et al. (1996) berdasarkan data lainnya adalah confirmed.

2. 1992

ini

hasil

mencapai

dalam

Pengaturan 1993 Swiss survei kesehatan dan asuransi kesehatan

pada waktu itu

ThefirstSwissHealthSurvey(SHS) hasbeencarriedoutbythe SwissFederal

Statistik Office (SFSO) tahun 1992 1993. Yang relevan aspectsoftheSHS,
andVonlanthen structuredaftertheexpositionbyZimmermannandThomas (1996) (1997),
aredescribedin detailin Holly etal. (1997). batasan ruang Giventhe, kami akan
menjelaskan hanya sejumlah terbatas fitur SHS.
Kota ini memiliki penduduk SHS target populasi penduduk permanen
terbentuk dari orang-orang yang berusia 15 tahun atau lebih tinggal di
rumah tangga pribadi. Populasi sampel telah diakses melalui telepon. SHS
adalah contoh stratified untuk meningkatkan representasi numerik beberapa

3 Di Holly et al. (1997), kami juga menyelidiki bagaimana rencana dan affect penjelasan variabel lainnya
frekuensi hari tinggal di rumah sakit selama 12 bulan sebelumnya. Kami juga menganalisis
variasi dalam jumlah kunjungan pencegahan dan jumlah kunjungan ke dokter karena penyakit.
Di Holly et al. (1997) analisis dilakukan berdasarkan persamaan tiga simultan 4
model dengan tiga variabel laten. Persamaan dua first dimaksudkan untuk berurusan dengan pilihan-diri
masalah. Persamaan ketiga ini mirip dengan persamaan kedua model yang disajikan di sini.

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A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

subgroups of the population (for example, residents of sparsely populated

regions).
Eventually, 15 288 individuals aged 15 or more, representative of the Swiss
resident population, have participated in the SHS. The refusal rates did not affect
therepresentativenessofthenetsampleintermsofsomecharacteristicsofthetarget
population such as gender, age and nationality. However, the fact that the
distribu- tion of other important characteristics could be affected cannot be
excluded.
The SHS was meant to provide nonmortality measures of the Swiss
popula- tions health status, notably self-reported health status and other
indicators of health. It gathered not only data concerning attitudes, life
conditions and behavior being able to influence health status, but also
information on health care utilization. Unfortunately, it did not contain data
concerning expenditure on health care services by individuals.
ParticipantsoftheSHShavebeenquestionedbytelephone,theninwritingon
their utilization of health services in the course of the 12 preceding months.
The questionsaimed in the first place at measuringthe frequenciesof recourse
to the different care providers (physicians, other health professionals,
hospitals, home- care organizations), but sought also to obtain some
indicators on the quality of benefits provided, such as health status, the
degree of patient satisfaction, services covered, etc. In addition, some
questions concerned health insurance plans (with or without deductible,
hospitalization in public ward, semi-private (two bed) or private (one bed)) in
the perspective of seeing whether these plans affect on the utilization of
health services.
The health system in Switzerland is very complex. Until 1994, health insur5 was not compulsory, but the Confederation encouraged it by granting
ance
subsidies to not-for-profit sickness funds. It fixed minimal requirements on
this category of sickness funds and defined very precisely what may
conveniently be called compulsory benefits or social insurance benefits. It
also imposed not- for-profit sickness funds to fill some obligations.
For-profit sickness funds were excluded from the social health insurance.
However, the law also provided for the payment of more extensive supplementary benefits. Both not-for-profit sickness funds and for-profit sickness
funds could provide supplementary voluntary insurance. In general terms,
health insurance plans were separated into: the basic insurance charged with
the so-called minimal compulsory benefit
or social benefits; semi-private
insurance and private insurance the names being given because of the
hospitalization in a room with two beds and with a single bed respectively. But
these three type of plans also varied along several dimensions: coverage of

1993,
5 For a quite complete description of the health system as it existed during the years 1992
see OECD (1994). For a description of those features of this system that are of special relevance to
the type of investigation presented in this paper, see Holly et al. (1997).

A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

517

supplementalinpatientandoutpatientservices,coverageofalliedhealthpersonnel and payment system of care providers for each procedure or service.
The insured had, in principle, the possibility to choose freely their doctor
and the hospital. However, free choice of the physician did not exist for
patients in hospital wards, that is to say for those who only had a basic insurance.
The social health insurance is essentially financed by contributions of the
insured.Theformerrepresentindeednearlythree-quartersofthetotalincomeof the
not-for-profit insurers. The other revenues consist of patient cost-sharing, subsidies
from public authorities, subsidies of employers and by various other sources. For
the basic insurance, the cost-sharing consisted of an annual deductible of SF 150
and a co-insurance rate of 10% on the expenses that exceeded the deductible.
Nevertheless, the co-payment could not exceed SF 750
andwasnotpaidincaseofhospitalization.However,theinsuredhadtosharein the
treatment costs at the rate of SF 10 per hospital day and up to SF 500 for
hospitalcare, although no payments were required forhospital care for children
orthosehospitalizedformorethan180daysorwomenreceivingmaternitycare.
Contributionsare per capita premiums,and are not therefore proportional to the
income of the insured person. The optional nature of the health insurance system
resulted in higher premiums for those who joined at a later age. Also, womens
premiums were higher than mens at the same age, but could not be more than
10% higher. As long as he was affiliated to the same sick fund, the insured used to
pay therefore the premium corresponding to the age where he joined and his sex
category, this premium increasing, nevertheless, with the increase of the health
costs.

For inpatient care, agreements on charges billed were often made directly
between hospitals and cantonal health insurance associations. For the same
care, charges could vary considerablyfrom one hospital to another, even
within the same canton. For patients hospitalized in public wards
that is to say for insurers usuallymade full payment to
cover
the cost
careinsurance
provided.
For people with a supplemental insurance
those who
hadofa all
basic
(private or semi-private insurance), the hospital could charge a daily rate to which
fees for medical and technical care were added. In addition, the pricing of medical
care theoretically was determined by the private market. However, physicians
associationsdid set guidelines for their members in which the point systemused for
the basic insurance was also used as a reference to set the fees for private medical
practice within a hospital. For the same medical care, fees were much higher for
patients who purchased a supplemental insurance.

3. Econometric model for the use of health care services

Let y* an endogenous variable representing the propensity of a person to
1
select a supplemental health insurance plan, andy* the propensity of the same
2

A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

518

person to have at least one inpatient stay given that he has used some
medical treatment.
In this paper, we estimate a simultaneous two equation model. The first
equation is a reduced form equation for y* which is determined by a set of
1 the personis ill, the determination
exogenousvariables X. We assume that once
to use inpatient services depends on the insurance plan he purchased. Thus,
the second equation is a structural form equation for
y* which is simultaneously
2
y
,
the
dichotomous
variable
associated
with y*, and a set of
determined by
1
1
exogenous variables X . The model may thus be written as
2
y*"Xb0#u0,
(1)
1
1
1
y*"X b0#a0 y #u0,
(2)
2 2
21 1
2
2
where

A B AAB A
G

BB

u0
r0
0
1
1 "N
12
,
u0
r0 1
0
2
12
1 if y*'0,
1
y "
1
0 otherwise,

if y*'0 and the person has received a medical treatment,

2
y " 0
if y*40 and the person has received a medical treatment,
2
2
n. a. d. otherwise,
1

since y* isnotappropriatelydefinedfora personwhohas notreceivedamedical

2
treatment.
The simultaneous two equation model we have just introduced is a model
with a mixed structure; it contains endogenous latent variables as well as an
endogenous dummy variable, y . It may be compactly written, with obvious
2
notation, as
A0y*#C0y"Xb0#u0.

(3)

We assume that X does not include all the exogenous variables in X for,
2
6 Also,it isclear, fromthetriangularstructure
otherwise,Eq. (2) is not identified.
of the model (3), that it is logically consistent.7
6 For details, see the discussion of Model 6 in Maddala (1983, pp. 122123).
7 Thiscouldbeformallyshownbyusingthe
LemmainMaddala(1983,p.118).Alternatively,since
A0~1C0 is a triangular matrix with all its diagonal elements equal to zero, it follows from a
theorem
of Schmidt
(1982)that the model (3) is logically consistent without additional coherency or
logical-consistency conditions.

A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

519

The ML estimation of the simultaneous two equation model is available.

Given the joint distribution of (u0, u0),@ one can derive the expression for the
1 2
joint probability of (y , y ),@ denoted by P , and the likelihood function to be
1 2
y1y2
maximized is the product of these probabilities raised at appropriate powers.
We have

u(u)U[(2y !1) (X b0#Xa0 b0)

21 1
2
2 2
(2y1~1)Xb01
#(2y !1)r0 u] du,
(4)
1
12
where u refers to the standard normal density function and U refers to the
cumulative normal.
When u0 and u0 are independent, r0 is equal to zero and the likelihood
2
12
1
function Eq. (4) is the product of the likelihood functions for Eqs. (1) and (2).
This is due to the fact that y is (weakly) exogenous in Eq. (2). We thus have
1
=
P "
u(u)U[(2y !1) (X (b0#Xa0 b0)] du
y1y2
2
2 2
21 1
(2y1~1)Xb01
"U[(2y !1) (X b0#Xa0 b0)]U[(2y !1)X b0].
(5)
2 2
21 1
1
1 1
2
P "
y1y2

The endogenous and exogenous variables used in the econometric

estimation of the model are defined in Tables 1 and 2, respectively. The
results of the estimation are shown in Table 3. We performed an exogeneity
test by carrying out a likelihood ratio test for the null hypothesis H :
r0 "0 against the
0 12
alternative H : r0 O0. The likelihood ratio test statistic is equal to 28.8 for
! 12
a chi-square with one degree of freedom, leading to a strong rejection of the
exogeneity of y in Eq. (2).
1
Furthermore,plan has asignificanteffect on theprobability of inpatientuseif
we control for all the other characteristics. The coefficient of 0.2033 is highly

Table 1
Definitions of endogenous variables
y*
1
"
Insured: ( y )
1

Propensity of a person to purchase a supplemental insurance.

Type of health insurance purchased by the insured participant scored
dichotomously (0 "basic insurance, 1"either semi-private insurance or
private insurance).

y*
2

Propensityofapersontohaveatleastoneinpatientstaygiventhathe
some medical treatment.

Hospit: ("y )
2

Variable indicator scored dichotomously (1"the participant spent at least

one day in the hospital, 0"otherwise).

hasused

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A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

Table 2
Definitions of exogenous variables
Gender (Sex)

Variable indicator scored dichotomously (1"male, 0"female).

Age (Alter)

Age of the participant (in years).

Age2

Age of the participant squared.

Income (Income)

Estimated total income of the household divided by a coefficient

equal #0.5
to 0.5 for each adult #0.3 for each children in the household.

Passive (Concept)

Attitude of the individual toward his own health status scored

dichotomously (1 "the individual is passive, 2"the individual influences it actively).

MedEnv

Variable indicator scored dichotomously (1"the participant works in

a medical environment, 0"otherwise).

Training (Bildung6)

Variable indicator for the highest educational level achieved scored

polytomously (0 "unfinished training, 1"compulsory schooling,
2"general training, 3"professional training, 4"higher professional
training, 5" university degree).

PhysAct (Actphys)

Variable indicator for the frequency of the physical activity of the

individual scored polytomously (0"never, 1"once or twice a week,
2"three times or more).

Tobacco (Tabac8)

Variable indicator for the consumption of tobacco by the individual

scored polytomously (0 "never smoked, 1"ex-smoker, 2"light
smoker, 3"heavy smoker).

Mastery (Mastery)

Variable indicator for the mastery level of the individual based on 4

questionnaire items. It is scored polytomously (0
"weak control,
1"average control, 2"strong control).

Alone

Variable indicator scored dichotomously (1"the participant lives

alone, 0"otherwise).

ProfCat (EGP-6)

Variable indicator for the socioprofessional category of the individual

scored polytomously (1 "manager, liberal profession, manufacturer,
tradesman, 2"intermediate professions, middle executive, 3"office
clerk,othernonmanualprofession,4 "self-employedworkerina small
firm, 5"foreman, qualified worker, 6"specialized worker, unskilled
worker).

HpW

Number of hours worked per week.

Symptom (Symptom)

Variable indicator for the health status in general of the individual

based on nine general symptom items. It is scored polytomously (1
"almost none, 2"some, 3"many).

Urban (MSREG (4))

Variable indicator for the region of residence of the individual scored

polytomously (1"in one of the five biggest towns, 2"in one of the
twenty average towns, 3"in one of the 50 small centers, 4"in one of
the 30 outlying regions).

BMI (BMI)

Body mass index ("weight in kilos/ (size in meters) ).

2
BMI2.

BMI2

A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

521

Table 3
Simultaneous probit estimation of the structural form of Eqs. (1) and (2)
Insured

Hospit

Variables

Coeff

t-stat

Insured
Constant
Gender
Age
Age2
Income
MedEnv
Training
Symptom
BMI
BMI2
Tobacco
Alone
Urban
ProfCat
HPW
Passive

!1.9438
0.1848
0.0064
!0.0006
0.1271
!0.2077
0.1851
!0.0208
!0.0095
!0.0002
!0.0581
!0.1853
!0.0382
!0.0519
!0.0023
!0.0105

(!7.62)
(5.25)
(6.60)
(!11.52)
(14.50)
(!3.37)
(11.96)
(!1.12)
(!2.27)
(!0.70)
(!2.87)
(!5.51)
(!2.83)
(!9.40)
(!2.70)
(!0.31)

Coeff

t-stat

0.2033
!0.8208
!0.0849
0.0026

(5.88)
(!2.37)
(!2.08)
(2.49)

!0.0535
0.1248
0.0045
0.0456
0.0070

(!5.55)
(1.88)
(0.28)
(2.27)
(1.68)

0.0232
0.0010
0.0151
0.0094
!0.0079
!0.1168

(1.11)
(0.02)
(1.02)
(1.46)
(!7.83)
(!3.23)

Note: Correlation"!0.22; likelihood"!8980.86.

significative. That is to say, if we hold other variables constant, the effect of

supplementalinsuranceplan is to increasethe probabilityof a person to have at
least one inpatient stay given that he has used some medical treatment.
Although we use different data, we reach the same conclusion as
Domenighetti et al. (1996). Extension of the preliminary work presented here
is carried out in Holly et al. (1997).

Acknowledgements
We would like to thank Mrs. Claudine Marcuard, from the Swiss Federal
Social Insurance Office and Mr. Luc Schenker from the Service des hospices
cantonaux vaudois for providing us with extremely useful information on the
Swiss health system. We are indebted to Mr. Thomas Spuhler, from the Swiss
Federal Statistical Office for allowing us to use the 1992/93 Swiss Health
Survey data. We also benefitted from discussions with James J. Heckman and
from a correspondence with G.S. Maddala. We are also extremely grateful to
Bruno Cre pon and Emmanuel Duguet for providing us with asoftware
program that they have designed for the estimation of qualitative data and
count data models with

522

A. Holly et al. / European Economic Rev iew 42 (1998) 513 522

SASIML. An extended preliminary version of this paper was presented at the

NBER Summer Institute Franco American Seminar/CRIW pre-conference in
July 1997. We would like to thank the seminar participants, in particular Joe
Newhouse, Zvi Griliches and Jacques Mairesse for helpful discussions and
comments.Responsibilityfor any shortcoming and possible errors are our own.

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