Can beneficiary information improve hospital accountability? Experimental evidence from a public health insurance scheme in India
中文摘要
我们研究医院合规在印度政府医疗保险发挥成效中的作用。通过患者调查，我们发现，参与该计划的医院向有资格获得免费医疗服务的贫困患者收取未经授权的费用。接受慢性肾病治疗的患者平均每月自付费用（OOPP）为43美元，相当于年人均GDP的25%；无论在公立医院还是私立医院，这一费用都很高。尽管患者已经使用该保险数月，他们对计划福利的知晓程度仍然很低。我们开展了一项随机实验，以检验通过电话提供计划福利信息能否帮助保险受益人向医院问责并降低自付费用。该干预使患者对计划的知晓程度提高了0.17个标准差，但总体上并未影响自付费用。然而，不同医院部门的效应差异很大：私立医院患者虽然增加了议价与搜寻行为，但其自付费用没有变化；前往公立医院就诊的患者较为贫困且种姓地位较低，他们的每月自付费用下降了12美元（35%），原因是他们能够通过协商在医院内获得更多本应由计划覆盖的福利，而不必在院外为这些服务或物品付费。研究结果表明，即使在专科三级医疗领域，患者驱动的问责也能够切实改善公共服务供给；但对于私营服务提供者，它可能无法替代自上而下的监督。
Abstract
We study the role of hospital compliance in the effectiveness of government health insurance in India. Using patient surveys, we document that participating hospitals charge unauthorized fees to poor patients eligible to receive free care. Average out-of-pocket payments (OOPP) for chronic kidney care patients are $43 per month, or 25% annual GDP per capita, and are high at both public and private hospitals. Awareness of program benefits is low despite patients having used insurance for several months. We conduct a randomized experiment to test whether phone-based information about program benefits can enable insurance beneficiaries to hold hospitals accountable and lower OOPP. The intervention effectively increases program awareness by 0.17 standard deviations but has no effect on OOPP overall. However, effects differ dramatically by hospital sector: patients at private hospital see no change in OOPP despite increased bargaining and search; monthly OOPP among patients visiting public hospitals, who are poorer and lower caste, drop by $12 (35%), because they are able to negotiate to get more of their benefits at the hospital instead of paying for them off-site. The findings suggest that patient-driven accountability can meaningfully improve public service delivery, even in the context of specialized tertiary care, but may not substitute for top-down monitoring of private agents.