An empirical examination of risk equalisation in a regulated community rated health insurance market

Despite universal access entitlements to the public healthcare system in Ireland, over half the population is covered by voluntary private health insurance. The market operates on the basis of community rating, open enrolment and lifetime cover. A set of minimum benefits also exists, and two risk equalisation schemes have been put in place but neither was implemented. These schemes have proved highly controversial. To date, the debate has primarily consisted of qualitative arguments. This study adds a quantitative element by analysing a number of pertinent issues. A model of a community rated insurance market is developed, which shows that community rating can only be maintained in a competitive market if all insurers in the market have the same risk profile as the market overall. This has relevance to the Irish market in the aftermath of a Supreme Court decision to set aside risk equalisation. Two reasons why insurers’ risk profiles might differ are adverse selection and risk selection. Evidence is found of the existence of both forms of selection in the Irish market. A move from single rate community rating to lifetime community rating in Australia had significant consequences for take-up rates and the age profile of the insured population. A similar move has been proposed in Ireland. It is found that, although this might improve the stability of community rating in the short term, it would not negate the need for risk equalisation. If community rating were to collapse then risk rating might result. A comparison of the Irish, Australian and UK health insurance markets suggests that community rating encourages higher take-up among older consumers than risk rating. Analysis of Irish hospital discharge figures suggests that this yields significant savings for the Irish public healthcare system. This thesis has implications for government policy towards private health insurance in Ireland.

Risk management and the potential of cattle insurance in Tigray, Northern Ethiopia

This study explores the role of livestock insurance to complement existing risk management strategies adopted by smallholder farmers. Using survey data, first, it provides insights into farmers’ risk perception of livestock farming, in terms of likelihood and severity of risk, attitude to risk and their determinants. Second, it examines farmers’ risk management strategies and their determinants. Third, it investigates farmers’ potential engagement with a hypothetical cattle insurance decision and their intensity of participation. Factor analysis is used to analyse risk sources and risk management, multiple regressions are used to identify the determinants; a Heckman model was used to investigate cattle insurance participation and intensity of participation. The findings show different groups of farmers display different risk attitude in their decision-making related to livestock farming. Production risk (especially livestock diseases) was perceived as the most likely and severe source of risk. Disease control was perceived as the best strategy to manage risk overall. Disease control and feed management were important strategies to mitigate the production risks. Disease control and participation on safety net program were found to be important to counter households’ financial risks. With regard to the hypothetical cattle insurance scheme, 94.38% of households were interested to participate in cattle insurance. Of those households that accepted cattle insurance, 77.38% of the households were willing to pay the benchmark annual premium of 4% of the animal value while for the remaining households this was not affordable. The average number of cattle that farmers were willing to insure was 2.71 at this benchmark. Results revealed that income (log income) and education levels influenced positively and significantly farmers’ participation in cattle insurance and the number of cattle to insure. The findings prompt policy makers to consider livestock insurance as a complement to existing risk management strategies to reduce poverty in the long-run.

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.

Evaluating the effectiveness of Z: The claims made about CICS and where we go from here

There have been few genuine success stories about industrial use of formal methods. Perhaps the best known and most celebrated is the use of Z by IBM (in collaboration with Oxford University's Programming Research Group) during the development of CICS/ESA (version 3.1). This work was rewarded with the prestigious Queen's Award for Technological Achievement in 1992 and is especially notable for two reasons: 1) because it is a commercial, rather than safety- or security-critical, system and 2) because the claims made about the effectiveness of Z are quantitative as well as qualitative. The most widely publicized claims are: less than half the normal number of customer-reported errors and a 9% savings in the total development costs of the release. This paper provides an independent assessment of the effectiveness of using Z on CICS based on the set of public domain documents. Using this evidence, we believe that the case study was important and valuable, but that the quantitative claims have not been substantiated. The intellectual arguments and rationale for formal methods are attractive, but their widespread commercial use is ultimately dependent upon more convincing quantitative demonstrations of effectiveness. Despite the pioneering efforts of IBM and PRG, there is still a need for rigorous, measurement-based case studies to assess when and how the methods are most effective. We describe how future similar case studies could be improved so that the results are more rigorous and conclusive.

An AI formalism for competing claims of identification: capturing the "Smemorato di Collegno" amnesia case

A formal representation is given of the situational structure, and the agents' beliefs about personal identity, in the Smemorato di Collegno amnesia case tried in 1927, in Pollenza, Italy. Another section discusses and formalizes a sample heuristic rule for conjecturing whether an individual identity other than personal, being conveyed by a toponym, was used literally or fictitiously in a given historical corpus of legal casenotes. For example, a landlocked city being named and referred to as though it was a sea port is a fairly good cue for assuming that the toponym is a disguise. Yet, the interpretation is governed by other conventions, when in a play by Shakeaspeare it is stated that a given scene is set on the sea coast of Bohemia. Further discussion of a situational casuistry for identification (especially individual and personal) along with more formal representations will appear in a companion paper "nissanidentifpirandello", also at the disciplinary meet of AI formalisms and legal applications.

How Does the Unemployment Insurance System Shape the Time Profile of Jobless Duration?

This paper updates a sparse literature on the effects of unemployment benefits (UB) on the time profile of escape rates from unemployment. These effects, as well as those of other regressors, are found to vary profoundly over the course of unemployment.

Monkey mountain as a megazoo: analysing the naturalistic claims of “wild monkey parks” in Japan

In Japan yaen koen or ‘wild monkey parks’ are popular visitor attractions that show free-ranging monkey troops to the paying public. Unlike zoos, which display animals through confinement, monkey parks control the movements of the monkeys through provisioning. The parks project an image of themselves as ‘natural zoos’, claiming to practice a more authentic form of wild animal display than that practiced by the zoo. This article critically evaluates the monkey park’s claim by examining park management of the monkeys. The monkey park’s claim to display ‘wild monkeys’ is shown to be questionable because of the way that provisioning changes monkey behaviour. Against the background of human encroachment onto the forest habitat of the monkey, the long-term effect of provisioning is to sedentarize what were nomadic monkeys and to turn the ‘wild monkey park’ into a megazoo.

Personal Injury Liability in Sport: Emerging Trends

Violent play during the course of a game or sport is not a new phenomenon; accompanying legal proceedings are. This article considers personal injury liability for injuries inflicted by a participant upon an opponent during a sporting pursuit. The jurisdictional focus is on England and Wales. The sporting emphasis of the article is on competitive, body contact games. The legal emphasis is on the tort of negligence. Analogous to the law of criminal assault, breach of "implied sporting consent" or the volenti of the claimant will be seen as central in application, as assessed through a number of objective criteria, including the skill level of the injuring party and whether that defendant was acting in "reckless disregard" of the claimant's safety. These criteria or evidential guidelines, which emerge from a careful doctrinal analysis of the relevant case law, are seen as crucial to the examination of the appropriate degree of care in negligence within the prevailing circumstances of sport. The article also searches for some theoretical coherency within the case law, premising it on Fletcher's idea of reciprocal risk-taking. In addition, the underlying policy-related issue of sport's social utility is discussed, as are practical matters relating to vicarious liability, insurance and the measure of damages for "lost sporting opportunity". Moreover, it will be shown that personal injury claims relating to sports participant liability now extend to a consideration of the duties of coaches, referees, sports governing bodies and schools. Finally, this article is set against the backdrop of an apparently spiralling "compensation culture" and the concomitant threat that that "blame culture" poses for the future promotion, operation and administration of sport.