Fee-per-service Vs bundled payments

One of the biggest challenges with cost-control in health insurance is with the payment model for health services delivery.

The prevailing fee-per-service model disaggregates services into doctor consultation, diagnostic services, and surgical treatments. Individual payments are made accordingly for each service. This naturally distorts incentives, in so far as it encourages each service provider to over-diagnose or over-treat, so as to maximize their revenues. Since many doctors also have their own diagnostic equipments, it is natural for them to prescribe the full range of diagnostic tests.

In contrast, in countries like India, treatment of a medical condition is the basis for insurance payments. In other words, payments are bundled into a package and the insurer makes the payment to the service provider. The service provider is generally a hospital which either has all these facilities in-house or has a contract with various other external service providers for delivery of integrated services for that particular treatment. This is a much more desirable model since it mitigates and eliminates many of the incentive distortions associated with fee-per-service models.

However, a more ideal payment model for insurers would be diagnosis based bundled payment. A typical diagnosis can have multiple treatment options, based on prior medical history, clinical judgement of the doctors, and so on. This has the potential to create incentive distortions, in so far as it can encourage doctors to prescribe surgery and other invasive treatment intensive treatment regimes where they stand to benefit. A diagnosis based payment model, wherein all treatments in a Diagnosis Related Group (DRG) are covered by a flat fee, can align the incentives of all sides to optimize among treatment alternatives.

Interestingly, the bundled payment regime in India, followed by many state and private insurance programs in the country, is a consequence of the nature of the Indian health care market. In US, Canada, and especially Western Europe, individual medical practitioners and diagnostic testing centers maintain their separate identitities from clinics and hospitals, thereby forcing insurers to deal with them separately. However, in India, the larger integrated specialty hospitals have come to dominate the formal health care market. Insurers therefore deal with them directly or with hospitals who in turn contract with certain diagnostic testing centers and specialists elsewhere. Bundled payments therefore become possible.  

Any universal health insurance scheme for India should have bundled payments as one of its pillars.

Supervision Deficit

I have an op-ed in today's Mint which highlights the glaring deficiency with our field level supervisory bureaucracy.

Nudging on Donations

Mostly Economics points to the new working paper by Dean Karlan and John List that suggests an innovative way for charities to signal their credibility nudge donors into increasing their donations. Karlan and List write,

We develop a simple theory which formally describes how charities can resolve the information asymmetry problems faced by small donors by working with large donors to generate quality signals. To test the model, we conducted two large-scale natural field experiments. In the first experiment, a charity focusing on poverty reduction solicited donations from prior donors and either announced a matching grant from the Bill and Melinda Gates Foundation, or made no mention of a match. In the second field experiment, the same charity sent direct mail solicitations to individuals who had not previously donated to the charity, and tested whether naming the Bill and Melinda Gates Foundation as the matching donor was more effective than not identifying the name of the matching donor. The first experiment demonstrates that the matching grant condition generates more and larger donations relative to no match. The second experiment shows that providing a credible quality signal by identifying the matching donor generates even more and larger donations than not naming the matching donor. Importantly, the treatment effects persist long after the matching period, and the quality signal is quite heterogeneous - the Gates’ effect is much larger for prospective donors who had a record of giving to 'poverty-oriented' charities. These two pieces of evidence support our model of quality signals as a key mechanism through which matching gifts inspire donors to give.

In this context, I have blogged earlier about studies by the same duo and others about how matching contributions and its magnitude can provide signals that can increase the amounts of donations made by prospective donors. Quality signals are powerful mechanisms to "crowd-in" funds from donors.

But there is nothing surprising about this finding since this underlying premise underpins much of modern financial markets. If Warren Buffet invests in a particular stock or fund, the chances are that it will attract a herd of investors! In fact, hedge funds raise private capital by playing up the credibility of their prior investors and using that to encourage prospective investors. Start-up firms which have atleast one big angel investor will find it much easier to raise additional capital.

This also has important longer-term lessons for the aid and philanthropy businesses. The powerful impact of credible lead donors, like Bill and Melinda Gates, should be leveraged to multiply the amounts of money that can be raised. For example, the Gates Foundation could work with a series of smaller non-government organizations (NGOs) within sectors where the Foundation is already active, provide small seed capital, and then encourage those NGOs to leverage it to solicit additional funds from other donors. I am sure this model is already being used by the larger foundations and their donees, though the share of their funds routed through such partnerships may be small.  

In fact, this is what multilateral agencies like the World Bank and the UNICEF have been doing for years. They provide the first tranche or seed funding for new initiatives and projects,, which is then leveraged to raise additional capital, both from private sector and other non-government agencies. The presence of the Bank or UNICEF provides the necessary reassurance to these lenders and donors that necessary due diligence has been done and the project is worthy of support and their investments and donations are less likely to go down the drain.

Therefore, is it time that the larger and more reputed private donor agencies leverage their brand name and reputational value to help smaller organizations raise more capital and thereby multiply the amount of money that can be mobilized to serve the same causes espoused by the larger donor?

Why urbanization is environment friendly?

Two graphics from the recent Credit Suisse report on global urbanization trends shows how urbanization dramatically lowers carbon emissions from transportation. The first graphic shows trends from across the emerging world...

... while the second shows similar trend among US metropolitan areas.

Urbanization and economic growth

FT Beyondbrics points to the findings of a Credit Suisse report (pdf here) on global urbanization trends. The report has a very rich array of graphs and statistical correlations. It finds that on average, for every 5 percentage point increase in a country’s urban population there is an associated gain in per capita economic activity of 10%.

One of its most interesting findings is that countries hit a peak per capita GDP growth level between the 30-50% mark. Credit Suisse’s model suggests that as a country moves through a 40% urbanisation level it achieves peak real per capita GDP growth of close to 8% and that between 30 and 50%, an average 6% real GDP growth rate is achieved.

India, with slightly over 30% urbanization, is moving towards its sweet-spot growth rate range. China has been outlier, a positive one, in so far as its growth rate has been disporportionately higher at every level of urbanization. India's pace of urbanization, despite recent increases, will remain far lower than the rest of emerging world. In fact, the report estimates that among the major emerging economies, India will be the last to see urban population exceed rural population, not achieving it till 2044.

The last-mile challenge in banking for the poor

It has always been thought that lack of access to formal bank accounts prevented poor people from saving more and once accounts were opened they would be able to more optimally manage their finances. But now that we have made some progress, albeit tiny (only 5.5% of 650,000 Indian villages have bank branches and half the adults in the country do not have access to bank accounts), with access through the campaign for total financial inclusion (TFI), have the desired outcomes been achieved for those people?

Surprisingly, it does appear that having a bank account does not automatically translate into its use, much less efficient management of personal finances. Livemint points to a study by Skoch Development Foundation which found that only 11% of 25.1 million no-frills accounts opened between April 2007 and May 2009 are operational mostly because of the high costs.

India Development Blog points to an IFMR study of the impact of TFI campaign in Gulbarga District of Karnataka (claimed to have achieved 100% financial inclusion), which found that 36% of sample households remained without access to formal and semi-formal savings mechanisms and more importantly, access to bank accounts did not translate into bank account usage. It was found that the accounts were used mostly to manage NREGS payments or SHG transactions. Critical to the lesser than expected account usage is the high transaction costs, especially by way of travel costs.

I am inclined to believe that even if access to formal banking systems, by way of opening a bank account, is increased, actual usage is likely to remain low unless bridge the last mile gap and take banking to the door-step of the people, especially in rural areas. The recent decision by the Reserve Bank of India to approve the deployment of mobile bank business correspondents, equipped with electronic terminals, to transact at the sub-branch level is certain to increase the quality of access. This will ensure that, unlike now, rural account holders are more likely to actively transact using their accounts.   

In this context, mobile phones have the potential to revolutionize banking and increase utilization dramatically. Mobile phones-based technologies offer the attraction of directly placing the bank account in the hands of the customer, thereby lowering transaction costs and increasing the likelihood of account usage. It may therefore be tempting to get carried away by this possibility, coupled with a campaign to increase financial literacy, and assume that it will ensure account usage.

However, dovetailing NREGS and other government cash transfers through TFI accounts, extensive use of business correspondents and mobile phone-bassed technologies, and financial literacy, while necessary are not sufficient conditions to ensure optimal account usage.In fact, unless complemented with other initiatives, mere increase in access to banking accounts, could be counter-productive. It could just as easily enable access to debt and other less than desirable financial products, whose extensive adoption could be detrimental to the interests of the poor people.

Behavioural science teaches us that even with access to their accounts and adequate financial literacy, human beings are cognitively constrained. This in turn means that despite firm commitment to save or spend on certain things, people tend to renege and fall short on achievement. People discount the value of later rewards by a factor that increases with the length of the delay. They are therefore tempted to spend on immediate needs as opposed to save for important long-term requirements. Further, drawing from theories of "mental accounting", it has also been found that people tend to save optimally when they they know what they are saving for.  

It is therefore necessary that the bank accounts are structured to address these cognitive biases. This assumes importance since we need to bear in mind that the ultimate objective is not to merely enable access to bank account, but to enable poor people with systems to more effectively manage their scarce finances. What can be done to ensure that poor people save more, optimize on their interest returns, manage their long-term needs like health care, children's education and pensions, make more effective purchase decisions, and so on? In simple terms, how do we ensure that people not only manage their finances effectively, but also overcome their cognitive urges which are often determental to their interests?

I have written about several examples of how innovative financial products can overcome such cognitive biases and increase the likelihood of optimal outcomes for poor people with management of their finances. In fact, bank savings accounts and financial products, with subtle commitment features, have the potential to dramatically increase not only usage but also effective usage of bank accounts. I have bloggged earlier about Save More Tomorrow, default pension savings, lottery savings products, products to increase fertilizer consumption, multi-tier accounts (also here), and budgeting family expenditures. See also this and this.

In this context, there is a big window of opportunity. Bill and Melinda Gates Foundation have just pledged $500 million to helping poor people learn to save money. They propose to fund research and project interventions in this area to emulate the examples like the hugely successful mobile banking for the poor — via cellphone in Kenya and Bangladesh and smart card in Mexico. Spurred on by the low domestic savings rate, this area has been the focus of considerable interest in the US too. It is appropriate that some part of this be leveraged into experimenting with financial products and structured accounts that help overcome cognitive biases.

It needs to be borne in mind that TFI and optimal utilization of bank accounts by the poor needs to go beyond mere door-step acceess to bank accounts.

The return of Iceland?

Amidst all the gloom surrounding Europe, Iceland's apparent recovery from the depths of despair should be a cause for some celebration.The FT has a nice story that chronicles the Icelandic saga over the past five years.

Iceland's story till its meltdown in 2008 is classic Bubble Economics 101. The aggressive financial deregulation of early 2000s led to massive capital inflows and over-leveraged local banks. Asset prices inflated, construction activity boomed, businesses borrwed heavily in foreign currency and purchased assets abroad. Then the music stopped and the bubble burst, leaving the banks heavily leveraged, especially with foreign loans.

Iceland's recipe for restoring normalcy was to let its banks collapse and default on their loans. In contrast to countries like US, UK, and Ireland which injected billions to prop up their too-big-to-fail banks, Iceland let its inflated banking sector collapse. In 2008, the three biggest banks by assets – Kaupthing, Landsbanki and Glitnir - defaulted on $85bn of debt. This led directly to the collapse of the currency, the government and much of the economy. While the domestic assets of Iceland’s lenders were protected – costing the state 20% of GDP, according to the IMF – the lion’s share of the collapse was borne by foreign creditors.

Capital controls were introduced to prevent money leaving the country. The kroner underwent over 50% devaluation against the euro in 2007-08, which contributed towards restoration of national competitiveness. A rebound in tourism and fishing exports, boosted by the devaluation, have been critical drivers of the recovery. 

Iceland's economic recovery has been slow but unmistakable. As Paul Krugman has pointed out, the contrast with Latvia, which followed the orthodox prescription of fiscal consolidation and austerity, is stark.

On every parameter, the Icelandic economy has been making slow progress. In February, Iceland’s debt was upgraded from “junk” to investment grade by Fitch, the rating agency.

The FT article writes approvingly,

In August, Iceland completed a three-year IMF-supported restructuring programme, including loans of $10bn, and has started borrowing again on global credit markets. It has been held up by the IMF as a model of crisis management. GDP is set to expand by a respectable 2.5 per cent this year – which, added to last year’s 2.5 per cent, solidifies the sense of a country on the mend. The figures contrast with the 0.3 per cent contraction the European Commission expects in the eurozone this year.

But normalcy is still some distance away. The households and business balance sheets remain over-leveraged and it will be sometime before consumption and business investment will return to normalcy.  

The average household has suffered a 30 per cent fall in purchasing power since 2008. The private sector remains heavily indebted, with household debt levels exceeding 200 per cent of disposable income and corporate debt 210 per cent of GDP, according to Fitch. Partly because of this, domestic companies are reluctant to invest.