Risco moral e indução de demanda no mercado de planos de saúde: evidências empíricas para o Brasil

Abstract

This thesis provides comprehensive empirical evidence on moral hazard and induced demand in the utilization of healthcare services within the private sector. It is pioneering in the national literature by analyzing a portfolio of beneficiaries from the same private health company, encompassing different types of insurance contracts distinguished by the cost-sharing intensity and provider network. The advantage of this portfolio is that all beneficiaries and providers are subject to the same contractual rules. In addition, the insurer offers services both through its own network, which constitutes a vertical structure, and through a network of contracted providers. The thesis is composed of three articles. The first analyzes the effect of copayment on the demand for office visits within a portfolio of beneficiaries holding individual and family private health insurance and employer-based private health insurance, followed longitudinally for nine years. The individuals are exposed to seven types of insurance contracts, which differ in copayment intensity and provider network. The main findings show the moderating effect of copayment, with a reduction in demand for consultations ranging from 17% to 30% for individual and family private health insurance, and from 12% to 20% for employer-based private health insurance. The second article explores how the design of contracts, specifically the conditions of access to the provider network, influences the decision to undergo a C-section. The findings point to practices of induced demand. Women with insurance contracts that restrict the offer of services to the insurer’s own network are 26% less likely to undergo a C-section. Additionally, there is up to a two-fold higher likelihood of a C-section in hospitals within the accredited network compared to hospitals within the insurer’s network, as well as among doctors who performed deliveries exclusively in accredited network hospitals compared to those who worked only in the insurer’s own hospitals. The third article explores demand induction in performing obstetric ultrasound examinations during prenatal care. The findings show that beneficiaries with contracts that restrict access to the insurer’s network had a reduction ranging from 19% to 30% in the number of obstetric ultrasounds compared to beneficiaries with contracts that allow access to a wide network. The results of this study provide, for the first time, important evidence of moral hazard in consumer behavior and demand induction in provider behavior within Brazil’s private health insurance sector. These behaviors generate inefficiencies that translate into higher costs, resulting in social welfare losses.