In a major shift away from direct public provision, governments around the world are expanding public insurance programs that contract the private sector to deliver health services at pre-specified reimbursement rates. These rates are a key policy lever to shape provider incentives, but there is little evidence on their effects in lower-income contexts with limited regulatory capacity. Using over 1.6 million insurance claims and 20,000 patient surveys, and exploiting a policy-induced natural experiment, this paper provides evidence on private hospital responses to reimbursement rate changes under government health insurance in India. It shows that: 1) Private hospitals engage in coding manipulation to increase revenues at government expense. Manipulation is highly responsive to changes in the relative reimbursement rates of similar services. 2) Rate increases also induce an increase in service volumes. 3) Hospitals charge patients for care that should be free under program rules. Raising rates reduces these charges significantly, but hospitals capture about half of the increase. Pass-through is driven entirely by less concentrated markets, suggesting that competition limits hospital capture of public subsidies. There is no evidence of changes in care quality or patient composition. These findings highlight the critical role of prices and market structure when contracting the private sector for delivery of social services.
Winner of the International Health Economics Association (IHEA) 2021 Adam Wagstaff Award for Outstanding Research on the Economics of Healthcare Financing and Delivery in Low- and Middle-Income Countries. Ideas of India interview.
Dupas, P. and Jain, R. (2021) Women Left Behind: Gender Disparities in Utilization of Government Health Insurance in India. NBER Working Paper.
Using administrative data on over 4 million hospital visits, we document striking gender disparities within a government health insurance program that entitles 46 million poor individuals to free hospital care in Rajasthan, India. Females account for only 33% of insurance claims among young children and 42% among the elderly. These shares are lower for more expensive types of care, and far lower than sex differences in illness prevalence can explain. Almost two-thirds of non-childbirth spending is on males. We combine these data with patient survey, census, and electoral data to show that 1) households are willing to allocate more resources to male than female health, which results in disparities in hospital utilization because the program is unable to fully offset the costs of care-seeking; 2) lowering costs does not reduce disparities, because males benefit as much as females do; and 3) long-term exposure to village-level female leaders reduces the gender gap in utilization, but effects are modest and limited to girls and young women. In the presence of gender bias, increasing access to and subsidizing social services may increase levels of female utilization but fail to reduce gender inequalities without actions that specifically target females.
We study hospital compliance with a public health insurance program in a large Indian state. Using patient surveys, we first document that participating hospitals regularly charge fees to patients eligible to receive free care, resulting in high levels of out-of-pocket payments in and outside the hospital; and that eligible patients lack information about the program. To test whether information is sufficient to enable intended beneficiaries to hold hospitals accountable, we conduct a randomized phone-based information intervention among approximately 1,100 patients requiring chronic kidney disease management. We find that the intervention effectively increases program awareness and triggers some patients to switch provider, but has heterogeneous impacts on patients' ability to obtain cheaper or more comprehensive care. The intervention dramatically reduced out-of-pocket payments for patients at public hospitals, but not at private hospitals. Our findings suggest patient-driven accountability is an important tool in improving service delivery, but may not substitute for top-down monitoring in the context of specialized tertiary care.
Papers in Health Journals
Jain, R., Dupas, P. (2022). The Effects of India's COVID-19 Lockdown on Critical Non-COVID Health Care and Outcomes: Evidence from Dialysis Patients. Social Science and Medicine, 114762.
Jain, R., Chopra, A., Falezan, C., Patel, M., Dupas, P. (2021). COVID-19 Related Immunization Disruptions in Rajasthan, India: A Retrospective Observational Study. Vaccine, 39(31), 4343-4350.
Novosad, P., Jain, R., Campion, A., Asher, S. (2020). “The COVID-19 Mortality Effects of Underlying Health Conditions in India: A Modelling Study.” BMJ Open, 10(12), e043165.
Eggleston, K., Jain, R. (2020). “Cost-effective Interventions to Prevent Non-communicable Diseases: Increasing the Evidence Base in India and Other Low- and Middle-income Settings.” BMC Medicine 18(1), 1-3.
Policy blog post: Development Asia (ADB).
Strategies to Counteract Intrahousehold Gender Bias in Resource Allocation for Health Care
Strengthening Government Oversight of Private Agents to Improve Health Service Delivery
The Drivers of Gender Disparities Across the Care-seeking Process
Migration, Urbanization, and the Changing Geography of Health and Health Care in India