The effects of patient insurance on healthcare provision

Last registered on February 14, 2024
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Pre-Trial

Trial Information

General Information

Title
The effects of patient insurance on healthcare provision
RCT ID
AEARCTR-0012968
Initial registration date
February 08, 2024

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
February 14, 2024, 4:39 PM EST

First published corresponds to when the trial was first made public on the Registry after being reviewed.

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Primary Investigator

Name
Mylene Lagarde
Affiliation
LSE
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Other Primary Investigator(s)

Additional Trial Information

Status
In development
Start date
2024-02-11
End date
2024-12-31
Keywords
Health
Additional Keywords
Health insurance, standardized patients, quality of care, provider moral hazard
JEL code(s)
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
To date, there is scarce evidence about how providers respond to insurance schemes in low- and middle-income countries. We design an experimental audit study in Ghana to answer two questions: (1) to what extent do providers in public primary health centres treat differently patients who are insured in the national health insurance scheme, compared to those who are not? (2) is there evidence of fraudulent behaviour? Unbeknownst to the consulting providers, we send two pairs of standardized patients to pass as patients in 120 health centres. Within a pair, the two SPs are matched on gender and trained to present the same clinical condition to the same facilities. For each facility visited by a pair of SP, we randomly choose which one presents their national health insurance card and which one does not. We look at the effect of insurance cover on cost, quality and efficiency outcomes. Subject to being able to link the SP visit to claims data, we will also look at the prevalence of a range of fraudulent behaviours.
External Link(s)

Registration Citation

Citation
Lagarde, Mylene. 2024. "The effects of patient insurance on healthcare provision." AEA RCT Registry. February 14. https://doi.org/10.1257/rct.12968-1.0
Sponsors & Partners
Experimental Details

Interventions

Intervention(s)
Being a beneficiary of the National Health Insurance Scheme in Ghana
Intervention Start Date
2024-02-11
Intervention End Date
2024-04-30

Primary Outcomes

Primary Outcomes (end points)
Cost to the patient (out-of-pocket expenditures)
Quality of care provided: provider effort; correct management ; availability of treatment
Over-provision (unnecessary drugs and diagnostic tests)
Primary Outcomes (explanation)
Out-of-pocket expenditures=amount charged to the patient for the consultation (consultation fee + cost of drugs)
Provider effort: (1) duration of the consultation and (2) proportion of relevant questions asked and examinations done during consultation; Correct management= whether or not the patient treatment (drugs prescribed and/or dispensed) follows the recommended treatment guidelines for the case presented
Availability of treatment= porportion of visits where treatment recommended is dispensed (not prescribed); number of drugs dispensed (not prescribed)
Over-provision: number and cost of unnecessary drugs prescribed or dispensed; proportion of patients with unnecessary diagnostic tests; number of unnecessary diagnostic tests.

Secondary Outcomes

Secondary Outcomes (end points)
Fraudulent behaviour (partly dependent on the possiblity to link to claims data)
Secondary Outcomes (explanation)
(1) proportion of visits where the service claimed is more expensive than the service actually provided to the patient.
(2) proportion of visits where a provider claims the reimbursable amount but also charges the patient.
(3) proportion of visits where insured patients are denied care (prescribed, not dispensed, drugs that are in stock)

Experimental Design

Experimental Design
We send two pairs of standardized patients to pass as patients in 120 health centres. The two standardized patients of each pair are matched on gender and trained to present the same clinical condition to the same facilities, visited at least 10 days apart.
Then, for each facility visited by a pair, we randomly choose which of the two SPs presents their national health insurance card, and which one does not present it.
Experimental Design Details
Not available
Randomization Method
Computer-based (stata)
Randomization Unit
THe random allocation is done at the standardised patient-visit level.
Was the treatment clustered?
No

Experiment Characteristics

Sample size: planned number of clusters
A total of 120 health centres.
Sample size: planned number of observations
Each health centres will have 4 visits by SPs, so a total of 480 visits.
Sample size (or number of clusters) by treatment arms
240 SP-visits by insured patients and 240 by uninsured patients.
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Supporting Documents and Materials
IRB

Institutional Review Boards (IRBs)

IRB Name
Ghana Health Service Ethics Review Committee
IRB Approval Date
2023-07-17
IRB Approval Number
GHSERC 014/03/23
Analysis Plan