THE EFFECTS OF DEMOGRAPHICS AND INSURANCE PLAN CHARACTERISTICS ON MEDICAL CLAIMS IN EMPLOYER - SPONSORED HEALTH INSURANCE
DOI:
https://doi.org/10.51200/mjbe.v12i2.7185Keywords:
Insurance Plan, Group Health Insurance, Private Insurance, Hospitalisation, Two Part ModelAbstract
Accelerating health care costs because of technological advances and a higher prevalence of communicable and non-communicable diseases have contributed to the rising costs of providing health care benefits by many employers. This study identified the factors affecting medical claims for hospitalisation under employer-sponsored health insurance (ESHI) plans where the premiums are partly sponsored by the employer. Data were extracted from one of the government statutory bodies in Malaysia that provides private health insurance coverage to its employees. The research is novel for the fact that government employees are eligible for almost free health care benefits at public health institutions, but the institution in this study offers private health insurance. We use the two-part model (TPM) to identify factors that affect the probability of filing at least one claim and also to identify the determinants of total expenditure incurred during the period under study. The results reveal that marital status, age, type of plan, and premium level are significant factors that determine the probability of claiming, while age and gender significantly influenced the amount of claims. Therefore, understanding the design of health benefits and the composition of employees and their expenditures on health care is a continuous process in ensuring that the health benefits program is not only appropriate but also sustainable. The implications of the study extend beyond the local context, offering valuable lessons for employers, insurance providers, and policymakers worldwide in balancing cost efficiency with employee well-being.
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