Plain English Summary
Background and study aims
Medical expenses are not the only financial costs people face due to treatment for sickness. An additional cost is lost income due to treatment. In theory, the loss of income following illness may be attributable to an inability to work due to sickness and/or the need to miss work for medical treatment. This project studies the latter component. Loss of income due to the inability to work during treatment may impact the value of health insurance and the amount of health care utilization. The full cost of medical care has at least four components: the medical bill from providers, the cost of transportation to the provider, the cost of financing medical bills and transportation, and the loss of income during treatment. Health insurance typically only assists with the first three items at the time of medical care. Thus, like deductibles and co-pays, the lost wages during treatment are a form of co-insurance that increases the price of care at the margin, and thereby deters health insurance usage. These types of losses can reduce the value of health insurance if demand for insurance is decreasing in level of co-insurance. They can also reduce care at the margin relative to having no wage loss during treatment. This study therefore analyses two “hospi-cash” policies offered by VimoSEWA, an insurance company under the umbrella of the larger SEWA cooperative, that provide fixed indemnity payments for each day a beneficiary is hospitalized, up to some annual maximum. This study aims to estimate the demand for and value of a hospi-cash policy, which will help VimoSEWA decide whether to continue offering these products to its 1.4 million members in Gujarat, India. This study can also help the National Health Agency, which administers the national public health insurance plan, Ayushman Bharat (AB), determine whether AB should include a hospi-cash component. This study also aims to determine whether, in low-income countries like India, medical treatment has important costs that aren’t covered by health insurance. Third, this study contributes to the econometric literature on demand estimation and experimental design, as we estimate bounds on a non-parametric demand function using a novel technique rather than producing point estimates of a parametric demand function.
Who can participate?
Women aged 18 – 54 who currently are not holders of an existing VimoSEWA hospi-cash product.
What does the study involve?
The study involves two pilots—one to determine the coverage and indemnity rates for the two hospi-cash policies we want to offer and one to determine how we price these hospi-cash policies. After these pilots, we randomize SEWA Union members, at the village-level, to one of four distinct price combinations for these products. Based on the fraction of SEWA Union members that purchase each of these products, we estimate bounds on a non-parametric demand function for these products. Using the randomized prices as instruments for uptake of wage insurance, we causally identify the impact of hospi-cash on health insurance uptake, hospital usage, number of days of work, daily wages, asset portfolios, etc. We also estimate adverse selection into and moral hazard from hospi-cash.
What are the possible benefits and risks of participating?
The main benefit to participants is compensation for missing work to seek medical care, and all of the benefits that accrue from seeking medical care. There are no foreseeable risks.
Where is the study run from?
The University of Chicago (USA).
When is the study starting and how long is it expected to run for?
March 2020 to March 2021
Who is funding the study?
The University of Chicago (USA).
Who is the main contact?
Jake Kramer
jdkramer@uchicago.edu
Morgen Miller
mmmiller@uchicago.edu
Trial website
Contact information
Type
Public
Primary contact
Mr Jake Kramer
ORCID ID
Contact details
University of Chicago Law School
1111 East 60th Street
Chicago
IL
60637
United States of America
+1 (773) 702-7162
jdkramer@uchicago.edu
Type
Public
Additional contact
Ms Morgen Miller
ORCID ID
Contact details
University of Chicago Law School
1111 East 60th Street
Chicago
IL
60637
United States of America
+1 (773) 704-6631
mmmiller@uchicago.edu
Additional identifiers
EudraCT number
Nil known
ClinicalTrials.gov number
Nil known
Protocol/serial number
AEARCTR-0004240
Study information
Scientific title
Self-Employed Women’s Association Wage Insurance Experiment
Acronym
SWIE
Study hypothesis
The take-up of a hospi-cash insurance policy, which compensates policyholders for a set amount of money on days they skip work to seek qualified medical treatment, positively impacts the uptake of health insurance and hospital use.
Ethics approval
1. Approved 18/06/2019, The University of Chicago Social and Behavioral Sciences Institutional Review Board (1155 E. 60th Street, Room 418, Chicago, IL 60637, USA; +1 (773) 702-2915; sbs-irb@uchicago.edu), ref: IRB19-0219
2. Approved 10/06/2019, Institute for Financial Management and Research Human Subjects Committee (196, Parthasarathy Gardens, TT Krishnamachari Road, Alwarpet, Chennai, Tamil Nadu 600018, India; +91 044 2827 9208; sundar@ifma.ac.in), ref: IRB00007107
Study design
Interventional randomized controlled trial with four treatment arms
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Trial setting
Home
Trial type
Other
Patient information sheet
Not available in web format, please use contact details to request a participant information sheet.
Condition
Uptake and use of hospi-cash insurance policy, and its effects on health insurance and hospital use
Intervention
Randomized controlled trial:
- Products: The researchers offer households the opportunity to purchase one of two hospi-cash policies. These policies provide a fixed indemnity payment for each day a beneficiary is hospitalized, up to some annual maximum. These policies have a coverage cap of 15 days per year and cover a certain number of adults and a certain number of children in each household. The two plans offered cover two adults and three children with a daily indemnity equal to INR 600 (2+3/600) or one adult only with a daily indemnity equal to INR 500 (1+0/500). Respondents pay for these policies on an annual basis.
- Randomization: The researchers offer both products in each village. For both products, there are four distinct price combinations. The researchers randomly assign one of these four price combinations to each village. The researchers ensure these four combinations are represented in equal proportion across our sample. The sample consists of 204 villages, ~51 households per village, meaning our full sample consists of 10,450 households. Our universe is defined by members of the Self-Employed Women’s Association, a trade union comprised of low-income, independently employed female workers. The researchers create three blocks within each village based on the age distribution in that village. For villages with household-level income information, the researchers create additional blocks on income within each age block. The researchers then randomly select households within each age block or age x income block to market products to.
- Treatment group: Those who take up one of the two products (2+3/600 or 1+0/500) are in the treatment group. Households elect whether to take up these products.
- Control group: Those who do not take up one of the two products are in the control group. Households in the control group do not receive anything.
Study overview:
This study will include two pilot surveys, a baseline survey, and an end-line survey approximately one year after the end of the baseline. The researchers will be running this experiment in 214 villages in Ahmedabad and Gandhinagar, two districts in the Indian state of Gujarat, which have 30,898 current and former SEWA members.
In both pilots, the researchers conduct surveys in three representative villages in Ahmedabad and two representative villages in Gandhinagar. Within each village, the researchers select 50 representative households, yielding a total of 250 households in the first pilot and 250 households in the second pilot. Villages selected for the pilots are excluded from the main study.
During the first pilot, the researchers implement a willingness-to-pay exercise in five villages in Ahmedabad and Gandhinagar to determine which two products yield the most consumer surplus. The researchers vary the products along two dimensions: indemnity rates (i.e., amount of money paid out when a claim is made) and coverage (i.e., number of people in a household covered). Within each village, the researchers randomly assign 25 households to the insurance product that varies along the indemnity rate dimension, but is fixed along the coverage dimension, and 25 to the insurance product that varies along the coverage dimension, but is fixed along the indemnity rate dimension. The researchers then choose the two products with the greatest consumer surplus.
Approximately two the researcherseks after the first pilot ends, the second pilot will begin. During the second pilot, the researchers conduct another willingness-to-pay exercise focused on the two products selected in the first pilot. This pilot is conducted on survey respondents in a different set of five villages in Ahmedabad and Gandhinagar to determine optimal prices for the two products the researchers've selected after the first pilot.
After the pilots, the researchers randomly assign the remaining 204 villages to one of the four possible price combinations for the two products offered. Again, within each village, the researchers select ~51 representative households, yielding a total of 10,450 households. SEWA representatives will offer the two hospi-cash policies selected in pilot 1 to households in each village at the prices assigned to that village. SEWA will also continue to offer its standard suite of non-hospi-cash policies to SEWA households. This hospi-cash marketing push will last 6 to 9 months.
At the beginning of the marketing push, the researchers will conduct a baseline survey of sample households. After the marketing push, the researchers will gather data from SEWA on which households purchased a hospi-cash policy and which one they purchased. The researchers will also obtain from SEWA claims data for one year for all sample households that enrol in a hospi-cash plan. Approximately one year after the end of the baseline, the researchers will conduct an end line.
Intervention type
Other
Phase
Drug names
Primary outcome measure
Collected during baseline and one year after baseline using a novel questionnaire:
1. Uptake of each of the 2 selected hospi-cash products
2. Uptake of SEWA’s health insurance product and savings product
3. Days of hospitalization, by each adult member and by any minor members of the household. In addition, the number of days reimbursed by health insurance.
Secondary outcome measures
Collected during baseline and one year after baseline using a novel questionnaire:
1. Number of days of work in last month and average daily wage on days worked
2. Asset index
3. Savings
4. Monthly consumption budget (net of medical expenses)
Overall trial start date
26/06/2019
Overall trial end date
31/03/2021
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
1. Women
2. Ages 18-54
3. Currently are not holders of an existing VimoSEWA hospi-cash product
Participant type
Other
Age group
Adult
Gender
Female
Target number of participants
10,450
Participant exclusion criteria
Does not meet inclusion criteria
Recruitment start date
01/03/2020
Recruitment end date
31/03/2021
Locations
Countries of recruitment
India
Trial participating centre
The University of Chicago
Edward H. Levi Hall
5801 South Ellis Avenue
Chicago, IL
60637
United States of America
Trial participating centre
Villages in Ahmedabad and Gandhinagar
Gujarat
-
India
Sponsor information
Organisation
University of Chicago
Sponsor details
Edward H. Levi Hall
5801 South Ellis Avenue
Chicago
IL
60637
United States of America
+1 773 702 1234
infocenter@uchicago.edu
Sponsor type
University/education
Website
Funders
Funder type
University/education
Funder name
University of Chicago
Alternative name(s)
UChicago
Funding Body Type
private sector organisation
Funding Body Subtype
Universities (academic only)
Location
United States of America
Results and Publications
Publication and dissemination plan
Planned publication in a high-impact peer-reviewed journal
IPD sharing statement: data generated or analyzed during this study will not be made available for public release.
Intention to publish date
31/03/2022
Participant level data
Not expected to be available
Basic results (scientific)
Publication list