Assessing health insurance literacy in Switzerland - Towards an operational framework and measurement tool

Background and rationale: In Switzerland, where individuals have the opportunity to freely choose their health insurance in a competitive market during a yearly open enrollment period, data shows that up to 17% of the population does not know the details of their health insurance plan. Overspending because of a financially inefficient health plan, and potentially foregoing care due to high out-of-pocket expenditures, can pose a considerable threat to individuals’ health and wellbeing, ultimately having a substantial impact on the health system as a whole. Health insurance literacy (HIL) may be one important explanatory variable in this context. HIL has only recently gained attention in the literature and been predominantly promoted as a field of research and practice in the US, with little implication for and no reliable tools available to assess the concept in other countries and populations outside the US.Aims of the project: The objectives of the proposed project are (1) to develop an operational framework for HIL that is relevant to the Swiss context, (2) to develop a population HIL measurement tool that is based on a conceptualization relevant to the Swiss health system and the individuals navigating it; and (3) to validate and apply such a tool to investigate the distribution of HIL in Switzerland, and to describe potential relationships between HIL and relevant outcomes. Methods: Four studies are envisioned to achieve the project’s objectives. Study 1 will be a systematic literature review with the aim to review current measurement tools that assess HIL and related concepts, and to provide a description of the conceptual dimensions assessed by those tools. Study 2 will consist of a modified Delphi study, using a panel of experts and a web-based survey. Based on the experts` opinions and the results of the aforementioned review the objective is to generate a list of competencies and an operational definition that are relevant to the concept of HIL in the Swiss context. In study 3 a population HIL measurement tool will be developed. The competencies identified in study 2 will guide the collection and development of items to be included in the tool. Items to be included will be pooled from the measurement tools found through the review (study 1) and adapted to the Swiss context. Additional items will be developed if found fit based on the Delphi study (study 2). Items will be reviewed by experts, using semi-structured interviews, and will be pretested with lay people, using cognitive interview techniques. In a final step, study 4 aims at validating the newly developed HIL measurement tool and to investigate the distribution of HIL and related outcomes in the Swiss population. A cross-sectional study design will be implemented by incorporating the HIL measurement tool into a broader questionnaire that will also assess concepts such as health literacy, behaviors relevant to health insurance choices, and subjective health status.Expected results and impact of the project: Developing a validated and reliable HIL measurement tool for the Swiss context will have important theoretical and practical implications. From a theoretical perspective it will contribute to the still emerging discussion on how HIL influences health insurance decision-making, and related outcomes. From a practical perspective, it is important to understand the distribution of HIL to develop strategies and interventions that would enhance the health insurance decision-making process and empower individuals to make better choices regarding their health plans, and subsequently utilization of healthcare and their well-being.