{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T21:34:20Z","timestamp":1780522460055,"version":"3.54.1"},"reference-count":39,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T00:00:00Z","timestamp":1756166400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003086","name":"Basque Government","doi-asserted-by":"publisher","award":["IT1555-22"],"award-info":[{"award-number":["IT1555-22"]}],"id":[{"id":"10.13039\/501100003086","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Information"],"abstract":"<jats:p>Designing fair and sustainable pricing mechanisms for health insurance requires accurate risk assessment and the formulation of incentive-compatible strategies among stakeholders. This study proposes a hybrid framework that integrates machine learning with game theory to determine optimal, risk-based premium rates. Using a comprehensive dataset of insured individuals, the XGBoost algorithm is employed to predict medical claim costs and calculate corresponding premiums. To enhance transparency and explainability, SHAP analysis is conducted across four risk-based groups, revealing key drivers, including healthcare utilization and demographic features. The strategic interactions among the insurer, insured, and employer are modeled as a repeated game. Using the Folk Theorem, the conditions under which long-term cooperation becomes a sustainable Nash equilibrium are explored. The results demonstrate that XGBoost achieves high predictive accuracy (R2 \u2248 0.787) along with strong performance in error measures (RMSE \u2248 1.64 \u00d7 107 IRR, MAE \u2248 1.08 \u00d7 106 IRR), while SHAP analysis offers interpretable insights into the most influential predictors. Game-theoretic analysis further reveals that under appropriate discount rates, stable cooperation between stakeholders is achievable. These findings support the development of equitable, transparent, and data-driven health insurance systems that effectively align the incentives of all stakeholders.<\/jats:p>","DOI":"10.3390\/info16090733","type":"journal-article","created":{"date-parts":[[2025,8,26]],"date-time":"2025-08-26T06:26:31Z","timestamp":1756189591000},"page":"733","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Designing a Smart Health Insurance Pricing System: Integrating XGBoost and Repeated Nash Equilibrium in a Sustainable, Data-Driven Framework"],"prefix":"10.3390","volume":"16","author":[{"given":"Saeed","family":"Shouri","sequence":"first","affiliation":[{"name":"Faculty of Administrative and Economic Sciences, Ferdowsi University of Mashhad, Mashhad 91779-48974, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9320-9433","authenticated-orcid":false,"given":"Manuel","family":"De la Sen","sequence":"additional","affiliation":[{"name":"Institute of Research and Development of Processes, University of the Basque Country (UPV\/EHU), 48080 Bilbao, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Madjid Eshaghi","family":"Gordji","sequence":"additional","affiliation":[{"name":"Department of Mathematics, Semnan University, P.O. Box 35195-363, Semnan 35196-45399, Iran"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/S2468-2667(18)30268-8","article-title":"Universal Health Coverage: Realistic and achievable?","volume":"4","author":"Health","year":"2019","journal-title":"Lancet Public Health"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1016\/S0140-6736(12)61147-7","article-title":"Moving towards universal health coverage: Health insurance reforms in nine developing countries in Africa and Asia","volume":"380","author":"Lagomarsino","year":"2012","journal-title":"Lancet"},{"key":"ref_3","unstructured":"Chan, M. (2012, January 21). Best days for public health are ahead of us, says WHO Director-General. 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