INEQUALITIES IN HEALTH CARE

SERVICES UTILISATION

IN OECD COUNTRIES

Marion Devaux, OECD Health Division 2014 QICSS International Conference on Social Policy and Health Inequalities, Montreal, 9-May-2014

1

• Policy objectives: reduction of inequalities in health status and equal access to health care based on need

• Equality and equity in health care use: – Inequity: inequalities remaining after adjusting for

needs for health care

2

Background (1/2)

• Evidence for inequity in health care use, especially for specialist and dentist visits, but less clear-cut for GP visits. – Internatinal studies around the years 2000 (van

Doorslaer & Masseria, 2004; Or et al., 2008; Bago d’Uva et al., 2008), but no recent update.

• Evidence for inequality in preventive care – Two studies aimed at gauging inequalities (Cervical

cancer screening: McKinnon et al., 2011; European countries: Carrieri & Wubker, 2012)

3

Background (2/2)

1. To update earlier results on inequity in health care use (van Doorslaer and Masseria, 2004) to extend the analysis to new preventive care services and to new OECD countries.

2. To examine inequalities in conjunction with health systems characteristics (with focus on financial barriers)

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Objective of the study

• Measuring inequities by income level in doctor visits by adjusting for differences in people’s need for health care.

Horizontal equity principle

• Measuring income-related inequalities in dentist visits and breast and cervical cancer screening.

• Concentration index to measure the degree of inequality/inequity.

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Methods

• Latest national health survey data for 19 OECD countries

• Doctor visits in the past 12 months

• Dentist visits

• Breast & cervical cancer screening

• Needs for health care

• Individual characteristics

• Income level of the household.

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Data 19 OECD countries

Austria (EHIS 2006/7)

Belgium (EHIS 2008)

Canada 2007/08

Czech republic (EHIS 2008)

Denmark 2005

Estonia (EHIS 2006/7)

Finland 2009

France 2008

Germany 2009

Hungary( EHIS 2009)

Ireland 2007

New Zealand 2006-07

Poland (EHIS 2009)

Slovak republic (EHIS 2009)

Slovenia (EHIS 2007)

Spain 2009

Switzerland 2007

United Kingdom 2009

United States 2008

• Small variations across income groups.

• Before need-adjustment, low-income people are more likely to see a GP in 13 of 17 countries.

• After need-adjustment, low-income people are as likely as high-income people to see a GP (in 8 of 17 countries).

• Once they go to visit a GP, low-income people are more likely to consult more often.

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GP visits in the past 12 months

Source: OECD Health Working Paper No 58. Devaux and de Looper, 2012. (*) in past 3 months in Denmark

France

Belgium

New Zealand

Austria

Canada

Slovak Republic

Spain

Hungary

United Kingdom

Ireland

Czech Republic

Poland

Slovenia

Estonia

Switzerland

Finland

Denmark*

Need-adjusted probability of a GP visit in last 12 months

by income quintile (age 16-85)

0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00

Rates of GP visits in the past 12 months

Lowestincome quintile

Average Highest incomequintile

• Large variations across income groups, low-income people being less likely to see a specialist in all countries.

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Specialist visits in the past 12 months

Hungary

Czech Republic

France

Canada

Slovak Republic

Spain

Switzerland

Belgium

Poland

Estonia

Slovenia

United Kingdom

Finland

New Zealand

Denmark*

Need-adjusted probability of a specialist visit in last 12 months

by income quintile (age 16-85)

0.00 0.20 0.40 0.60 0.80

Rates of specialist visits in the past 12 months

Lowestincome quintile

Average Highest incomequintile

Source: OECD Health Working Paper No 58. Devaux and de Looper, 2012. (*) in past 3 months in Denmark

-0.10

-0.05

0.00

0.05

0.10

0.15

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Inequity Index in GP and Specialist visits

-0.10

-0.05

0.00

0.05

0.10

0.15

Source: OECD Health Working Paper No 58. Devaux and de Looper, 2012. (*) in past 3 months in Denmark

Inequity in GP visits Inequity in Specialist visits

Pro-poor inequity

Pro-rich inequity

Pro-rich inequity

• People with higher incomes are also more likely to visit a dentist

• Main reasons = Financial barriers

• Dental care not -or only partly- reimbursed under health insurance plans

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Dentist visits in the past 12 months

Source: OECD Health Working Paper No 58. Devaux and de Looper, 2012.

(*) France past 24 months; (**)Denmark past 3 months.

Czech Republic

United Kingdom

Slovak Republic

Switzerland

Canada

Austria

Finland

Belgium

Slovenia

Ireland

New Zealand

Estonia

Spain

United States

Poland

Hungary

France*

Denmark**

Probability of a dentist visit in last 12 months

by income quintile (age 16-85)

0.00 0.20 0.40 0.60 0.80 1.00

Rates of dentist visits in the past 12 months

Lowestincome quintile

Average Highest incomequintile

• In countries with cancer screening programmes, services are made available to all at little or no cost

• Despite this, uptake varies among socioeconomic groups

• Often, geographic reasons such travelling distance or availability of screening facilities create many barriers

• Lower levels of awareness of programmes, symptoms or risks, especially among women with low incomes or from minority groups

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Pro-rich inequality in cancer screening

United States

Austria

Spain

Slovenia

Canada

New Zealand

France

Poland

Denmark

Belgium

Czech Republic

Hungary

Slovak Republic

United Kingdom

Switzerland

Estonia

Ireland*

Probability of cervical cancer screening in last 3 years

by income quintile (age 20-69)

0.00 0.20 0.40 0.60 0.80 1.00

Rates of cervical cancer screening in the past 3 years

Lowestincome quintile

Average Highest incomequintile

(*) Ireland: in past 12 months

Source: OECD Health Working Paper No 58.

• Country ranking remained rather stable

• Size of inequality remained very stable for doctor and GP visits.

• Some discrepancies found for specialist (Finland) and dentist visits (Finland and Spain) mainly due to differences in survey methodology and wording of questions.

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Comparison with earlier findings

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Comparison with earlier findings

Panel A. GP visits: probability Panel B. Specialist visits: probability

Panel C. Dentist visits: probability

-0.04

0

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• Organisation of health systems

• Financing of health care services

• Cultural and information barriers

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Which health system features characterise

countries with lower levels of inequity?

Primary care physicians referral to access secondary care

Required Incentives

No requirement, no incentive

Register with a

primary care

physician

Required

Denmark, Finland, Ireland, Italy, Netherlands,

Portugal, Slovenia, Spain

Czech Republic,

Incentives

Australia, New Zealand, Norway,

Poland,

Belgium, France, Switzerland

No requirement, no incentive

Canada, Chile, United Kingdom

Mexico

Austria, Germany,

Greece, Iceland, Israel, Japan,

Korea

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Gatekeeping system --Preliminary data-

Source: OECD Health System Characteristics Survey 2012 and Secretariat’s estimates.

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Iceland

Ireland

Israel

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Japan

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s Note: coverage for an adult not subject to any exceptions

Source: OECD Health System Characteristics Survey 2012 and Secretariat’s estimates

Level of coverage for different types of care

--Preliminary data--

100% 99-95% 94-85% 84-65% 64-40% 40-0%

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Cost-sharing arrangements

--Preliminary data-

Country Cost-sharing arragements, 2012

Austria Mostly free at the point of use for contracted physicians

Belgium Per-visit co-payments for outpatient care

Canada Free at the point of care

Czech Republic Per-visit co-payments for outpatient care

Estonia n.a.

Finland Per-visit co-payments for outpatient care

France Per-visit co-payments for outpatient care

Germany Free at the point of care

Hungary Per-visit co-payments for outpatient care

IrelandFree for medical card holders (40% of pop) and full cost for non-

medical card holders.

New ZealandCost-sharing for outpatient primary care, no cost-sharing for specialist

care

Poland Free at the point of care

Slovak Republic n.a.

Slovenia Cost-sharing

Spain Free at the point of care

Switzerland Cost-sharing after general deductible

United Kingdom Free at the point of care

USA n.a.

Source: OECD Health System Characteristics Survey 2012 and Secretariat’s estimates

• Universal health coverage not achieved

• Large share of private financing and out-of-pocket payments

• Care not free at the point of delivery

• No gatekeeping system

• Mostly private provision of health care

• Non-existence of public screening programmes

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Health system features likely associated

with larger inequalities

• A greater share of OOP is associated with greater inequity in specialist and dental care.

• Weak correlation possibly because countries with high OOP have introduced measures to offset the negative effects on access

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Out-of-pocket payments (OOP)

Czech Republic

Finland

Slovenia

Belgium

Spain

Hungary

Switzerland

Poland

R² = 0.2786

0

0.04

0.08

0.12

0 5 10 15 20 25 30 35 40

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Out-of-pocket payment as % of total expenditure on specialist care

France

Belgium

Slovenia

Austria

Canada

CzechRepublic

Slovak Republic

Finland

Estonia

New Zealand

Poland Hungary

Spain

R² = 0.2717

0

0.04

0.08

0.12

0 20 40 60 80 100

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Out-of-pocket payment as % of total dental expenditure

Source: OECD Health Working Paper No 58.

• Update of previous work

– Inequities in health care utilisation persist across OECD countries

– For the same level of needs, the better-off are more likely to visit doctors - especially specialists and dentists - than those with lower incomes.

• Need for strengthening equity

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Concluding remarks

• Reducing financial barriers – Targeting population the most at risk (exemptions)

– Increasing coverage (e.g. dental and eye care)

– Trade-off with budgetary constraints

• Reducing non-financial barriers – Geographic distribution of services

– Social dimension (education level, ethnic and language)

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Possible policy actions to strengthen

equal access to care

Contact: marion.devaux@oecd.org

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