Confidence in receiving medical care when seriously ill: a seven-country comparison of the impact of cost barriers

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1 doi: /j x Confidence in receiving medical care when seriously ill: a seven-country comparison of the impact of cost barriers Claus Wendt MD,* Monika Mischke MA, Michaela Pfeifer MA and Nadine Reibling MAà *Professor of Sociology of Health and Healthcare Systems, University of Siegen, Siegen, Lecturer, Department of Sociology, University of Siegen, Siegen and PhD student, School of Social Sciences, University of Mannheim, Mannheim and àphd student, School of Social Sciences, University of Mannheim, Mannheim, Germany Correspondence Claus Wendt Chair, Sociology of Health and Healthcare Systems Department of Sociology University of Siegen Adolf-Reichwein-Straße 2 D Siegen Germany and External Fellow, Project Director Mannheim Center for European Social Research University of Mannheim A5, Mannheim, Germany wendt@soziologie. uni-siegen.de Accepted for publication 10 March 2011 Keywords: comparison, confidence, cost barriers, Europe, health-care systems, United States Abstract Objective This paper examines how negative experiences with the health-care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Methods The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, with nationally representative samples of adults aged 18 and over. For the analysis of the experience of cost barriers and confidence in receiving medical care, we conducted pairwise comparisons of group percentages as well as country-wise multivariate logistic regression models. Results Individuals who have experienced cost barriers show a significantly lower level of confidence in receiving safe and quality medical care than those who have not. This effect is most pronounced in the United States, where people who have foregone necessary treatment because of costs are four times as likely to lack confidence as individuals without the experience of cost barriers (adjusted odds ratio 4.00). In New Zealand, Germany, and Canada, individuals with the experience of cost barriers are twice as likely to report low confidence compared with those without this experience (adjusted odds ratios of 1.95, 2.19 and 2.24, respectively). In the Netherlands and UK, cost barriers are only a marginal phenomenon. Conclusions The fact that the experience of financial barriers considerably lowers confidence indicates that financial incentives, such as private co-payments, have a negative effect on overall public support and therefore on the legitimacy of health-care systems. Introduction The ability to guarantee security against life risks is a major accomplishment of modern health-care systems. As the availability of health services can be a matter of life and death, people need the security that necessary care will be provided in the case of serious illness or injury. Cost pressures and economistsõ promotion of the 1

2 2 Confidence in receiving medical care, C Wendt et al. idea of moral hazard 1 have fostered the introduction and expansion of cost-sharing instruments. While we have observed a general trend of using cost-sharing measures over the last decades, substantial differences among countries remain in the form (e.g. co-payment, co-insurance, deductibles) and level of cost-sharing, as well as in the applied protection mechanisms (e.g. exemptions, reduced rates, annual caps). 2,3 While many studies have investigated the effects of cost-sharing measures, both in terms of their effectiveness in reducing utilization and costs and in terms of their unintended consequences in the form of inequalities and deterioration of health status, 3 5 the impact of cost barriers on trust in the health-care system has, to our knowledge, not yet been investigated. This paper analyses the effect of cost barriers on peopleõs confidence in receiving safe and quality medical care when falling seriously ill and is based on data from the 2007 Commonwealth Fund International Health Policy Survey. More specifically, we investigate whether there are differences in cost barriers among countries; differences in trust levels because of cost barriers among countries; and inequalities among groups with different levels of income, health and insurance arrangements in both experienced cost barriers and trust levels. Theoretical background The level of confidence in receiving medical care is an important indicator of trust that people have in the medical system. 6 9 Trust, which, according to Mechanic, 6 is Ôthe expectation that individuals and institutions will meet their responsibilities to us,õ has been analysed from different angles. Studies have focused on satisfaction with the health-care system, 9 12 on trust in oneõs own medical doctor, 6,8,13 15 on patient preferences and on past experiences 6,13 when analysing trust in the medical system. These studies have enhanced our understanding of peopleõs perception of health care and healthcare systems in various ways. It has been shown that not only people in the United States but also those in other developed nations are increasingly dissatisfied with their health-care systems At the same time, however, they express great trust in their personal physicians. 6,8,11 13 When analysing the factors influencing trust, delayed care and unmet needs have demonstrated a negative effect on patientsõ trust in a physician, 14 but studies have also pointed towards trust-enhancing factors, such as good access to health care, patient-centredness and continuity of care. 13,17,19 When analysing peopleõs confidence in receiving safe and quality medical care when falling seriously ill, we focus on questions that, to our knowledge, have been neglected in previous comparative research. Generally speaking, we can expect that those with higher educational levels and higher incomes are more likely to trust in the capabilities of health-care systems, for they gain access to general practitioners and specialists more easily and have fewer difficulties in meeting co-payments. Moreover, we expect that this Ôfeeling of securityõ is influenced by past experiences with the health-care system. 16,20,21 Because Ôconfidence in receiving medical careõ is presumably related to the overall health-care system and, in particular, co-payments, we expect that institutional structures matter. Consequently, the impact of individual socio-economic status on confidence in receiving health care should vary across healthcare systems. 8 We therefore compare citizensõ levels of trust in the health-care systems of Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. The selection of countries, although partly guided by data availability, has the advantage that different types of health-care systems are included in the analysis. Health-care systems have been differentiated as national health systems, social health-insurance systems and private health-insurance systems; 22,23 however, this distinction provides little insight in terms of cost barriers and other issues concerning patientsõ access to health-care services. Table 1 gives an

3 Confidence in receiving medical care, C Wendt et al. 3 Table 1 Cost barriers Cost-sharing 1 Out-of-pocket payments 2 Country Coverage (%) 1 General practitioner Specialist In-patient care Pharmaceuticals % of total population with no outof-pocket payments % who pay more than 1000 USD (Commonwealth Survey) Australia 100 For 25% of bills, average of USD 5. General patient reimbursement 85% of schedule fee if not bulk billed For 71% of bills, average of USD 8. Patient reimbursement 85% of schedule fee if referred None Maximum AUD (around USD 18) per prescription for general patients for drugs on the PBS Scheme Canada 100 None None None Discretion of provinces Germany 89.4 (public), 10.4 (private) Fee of 10 EUR covers all visits during the quarter. Preventive measures are exempt from practice fees Patients who are referred by one doctor to another pay no additional practice fees as long as the referral falls within the same quarter Co-payment of EUR 10 per day, limited to a maximum of 28 days in a calendar year Co-payment amounting to 10% of the price, but no less than EUR 5 and no more than EUR 10 per medication Netherlands 98.6 None None None Generics covered. Non-generics covered if no alternatives available New Zealand United Kingdom United States 100 Extra billing Outpatients USD 3 USD 17 None USD 2 USD 8 with stop loss 100 None None None USD 9 per prescription; free with a Ôseason ticketõ of USD 130. Many persons exempt 27.4 (public) 57.9 (private) 20% in excess of 100 USD deductible. Also a USD monthly premium for coverage of physician services 20% in excess of 100 USD deductible. Also a USD monthly premium for coverage of physician services 876 USD deductible for first 60 hospital days % The OECD Health Project (2004): Towards High-Performing Health Systems, Paris: OECD. 2 Calculations based on Commonwealth Survey.

4 4 Confidence in receiving medical care, C Wendt et al. overview of existing cost barriers in the seven countries under study. Cost barriers consist of coverage levels and cost-sharing arrangements. Coverage represents a cost barrier because those individuals not covered by a public or private health-care scheme need to pay the total costs of their utilized health care. We can thereby see clear country differences with regard to cost barriers. Canada, the Netherlands and the UK not only provide full coverage to their citizens, but they also have no cost-sharing except for pharmaceuticals. Australia, Germany and New Zealand have moderate cost barriers. While these countries provide universal coverage (quasi-universal in Germany), they have introduced cost-sharing for out-patient care and pharmaceuticals (and also for in-patient care in Germany). While costsharing in these countries can represent a substantial cost barrier to access, cost-sharing levels are still significantly lower than in the United States, which has a deductible of 100 USD and a co-insurance level of 20% for outpatient care. In addition, many American citizens are without health insurance and therefore face tremendous cost barriers. The regulations are only partly matched by out-of-pocket expenditure data. The Netherlands and Canada have a particularly high number of persons (in per cent of total population) without out-of-pocket expenditures: 21 and 38%, respectively. The other countries range between 9% (in Germany) and 13% (in Australia). When looking at the percentage of persons with a particularly high level of out-ofpocket expenditures (more than 1000 USD per year), the United States stands out with 30%, followed by Australia with 19%. The UK and the Netherlands, with 5 and 4%, respectively, have a particularly low number of individuals facing high out-of-pocket expenditures. Based on these differences in terms of cost barriers, we would expect the Netherlands and the UK in particular to show a low number of skipped visits because of costs and therefore also high levels of confidence. 23,24 Beyond mere country differences, individual characteristics should be important for the relevance of cost barriers and confidence in receiving health care. In general, it is assumed that the higher cost barriers are, the higher their regressive effect will be, meaning that persons with low levels of income might be especially prone to skipping visits. 3,5 We can thus expect income to be an important predictor of confidence and skipped visits because of cost barriers in countries that have high cost barriers, such as in the United States and probably also in Australia and New Zealand. In contrast, income should play a minor role in the Netherlands and the UK. The same relationships should apply to people with poor health status. 4 In systems with low cost barriers, people in poor health might not skip a doctorõs visit owing to costs, but when cost barriers are high, visits to the doctor might no longer be affordable, particularly for those with chronic conditions. Our main theoretical argument was that earlier experiences have a strong influence on peopleõs trust in the future. 6,13,16,20 An important negative event is represented by the experience of not going to a doctor because of costs despite having a medical condition. In a first step, we investigate the extent to which various social groups actually experience cost barriers that keep them from visiting a doctor in different institutional settings. In a second step, we analyse differences in trust levels across countries. Methods Sample The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, which was conducted by Harris Interactive from March to May 2007, in seven countries with nationally representative samples of adults aged 18 and over. In Australia, 1009 people were interviewed, 1000 in New Zealand, 1407 in Germany, 1557 in the Netherlands, 1434 in the UK and 2500 in the United States. 25 The final samples were adjusted to expected population distributions using country-specific weights provided by Harris Interactive. These weights included age, sex and additional variables fol-

5 Confidence in receiving medical care, C Wendt et al. 5 lowing standards for each country. The samples thus reflect the demographic distribution of the adult population in the countries under analysis. As we expect that the experience of financial barriers to accessing health care has a strong effect on confidence, we first examine which population groups are particularly prone to having this negative experience within their respective national health system. Second, we investigate which factors impact the lack of confidence in receiving future medical care in the seven countries. In this part, we focus on socioeconomic characteristics, such as income and education, as well as on the respondentsõ own experiences within the health-care system, namely financial barriers to service access. Statistical analysis We conducted pairwise comparisons of group percentages using the Scheffé method for both dependent variables. 26 We also conducted country-wise multivariate logistic regression models to examine the net effects of the individual level characteristics. Study results The experience of not going to the doctor because of cost barriers is mainly dependent on the setup of the health-care system (public vs. private insurance, level of cost-sharing) and can therefore be directly influenced by health-policy measures. Dependent variables The aspect of financial barriers to the access of necessary health care was measured using the following question: ÔDuring the past 12 months, was there a time when you had a medical problem but did not visit a doctor because of cost?õ The lack of confidence in receiving good medical care in the future was measured with the following question: ÔHow confident are you that if you become seriously ill, you will get quality and safe medical care?õ In our analysis, we focused on those respondents who reported to be Ônot veryõ or Ônot at all confident.õ Not going to the doctor because of costs: national averages As shown in Fig. 1, only a small minority of the population has had the experience of not going to the doctor because of cost barriers in three countries (the Netherlands, the UK and Canada). In Australia and Germany, in contrast, more than 10% of respondents have experienced cost barriers, a figure that stands at 20 and 25% in New Zealand and the United States, respectively. The analysis of inequalities with respect to cost barriers is therefore restricted to the four latter countries. Not going to doctor because of costs (in percent) Netherlands United Kingdom Canada Germany Australia New Zealand 24.6 United States Figure 1 Experience of not going to the doctor because of costs, by countries, Source: AuthorsÕ calculations using the 2007 Commonwealth Fund International Health Policy Survey.

6 6 Confidence in receiving medical care, C Wendt et al. Socio-economic factors hardly matter In Australia and Germany, socio-economic factors do not influence the decision to not go to the doctor because of costs. In the United States, 37% of low-income earners skip a doctorõs visit because of costs compared with 15% of the high-income earners (P < 0.001). Furthermore, the United States is the only country in which less educated people skip a doctorõs visit significantly more often than those with a higher level of education (29 and 15%, respectively; P < 0.001; see Table 2). People in poor health skip a doctorõs visit more often in the United States The United States is the only country in which people who consider their own health to be fair Australia Germany New Zealand United States Total 13 (952) 12 (1253) 20 (948) 25 (2347) Gender Women 15 (609) 12 (652) 22 (573)* 27 (1452)* (0.086) (0.532) (0.043) (0.013) Men (ref.) 11 (343) 11 (601) 17 (375) 22 (895) Age Age (455)* 15 (725)* 26 (519)* 31 (1081)* (<0.001) (<0.001) (<0.001) (<0.001) Age 50+ (ref.) 5 (497) 7 (528) 8 (429) 15 (1266) Education High school 13 (455) 11 (781) 20 (418) 29 (730)* (0.927) (0.991) (0.697) (<0.001) College 13 (177) 15 (316) 22 (253) 27 (768)* (0.895) (0.365) (0.391) (<0.001) Tertiary (ref.) 14 (320) 10 (156) 17 (277) 15 (849) Income Below average 16 (302) 14 (442) 24 (240)* 37 (766)* (0.093) (0.087) (0.037) (<0.001) Average 15 (188) 11 (289) 25 (167) 23 (459)* (0.294) (0.730) (0.057) (0.005) Above average (ref.) 11 (462) 10 (522) 16 (541) 15 (1122) Health status Fair-poor 17 (149) 15 (207) 22 (90) 37 (417)* (0.163) (0.123) (0.646) (<0.001) Good-excellent (ref.) 13 (803) 11 (1046) 20 (858) 22 (1930) Insurance status (Australia, Germany, New Zealand) Standard 17 (365)* 13 (1015)* 27 (470)* (0.003) (0.013) (<0.001) Private (ref.) 10 (587) 7 (238) 12 (478) Insurance status (United States) Employer 18 (1306)* (0.023) Other private 24 (175)* (0.009) Medicaid 37 (158)* (<0.001) Uninsured 53 (221)* (<0.001) Medicare (ref.) 11 (496) Table 2 Percentage (N) not going to doctor because of costs, by countries and population subgroups, 2007 Source: AuthorsÕ calculations using the 2007 Commonwealth Fund International Health Policy Survey: Data weighted. P-value in brackets. *Significantly different from reference group (P 0.05).

7 Confidence in receiving medical care, C Wendt et al. 7 or poor skip a doctorõs visit significantly more often than healthier patients (37 and 22%, respectively; P < 0.001). Not going to the doctor because of costs is related to insurance status The way people are covered by the health-care system matters in all countries: In Australia, Germany, and New Zealand, patients covered by the standard system skip a visit to the doctor significantly more often because of costs than those with (supplementary) private health insurance (Australia: 17 vs. 10%, P = 0.003; Germany: 13 vs. 7%, P = 0.013; New Zealand: 27 vs. 12%, P < 0.001). In the United States, we distinguished between employer-based private insurance, other private insurance, Medicare, Medicaid and being uninsured. The difference compared with those who are covered by Medicare (11% of Medicare recipients skipped a doctorõs visit because of costs) is especially large for those with Medicaid coverage (37%, P < 0.001) and the uninsured (53%, P < 0.001). Multivariate analysis Controlling for gender and age, we applied logistic regression analysis including income, education, health status, and insurance status (Table 3). Considering respondentsõ socio-economic background, the probability of skipping a doctorõs visit does not vary with respect to education. Low-income earners skip a visit more often than respondents with a high income (except in Australia), and the difference between both groups is especially pronounced in the United States (adjusted odds ratio of 2.21 [1.52, 3.20]). Considering self-reported health, results point out that people with poor health are more likely to skip a doctorõs visit in the United States (adjusted odds ratio of 1.97 [1.37, 2.85]) and Germany (adjusted odds ratio of 1.7 [1.06, 2.72]). Furthermore, the multivariate analysis confirms that insurance status matters in all countries (not significant in Australia), the most pronounced effects being in the United States. Compared with Medicare patients, all other groups are significantly more likely to skip a visit to the doctor because of costs. Medicaid patients and the uninsured face major barriers when seeking health care (adjusted odds ratios of 2.71 [1.46, 5.05] and 5.54 [3.07, 10.01], respectively). In a second step, the lack of confidence in receiving safe and quality medical care when seriously ill is analysed. Lack of confidence: national average Only 5% of Dutch respondents lack confidence in the health-care system. In all other countries, between one-fifth and one-quarter of the population lacks confidence in receiving medical care when in need (Table 4). Education and income matter People with lower levels of education (compared with people with tertiary education) show less confidence in receiving safe and quality care (in four countries). In all countries, people with below-average incomes are less confident in receiving good medical care than those with above-average incomes. Poor health reduces confidence Those in poor health show much lower levels of confidence in receiving medical care than their healthier counterparts in all countries. In Germany, New Zealand, the UK and the United States, about 40% of those who consider their own health to be fair or poor are either not very or not at all confident that they will receive safe and quality medical care when seriously ill (see Table 4). The gap between groups with better and poorer health is greatest in the United States (39 and 17%, respectively, P < 0.001), followed by New Zealand (40 and 20%; P < 0.001). Cost barriers have a substantial effect In all countries, the experience of not going to the doctor because of costs has a strong negative effect on confidence. This factor has the most striking effect in five of seven countries. In the

8 8 Confidence in receiving medical care, C Wendt et al. Table 3 Not going to the doctor because of costs, by countries and respondentsõ characteristics, 2007: adjusted odds ratios from logistic regression models 1 Australia Germany New Zealand United States Female (vs. male) (0.266) (0.260) (0.195) (0.176) [0.78, 2.44] [0.85, 1.80] [0.86, 2.05] [0.91, 1.64] Age (vs. age 50+) 5.07*** 2.50*** 5.49*** 2.19*** (<0.001) (<0.001) (<0.001) (<0.001) [2.74, 9.39] [1.62, 3.85] [3.38, 8.90] [1.61, 2.97] Education (vs. tertiary) High school (0.577) (0.795) (0.391) (0.669) [0.44, 1.58] [0.51, 1.68] [0.75, 2.12] [0.74, 1.61] College (0.454) (0.425) (0.501) (0.074) [0.36, 1.58] [0.69, 2.40] [0.69, 2.16] [0.97, 1.91] Income (vs. above average) Below average *** (0.117) (0.065) (0.058) (<0.001) [0.85, 4.06] [0.98, 2.25] [0.98, 3.05] [1.52, 3.20] Average (0.216) (0.652) (0.206) (0.209) [0.74, 3.79] [0.68, 1.85] [0.82, 2.52] [0.86, 2.04] Self-reported health status (vs. excellent good) Fair poor * *** (0.294) (0.028) (0.342) (<0.001) [0.69, 3.49] [1.06, 2.72] [0.72, 2.61] [1.37, 2.85] Insurance status (Australia, New Zealand, Germany) Standard (vs. private) * 2.43*** (0.268) (0.028) (<0.001) [0.77, 2.58] [1.07, 3.33] [1.54, 3.83] Insurance status (United States) Employer scheme (vs. medicare) 1.69* (0.043) [1.02, 2.82] Medicaid (vs. medicare) 2.71** (0.002) [1.46, 5.05] Private plan (vs. medicare) 2.15* (0.027) [1.09, 4.22] Not insured (vs. medicare) 5.54*** (<0.001) [3.07, 10.01] AuthorsÕ calculations using the 2007 Commonwealth Fund International Health Policy Survey. Data weighted. P-value in brackets. *P < 0.05 **P < 0.01 ***P < Odds ratios [95% confidence interval (CI)] adjusted for all characteristics listed in the left column; comparing two groups, an odds ratio of 1 indicates identical chances for both groups that an event occurs (here, skipping a doctorõs visit). An odds ratio >1 indicates a higher chance compared with the reference group, an odds ratio of <1 a smaller chance. United States, the gap between patients with and without the experience of cost barriers is almost 30 percentage points (43 and 14%, respectively, P < 0.001). Multivariate analysis The bivariate results were generally confirmed in logistic regressions that controlling for gender

9 Confidence in receiving medical care, C Wendt et al. 9 Table 4 Lack of confidence in receiving medical care, by countries and population subgroups [in per cent of population, (N)], 2007 Australia Canada Germany Netherlands New Zealand United Kingdom United States Total 20 (952) 19 (2726) 26 (1253) 5 (1422) 22 (948) 27 (1170) 21 (2347) Gender Women 22 (609)* 21 (1463)* 32 (652)* 5 (825) 25 (573) 31 (697)* 20 (1452) (0.039) (0.005) (<0.001) (0.099) (0.015) (0.011) (0.499) Men (ref.) 17 (343) 17 (1263) 19 (601) 4 (597) 18 (375) 24 (473) 21 (895) Age Age (455) 19 (1454) 24 (725) 4 (522) 22 (519) 27 (548) 22 (1081)* (0.215) (0.916) (0.175) (0.664) (0.844) (0.476) (0.040) Age 50+ (ref.) 18 (497) 19 (1272) 28 (528) 5 (900) 21 (429) 28 (622) 19 (1266) Education High school 22 (455)* 23 (772)* 29 (781) 5 (954) 26 (418)* 29 (551) 26 (730)* (0.009) (0.004) (0.135) (0.973) (0.035) (0.999) (<0.001) College 17 (177) 19 (1130) 20 (316) 4 (372) 18 (253) 24 (312) 21 (768)* (0.595) (0.351) (0.967) (0.989) (0.999) (0.393) (<0.001) Tertiary (ref.) 13 (320) 16 (824) 21 (156) 4 (96) 18 (277) 29 (307) 12 (849) Income Below average 26 (302)* 25 (810)* 29 (442)* 7 (472)* 29 (240)* 35 (391)* 29 (766)* (0.001) (<0.001) (0.008) (0.018) (0.004) (0.001) (<0.001) Average 18 (188) 19 (583) 31 (289)* 4 (248) 23 (167) 23 (331) 19 (459) (0.777) (0.197) (0.004) (0.832) (0.423) (0.945) (0.190) Above average (ref.) 15 (462) 16 (1333) 20 (522) 3 (702) 18 (541) 24 (448) 15 (1122) Health status Fair-poor 35 (149)* 30 (328)* 38 (207)* 8 (570)* 40 (90)* 41 (241)* 39 (417)* (<0.001) (<0.001) (<0.001) (<0.001) (<0.001) (<0.001) (<0.001) Good-excellent (ref.) 17 (803) 18 (2398) 23 (1046) 3 (852) 20 (858) 24 (929) 17 (1930) Experience Cost barriers 29 (103)* 38 (100)* 41 (143)* 16 (30)* 33 (158)* 52 (22)* 43 (464)* (0.009) (<0.001) (<0.001) (0.003) (<0.001) (0.009) (<0.001) No cost barriers (ref.) 18 (849) 18 (2626) 24 (1110) 4 (1392) 19 (790) 27 (1148) 14 (863) AuthorsÕ calculations using the 2007 Commonwealth Fund International Health Policy Survey. Data weighted. P-value in brackets. *Significantly different from reference group (P 0.05). and age included income and education, health status and the experience of cost barriers (see Table 5). While education seems to be of lesser importance (except in the United States), income still matters after controlling for other factors (in Canada, Germany, and the UK). Beside an inferior health status, the experience of not going to the doctor has a substantial negative effect on confidence in the overall systemõs capacity to deliver health-care services when necessary (not significant in Australia and the Netherlands). Discussion Our results indicate a good match between costsharing regulations in different countries and experienced cost barriers. In the Netherlands, the UK and Canada, only a very small percentage skipped a doctorõs visit because of costs, whereas a quarter of the respondents in the United States did so. The experienced cost barriers not only affect the utilization of health care but also peopleõs trust in the system. We found a substantial effect of experienced cost barriers on peopleõs confidence in receiving medical care. While the overall level of confidence in medical care is rather high (between 75 and 95%), cost barriers seem to play an important role in country variation in confidence levels. Furthermore, it was hypothesized that the different institutional arrangements, particularly cost-sharing instruments of the respective health-care systems, affect socio-economic dif-

10 10 Confidence in receiving medical care, C Wendt et al. Table 5 Lack of confidence in receiving medical care, by countries and respondentsõ characteristics, 2007: adjusted odds ratios from logistic regression models 1 Australia Canada Germany Netherlands New Zealand United Kingdom United States Female (vs. male) * 1.83*** (0.157) (0.014) (<0.001) (0.429) (0.072) (0.066) (0.191) [0.87, 2.36] [1.05, 1.58] [1.39, 2.41] [0.60, 3.36] [0.97, 2.10] [0.98, 1.87] [0.62, 1.10] Age (vs. age 50+) (0.098) (0.247) (0.844) (0.813) (0.422) (0.651) (0.407) [0.93, 2.46] [0.92, 1.38] [0.77, 1.37] [0.52, 2.30] [0.79, 1.75] [0.77, 1.52] [0.84, 1.52] Education (vs. tertiary) High school ** (0.106) (0.147) (0.573) (0.872) (0.174) (0.168) (0.003) [0.90, 2.84] [0.93, 1.64] [0.73, 1.75] [0.20, 3.90] [0.86, 2.32] [0.48, 1.14] [1.23, 2.62] College * (0.376) (0.623) (0.297) (0.983) (0.622) (0.055) (0.018) [0.70, 2.53] [0.83, 1.37] [0.48, 1.25] [0.25, 4.17] [0.50, 1.51] [0.42, 1.01] [1.08, 2.22] Income (vs. above average) Below average ** 1.42* * 1.20 (0.185) (0.004) (0.025) (0.308) (0.154) (0.019) (0.324) [0.82, 2.73] [1.13, 1.86] [1.05, 1.94] [0.65, 3.87] [0.88, 2.22] [1.09, 2.65] [0.84, 1.72] Average ** (0.799) (0.389) (0.007) (0.906) (0.483) (0.852) (0.874) [0.54, 2.21] [0.86, 1.48] [1.14, 2.28] [0.38, 3.02] [0.69, 2.19] [0.63, 1.47] [0.63, 1.47] Self-reported health status (vs. Excellent good) Fair poor 2.48** 1.74*** 1.75** 2.51* 2.38** 2.04*** 2.38*** (0.002) (<0.001) (0.001) (0.011) (0.003) (<0.001) (<0.001) [1.41, 4.36] [1.32, 2.29] [1.25, 2.46] [1.23, 5.10] [1.35, 4.19] [1.40, 2.97] [1.69, 3.36] Experience (vs. no cost barrier) Cost barrier *** 2.19*** ** *** (0.201) (<0.001) (<0.001) (0.166) (0.005) (0.059) (<0.001) [0.80, 2.91] [1.45, 3.47] [1.49, 3.20] [0.72, 6.87] [1.22, 3.12] [0.97, 5.54] [2.91, 5.49] N Pseudo R AuthorsÕ calculations using the 2007 Commonwealth Fund International Health Policy Survey. Data weighted. P-value in brackets. *P < 0.05 **P < 0.01 ***P < Odds ratios [95% confidence interval (CI)] adjusted for all characteristics listed in the left column; comparing two groups, an odds ratio of 1 indicates identical chances for both groups that an event occurs (here: the lack of confidence). An odds ratio >1 indicates a higher chance compared with the reference group, an odds ratio of <1 a smaller chance. ferences in reaction to cost barriers and confidence in receiving care. We find that a low income significantly reduces confidence in receiving medical care. Those who consider their own health as fair or poor are more pessimistic about receiving health care when in need compared with people in better health. This group difference was most pronounced in the United States and New Zealand, countries with especially high co-payments, and might prove a barrier to care for those who need it most often. Because people in all countries who have skipped a doctorõs visit because of costs show lower confidence, it can be argued that financialbarrier experiences have a strong negative influence on trust in the overall health-care system. Controlling for other factors, lower-income groups in New Zealand, the United States and Germany face more cost barriers than do higherincome groups, and patients with a poorer health status skip a doctorõs visit more often in the United States and Germany. Furthermore, insurance status matters in all countries. People

11 Confidence in receiving medical care, C Wendt et al. 11 without (supplementary) private insurance skip a visit more often in New Zealand and Germany. In the United States, Medicaid patients and the uninsured are particularly prone to not go to the doctor. Compared with Medicare patients, those with employer plans and other private plans are significantly more likely to not go to a doctor because of costs despite having a medical condition. Our analysis contributes to the discussion of Ôtrust in the medical systemõ 6 9 in the following respect: Patients need to feel secure that they will receive health care when in need. This does not always occur, even if people trust their personal physician. In certain circumstances, patients must rely on doctors whom they have not met before. The question of confidence in receiving quality and safe medical care when one becomes seriously ill might therefore represent the missing link between Ôtrust in oneõs personal doctorsõ and Ôsatisfaction with the health-care systemõ and seems to be especially suited to capturing trust in the health-care systemõs ability to guarantee security in the case of illness. Limitations In this study, we cannot control for the severity of the condition despite which a person decides not to see a doctor because of costs. A study by Schoen and colleagues, however, provides some indication of the impact of severe conditions, for it focuses on people with serious chronic diseases. According to the results of the study, a substantial portion of this specific group reports access difficulties. 21 A further limitation to our study is that we cannot be certain about the causal direction of the relationship between confidence and skipped visits. Even though costs are the major reason for the skipped visits, people with low levels of confidence in the system might react especially strongly to co-payments. With regard to institutional factors, we have only used insurance status to explain which people did not go to the doctor because of costs. Other factors, such as the perceived quality of care or waiting times, which we did not enter into our equation, might also influence the propensity to not see a doctor in spite of a health condition. In the UK, for instance, existing socio-economic differences in the lack of confidence might be more strongly related to quality issues than to cost barriers. Policy implications Our analysis shows major disparities in all included countries among social groups regarding the confidence in receiving medical care when in need. Given the high emphasis of equality, especially in the British NHS, these differences in confidence require further elaboration. Our findings cannot provide direct lessons as to how the disparities between education and health groups could be reduced; however, the fact that the experience of financial barriers considerably lowers confidence has important health-policy implications. Although those who did not go to the doctor because of costs have less confidence in all countries, we could show that in Canada, and particularly in the UK and the Netherlands, only a few people have experienced cost barriers at all. This phenomenon could be partly related to the fact that visits to a doctor are free and that other private out-of-pocket payments have also been particularly low for many years in both countries while existing at a high level in the United States, Australia and New Zealand. 27 CanadaÕs health-care system, however, creates low cost barriers, although out-of-pocket payments are higher than in Germany. The type of co-payment, as well as the time of the introduction of co-payments, might play a role in establishing cost barriers. In Germany, for instance, a payment of ten Euros per quarter for a doctorõs visit was introduced in This fee seems to have a stronger impact on patientsõ decision to not see a doctor than do co-payments that were introduced earlier in other countries. When analysing group-specific risks of facing cost barriers in more detail, we find that socioeconomic factors hardly matter. But insurance status does. In Australia, Germany and New Zealand, the chances of experiencing cost bar-

12 12 Confidence in receiving medical care, C Wendt et al. riers are significantly reduced when patients subscribe to a supplementary private insurance. Even if the difference between patients with and without private insurance in Australia and Germany is modest, the inequalities between people with and without (supplementary) private insurance might indicate that health-care systems with universal coverage also face problems in guaranteeing equal access to necessary health care. The greatest inequalities across groups with different insurance statuses can be found in the United States. While the deprived position of the uninsured has been shown elsewhere, 20 our results indicate that Medicare is better suited for protecting patients from access problems than are employer-based plans, other private insurance plans or Medicaid. Although cost barriers should be especially low for Medicaid patients, our results show that this is not the case. The experience of financial barriers might be related to the fact that medical doctors often do not accept Medicaid patients, and this group might therefore face additional costs (e.g. travel costs) when visiting a doctor. Concerning the Ôpromise of securityõ against major life risks, Medicare seems to be closer to other nationsõ public health systems than alternative US plans are. In contrast to Medicare, however, the public schemes of other countries provide coverage for the entire population, not only for a small subgroup. Our findings indicate that the trend towards increased cost-sharing of patients has more unintended consequences than might have been previously realized. Beside the risk of an increased burden on low-income groups and seriously ill persons, experienced cost barriers also affect trust in the health-care system. As trust in the health-care system is not only important for the legitimacy of the system but also for treatment outcomes, we would suggest that policy makers consider the negative impact on trust when dealing with cost-sharing. Guaranteeing access to necessary health-care services for those who fall seriously ill can be considered the single most important task of health-care systems in modern societies, and cost barriers therefore represent a major health-policy issue. Acknowledgements The research reported here has received financial support from the Harkness Program of Health Policy & Practice of the Commonwealth Fund and the Bosch Foundation. A first version of this article was presented at The Commonwealth Fund Final Conference in 2009, and we gratefully acknowledge the helpful comments and criticism by the participants, particularly Brad Gray, Rubin Minhas, and Jako Burger as well as by Ted Marmor, Bob Blendon, Jason Beckfield, and three anonymous reviewers. References 1 Zweifel P, Manning WG. Moral hazard and consumer incentives in health care. In: Culyer AJ, Newhouse JP (eds) Handbook of Health Economics. Amsterdam Lausanne New York: Elsevier, 2000: Robinson R. User charges for health care. In: Mossialos E, Dixon A, Figueras J, Kutzin J (eds) Funding Health Care: Options for Europe. Buckingham: Open University Press, 2002: Thomson S, Mossialos E. What are the Equity, Efficiency, Cost Containment and Choice Implications of Private Health-Care Funding in Western Europe? Copenhagen: WHO Regional Office for Europe, Cherkin DC, Grothaus L, Wagner EH. The effect of office visit copayments on utilization in a health maintenance organization. Medical Care, 1989; 27: Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Medical Care Review, 1994; 51: Mechanic D. The functions and limitations of trust in the provision of medical care. Journal of Health Politics, Policy and Law, 1998; 23: Gray BH. Trust and trustworthy care in the managed care era. Health Affairs, 1997; 16: Calnan MW, Sanford E. Public trust in health care: the system or the doctor? Quality and Safety in Health Care, 2004; 13: Jovell A, Blendon RJ, Navarro MD et al. Public trust in the Spanish health-care system. Health Expectations, 2007; 10: Wendt C, Kohl J, Mischke M, Pfeifer M. How do Europeans perceive their healthcare system? European Sociological Review, 2010; 26: Blendon RJ, Benson JM. AmericansÕ views on health policy: a fifty-year historical perspective. Health Affairs, 2001; 20:

13 Confidence in receiving medical care, C Wendt et al Blendon RJ, Hunt K, Benson JM, Fleischfresser C, Buhr T. Understanding the American public s health priorities: a 2006 perspective. Health Affairs, 2006; 25: w508 w Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter. Milbank Quarterly, 2001; 79: Mollborn S, Stepanikova I, Cook KS. Delayed care and unmet needs among health care system users: when does fiduciary trust in a physician matter? Health Service Research, 2005; 40: Pescosolido BA, Tuch SV, Martin JK. The profession of medicine and the public: examining AmericansÕ changing confidence in physician authority from the beginning of the Ôhealth care crisisõ to the era of health care reform. Journal of Health and Social Behavior, 2001; 42: Slovac P. Perceived risk, trust, and democracy. Risk Analysis, 1993; 13: Cheraghi-Sohi S, Bower P, Mead N, McDonald R, Whalley D, Roland M. What are the key attributes of primary care for patients? Building a conceptual ÔmapÕ of patient preferences. Health Expectations, 2006; 9: Wensing M, Hermsen J, Grol R, Szecsenyi J. Patient evaluations of accessibility and co-ordination in general practice in Europe. Health Expectations, 2008; 11: Pandhi N, Schumacher J, Flynn KE, Smith M. PatientsÕ perceptions of safety if interpersonal continuity of care were to be disrupted. Health Expectations, 2008; 11: Blendon RJ, Schoen C, DesRoches CM, Osborn R, Scoles KL, Zapert K. Inequities in health care: a five-country survey. Health Affairs, 2002; 21: Schoen C, Osborn R, How SKH, Doty MM, Peugh J. In chronic condition: experiences of patients with complex health care needs, in eight countries, Health Affairs, 2009; 28: w1 w Hassenteufel P, Palier B. Towards neo-bismarckian health care states? Comparing health insurance reforms in Bismarckian welfare systems. Social Policy & Administration, 2007; 41: Wendt C. Mapping European healthcare systems: a comparative analysis of financing, service provision and access to healthcare. Journal of European Social Policy, 2009; 19: Reibling N. Healthcare systems in Europe: towards an incorporation of patient access. Journal of European Social Policy, 2010; 20: Harris Interactive Inc. The 2007 Commonwealth Fund International Health Policy Survey. Methodology Report. Available at: fund.org/content/surveys/2007/2007-international- Health-Policy-Survey-in-Seven-Countries.aspx, accessed 10 October UCLA Academic Technology Services. Available at: accessed 10 October OECD OECD Health Data Statistics and Indicators for 30 Countries. Paris: OECD, 2008.