INEQUALITIES IN HEALTH CARE SERVICES UTILISATION IN OECD COUNTRIES
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1 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
2 Background (1/2) 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
3 Background (2/2) 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
4 Objective of the study 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) 4
5 Methods 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. 5
6 Data 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. 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 Poland (EHIS 2009) Slovak republic (EHIS 2009) Slovenia (EHIS 2007) Spain 2009 Switzerland 2007 United Kingdom 2009 United States
7 GP visits in the past 12 months 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) Lowest income quintile (*) in past 3 months in Denmark Average Highest income quintile Rates of GP visits in the past 12 months 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. Source: OECD Health Working Paper No 58. Devaux and de Looper,
8 Specialist visits in the past 12 months Large variations across income groups, low-income people being less likely to see a specialist in all countries. Need-adjusted probability of a specialist visit in last 12 months by income quintile (age 16-85) Hungary Czech Republic France Canada Slovak Republic Spain Switzerland Belgium Poland Estonia Slovenia United Kingdom Finland New Zealand Denmark* Lowest income quintile Average Highest income quintile (*) in past 3 months in Denmark Rates of specialist visits in the past 12 months Source: OECD Health Working Paper No 58. Devaux and de Looper,
9 Inequity Index in GP and Specialist visits Inequity in GP visits Inequity in Specialist visits Pro-rich inequity Pro-rich inequity Pro-poor inequity (*) in past 3 months in Denmark Source: OECD Health Working Paper No 58. Devaux and de Looper,
10 Dentist visits in the past 12 months Czech Republic United Kingdom Slovak Republic Switzerland Canada Austria Finland Belgium Slovenia Ireland New Zealand Estonia Spain United States Poland Hungary Probability of a dentist visit in last 12 months by income quintile (age 16-85) Lowest income quintile Average Highest income quintile 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 France* Denmark** Rates of dentist visits in the past 12 months (*) France past 24 months; (**)Denmark past 3 months. Source: OECD Health Working Paper No 58. Devaux and de Looper,
11 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) Lowest income quintile Average Highest income quintile Rates of cervical cancer screening in the past 3 years (*) Ireland: in past 12 months Source: OECD Health Working Paper No 58. 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 11
12 Comparison with earlier findings 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. 12
13 Inequality index (CI) Inequity index (HI) Inequity index (HI) Comparison with earlier findings Panel A. GP visits: probability Panel B. Specialist visits: probability project Van Doorslaer & Masseria (2004) 2011 project Van Doorslaer & Masseria (2004) 0.2 Panel C. Dentist visits: probability project Van Doorslaer & Masseria (2004) 13
14 Which health system features characterise countries with lower levels of inequity? Organisation of health systems Financing of health care services Cultural and information barriers 14
15 Gatekeeping system --Preliminary data- Required Primary care physicians referral to access secondary care Required Denmark, Finland, Ireland, Italy, Netherlands, Portugal, Slovenia, Spain Incentives No requirement, no incentive Czech Republic, Register with a primary care physician 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 Source: OECD Health System Characteristics Survey 2012 and Secretariat s estimates. 15
16 Acute Inpatient Czech Rep. Out-patient primary care Denmark Finland France Germany Greece Hungary Iceland Outpatient specialist care Pharmaceuticals Ireland Israel Italy Japon Korea Clinical Lab Tests Diagnostic Imaging Physiothe rapy Eye products Dental care Dental prosthesis Level of coverage for different types of care --Preliminary data-- Australia Austria Belgium Canada Chile Czech Rep. Denmark Finland France Germany Greece Iceland Ireland Israel Italy Japan 100% 99-95% 94-85% 84-65% 64-40% 40-0% Note: coverage for an adult not subject to any exceptions Source: OECD Health System Characteristics Survey 2012 and Secretariat s estimates
17 Cost-sharing arrangements --Preliminary data- Country Cost-sharing arrage me nts, 2012 Austria Mostly free at the point of use for contracted physicians Be lgium Per-visit co-payments for outpatient care Canada Free at the point of care Cze ch Re public Per-visit co-payments for outpatient care E stonia n.a. F inland Per-visit co-payments for outpatient care F rance Per-visit co-payments for outpatient care Germany Free at the point of care H ungary Per-visit co-payments for outpatient care Ire land Free for medical card holders (40% of pop) and full cost for nonmedical card holders. New Zealand Cost-sharing for outpatient primary care, no cost-sharing for specialist care Poland Free at the point of care Slovak Re public n.a. Slove nia Cost-sharing Spain Free at the point of care Switze rland 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 17
18 Health system features likely associated with larger inequalities Universal health coverage not achieved Large share of private financing and out-ofpocket payments Care not free at the point of delivery No gatekeeping system Mostly private provision of health care Non-existence of public screening programmes 18
19 Inequity in specialist visits Inequality in dental visits Out-of-pocket payments (OOP) 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 Belgium Canada Estonia Poland Hungary Spain R² = Belgium Finland Spain Poland Switzerland Slovenia R² = France Austria Czech Republic Finland Slovak Republic New Zealand 0 Slovenia Hungary Czech Republic Out-of-pocket payment as % of total expenditure on specialist care Out-of-pocket payment as % of total dental expenditure Source: OECD Health Working Paper No
20 Concluding remarks 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 20
21 Possible policy actions to strengthen equal access to care 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) 21
22 Thank you Contact: Read more about our work Follow us on Website: Newsletter:
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