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The European Journal of Health Economics

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01.06.2015 | Original Paper

Income-related inequity in the use of GP services by children: a comparison of Ireland and Scotland

verfasst von: Richard Layte, Anne Nolan

Erschienen in: The European Journal of Health Economics | Ausgabe 5/2015

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Abstract

Equity of access to health care is a key component of national and international health policy, with most countries subscribing to the principle that health care should be allocated on the basis of need, rather than ability to pay or other criteria. The issue of health care entitlements for children is particularly pertinent given the strong causal links that have been demonstrated between eligibility for free care, utilisation and health outcomes. The Irish health care system is unusual in requiring the majority of the population to pay the full out-of-pocket cost of GP care. In contrast, all Scottish residents are entitled to free GP care at the point of use. This difference in public health care entitlements between Ireland and Scotland allows us to examine the impact of differences in financing structures on equity in GP care. In this paper, we use data from two nationally representative surveys of children in Ireland and Scotland to examine the degree of income-related inequity in the utilisation of GP services in both countries. We find that while the distribution of GP care is significantly pro-poor in Ireland, even after adjustment for health need, there is little or no significant inequity in GP utilisation among Scottish children. However, focusing just on children who pay the full price of GP care in Ireland, we find some evidence for a significant pro-rich distribution of GP visits. These results reflect the particular structure of health care entitlements that exist in two systems.

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Most empirical analyses examine income-related inequity in health care utilisation, but Stirbu et al. [18] and Bago d’Uva et al. [19] examine education-related inequity. A number of studies [7, 16, 17] examine inequities in expenditure, rather than utilisation.

We focus on Scotland (rather than the UK) due to data availability, i.e., data on GP utilisation among children are not collected in the UK-wide Millennium Cohort Study (see “Methods” section for further details).

A number of studies focus on sub-sets of the adult population. Allin et al. [14] focus on those aged 65+ years in the UK, while Cunningham et al. [16] examines health spending in the year prior to death for a sample of British Columbian individuals aged 65+ years.

See www.citizensinformation.ie/en/health/women_s_health/maternity_and_infant_welfare_services/ [last accessed 5 March 2014].

In 2010, an estimated 41 % of the population held PHI only; 6 % held both a full medical/GP visit card and PHI (‘dual cover’); 30 % held a full medical card or GP visit card only; and 23 % of the population had neither a full medical/GP visit card nor PHI [28].

Two other scenarios are possible. First, it is possible that there is differential take-up of the MICS for the different eligibility groups in Table 1. Unfortunately we have no information on take-up of the MICS among different population groups, and so cannot speculate on how our results may be affected. Second, it is also possible that GP visits under the MICS are excluded from our dependent variable (as the MICS specifically excludes visits that relate to the health of the child, rather than the developmental check, and the GUI question specifically asks about visits in relation to the health of the child) (see also Table 2).

In the Irish health care system, full medical and GP visit card holders are typically referred to as ‘public patients’ while those without a full medical card or GP visit card are typically referred to as ‘private patients’.

With the exception of the payments for enhanced services (which are supposed to reflect local health care needs), Scottish GPs operate under the UK-wide GP contract agreed in 2004 [45].

Data for 2002 indicated that PHI cover was much lower in Scotland than in other parts of the UK (8 % in comparison with a rate of 18–20 % in London and South-East England) [47].

Some studies distinguish between the probability of a GP visit, and the conditional number of visits, and often find conflicting results for the two decisions (for instance, van Doorslaer et al. [3] found an insignificant pro-rich distribution for the probability of visiting a GP in Ireland, but a significant pro-poor distribution for the conditional number of visits).

Bago d’Uva et al. [12] discuss this issue in greater detail. In the context of panel data, they argue that the ‘conventional’ HI may overstate the degree of inequity in health care utilisation as the residual variation in utilisation may be picking up some of the variation in unobserved need for health care (see also van Doorslaer et al. [3]).

As is apparent from Table 3, two of our health need variables are binary. In this case, the Wagstaff [49] and Erreygers [50] corrections are applied to the CIs for these variables.

In any case, there is some debate in the literature over whether panel data techniques (which control for unobserved time heterogeneity) are appropriate for analyses of children [51].

Data on prescription medicine consumption are not available in either GUI or GUS.

In the GUI survey, the GP variable includes telephone consultations. While we have no information on the proportion of visits that were classified as a telephone consultation, we recognise the possibility for bias in our results for the GUI cohorts if the different eligibility groups have different proportions of telephone consultations (for which the financial disincentive to visit should be far less).

As discussed in the “Introduction” section, the MICS complicates the picture in relation to the entitlement groups outlined in Table 1 for the GUI infant cohort; it is possible that the higher level of visiting among this group in part reflects the two free developmental checks that are free-of-charge to all infants.

The difference in GP visiting between quintile 1 (lowest) and quintile 5 (highest) is not statistically significant for the GUS birth cohort. Results of these tests are available on request from the authors.

The difference in GP visiting between quintile 1 (lowest) and quintile 5 (highest) is not statistically significant for the GUI child cohort. Once again, the MICS complicates the picture in relation to the entitlement groups outlined in Table 1 for the GUI infant cohort. However, assuming that there is no differential take-up of the MICS among different income groups, the patterns in Fig. 2 should not be affected.

While an indicator of chronic illness incidence is available in both the GUI and GUS surveys, the underlying question differs considerably across the surveys. In the GUI infant cohort, the variable is constructed from responses to the question ‘Has a medical professional ever told you that \(\left\langle {\text{baby}} \right\rangle\) has any of the following conditions? With 16 conditions specified (e.g., asthma, diabetes, epilepsy, etc.). In the GUI child cohort, the variable is constructed from the responses to the question ‘Does the Study Child have any on-going chronic physical or mental health problem, illness or disability?’ In GUS, the question is ‘Does ^childname have any longstanding illness or disability? By longstanding I mean anything that has troubled ^him over a period of time or that is likely to affect ^him over a period of time?’ Due to the differences in the underlying question, and the extent to which the GUI infant cohort indicator is an indicator of health need (rather than utilisation), we exclude the chronic illness indicator from our analyses. However, as detailed in the Appendix, we also check the robustness of the results to the inclusion of this variable (and other health need variables which are not available in comparable form across the four samples).

Summary statistics for all variables in table are presented in Table 7 in Appendix 1.

The CI ranges from −1 to 1, with a value of zero indicating no income inequality/inequity in the underlying variable. A negative value indicates a pro-poor distribution of the variable, while a positive value reflects a pro-rich distribution. Van Doorslaer and Koolman [52] have shown that multiplying the value of the concentration index by 75 gives the percentage of the underlying variable (in this case, GP visits) that would need to be (linearly) redistributed from the poorer half to the richer half of the population to arrive at a distribution with an index value of zero.

Detailed results are presented in Appendix 2.

Due to space constraints, the results of the decomposition analyses for the two-part models are not presented here, but are available on request from the authors.

However, there is some evidence for a significant pro-rich distribution for the probability of a GP visit among GUS 2 year olds.

As noted, the existence of the MICS potentially complicates the picture of entitlements for the analysis of the GUI infant cohort although in the absence of more detailed information on take-up of the MICS, it is impossible to speculate on the implications of the MICS for this analysis.

Bago d’Uva et al. [12] exploit the additional information available in longitudinal data to improve the measurement of income-related inequity in health care utilisation by including the time-invariant part of unobserved heterogeneity in the need standardisation procedure. While they find (using the ECHP), that many of the cross-country comparisons are ‘fairly robust’ to the panel data test, the panel estimates lead to significantly higher estimates of income-related inequity for most countries. This confirms that better estimation and control for need often reveals more pro-rich inequity in health care utilisation (also found by Grasdal and Monstad [15], among others).

For all samples, we tested the inclusion of variables relating to chronic illness incidence, acute illness (GUI infant cohort only), child sleeping problems (GUI infant and both GUS cohorts), breast feeding, mother’s smoking and drinking during pregnancy, and current childcare arrangements.

Culyer, A., Wagstaff, A.: Equity and equality in health and health care. J. Health Econ. 12(4), 431–457 (1993). doi:10.1016/0167-6296(93)90004-X CrossRefPubMed

Wagstaff, A., van Doorslaer, E.: Measuring and testing for inequity in the delivery of health care. J. Hum. Resour. 35(4), 716–733 (2000)CrossRef

van Doorslaer, E., Koolman, X., Jones, A.: Explaining income-related inequalities in doctor utilisation in Europe. Health Econ. 13(7), 629–647 (2004). doi:10.1002/hec.919 CrossRefPubMed

van Doorslaer, E., Koolman, X., Puffer, F.: Equity in the use of physician visits in OECD countries: has equal treatment for equal need been achieved? In: Measuring up: improving health system peformance in OECD countries. OECD, Paris (2002)

van Doorslaer, E., Masseria, C.: Income-related inequality in the use of medical care in 21 OECD countries. OECD Health Working Papers No. 14. OECD, Paris (2004)

van Doorslaer, E., Masseria, C., Koolman, X.: Inequalities in access to medical care by income in developed countries. Can. Med. Assoc. J. 174(2), 177–183 (2006)CrossRef

Layte, R., Nolan, B.: Equity in the utilisation of healthcare in Ireland. Econ. Soc. Rev. 35(2), 111–134 (2004)

Yiengprugsawan, V., Carmichael, G., Lim, L., Seubsman, S., Sleigh, A.: Explanation of inequality in utilization of ambulatory care before and after universal health insurance in Thailand. Health Policy Plan. 26(2), 105–114 (2011)CrossRefPubMedCentralPubMed

Lu, J., Leung, G., Kwon, S., Tin, K., Van Doorslaer, E., O’Donnell, O.: Horizontal equity in health care utilization evidence from three high-income Asian economies. Soc. Sci. Med. 64(1), 199–212 (2007). doi:10.1016/j.socscimed.2006.08.033 CrossRefPubMed

10.

van Doorslaer, E., Clarke, P., Savage, E., Hall, J.: Horizontal inequities in Australia’s mixed public/private health care system. Health Policy 86(1), 97–108 (2008). doi:10.1016/j.healthpol.2007.09.018 CrossRefPubMed

11.

van Doorslaer, E., Wagstaff, A., van der Burg, H., Christiansen, T., De Graeve, D., Duchesne, I., Gerdtham, U.-G., Gerfin, M., Geurts, J., Gross, L., Häkkinen, U., John, J., Klavus, J., Leu, R.E., Nolan, B., O’Donnell, O., Propper, C., Puffer, F., Schellhorn, M., Sundberg, G., Winkelhake, O.: Equity in the delivery of health care in Europe and the US. J. Health Econ. 19(5), 553–583 (2000). doi:10.1016/s0167-6296(00)00050-3 CrossRefPubMed

12.

Bago d’Uva, T., Jones, A., van Doorslaer, E.: Measurement of horizontal inequity in health care utilisation using European panel data. J. Health Econ. 28(2), 280–289 (2009)CrossRefPubMed

13.

van de Poel, E., van Doorslaer, E., O’Donnell, O.: Measurement of inequity in health care with heterogeneous response of use to need. J. Health Econ. 31(4), 676–689 (2012). doi:10.1016/j.jhealeco.2012.05.005 CrossRefPubMed

14.

Allin, S., Masseria, C., Mossialos, E.: Equity in health care use among older people in the UK: an analysis of panel data. Appl. Econ. 43(18), 2229–2239 (2010). doi:10.1080/00036840903196621 CrossRef

15.

Grasdal, A., Monstad, K.: Inequity in the use of physician services in Norway before and after introducing patient lists in primary care. Int. J. Equity Health 10(1), 25 (2011)CrossRefPubMedCentralPubMed

16.

Cunningham, C., Hanley, G., Morgan, S.: Income inequities in end-of-life health care spending in British Columbia, Canada: a cross-sectional analysis, 2004–2006. Int. J. Equity Health 10(1), 12 (2011)CrossRefPubMedCentralPubMed

17.

Propper, C., Upward, R.: Need, equity and the NHS: the distribution of health care expenditure 1974–87. Fisc. Stud. 13(2), 1–21 (1992)CrossRef

18.

Stirbu, I., Kunst, A., Mielck, A., Mackenbach, J.: Inequalities in utilisation of general practitioner and specialist services in 9 European countries. BMC Health Serv. Res. 11(1), 1–8 (2011). doi:10.1186/1472-6963-11-288 CrossRef

19.

Bago d’Uva, T., Lindeboom, M., O’Donnell, O., van Doorslaer, E.: Education-related inequity in healthcare with heterogeneous reporting of health. J. R. Stat. Soc. Ser. A (Stat. Soc.) 174(3), 639–664 (2011)CrossRef

20.

Macinko, J., Starfield, B., Shi, L.: The contribution of primary care systems to health outcomes within Organisation for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv. Res. 38(3), 831–865 (2003)CrossRefPubMedCentralPubMed

21.

Currie, J.: Socio-economic status and child health: does public insurance narrow the gap? Scand. J. Econ. 97(4), 603–620 (1995)CrossRef

22.

Currie, J., Decker, S., Lin, W.: Has public insurance for older children reduced disparities in access to care and health outcomes? J. Health Econ. 27(6), 1567–1581 (2008)CrossRefPubMed

23.

Currie, J., Gruber, J.: Health insurance eligibility, utilization of medical care, and child health. Q. J. Econ. 111(2), 431–466 (1996)CrossRef

24.

Case, A., Fertig, A., Paxson, C.: The lasting impact of childhood health and circumstance. J. Health Econ. 24(2), 365–389 (2005)CrossRefPubMed

25.

Ruane, F.: Report of the expert group on resource allocation and financing in the health sector. Department of Health and Children, Dublin, (2010)

26.

Smith, S.: The Irish health basket: a basket case? Eur. J. Health Econ. 11(3), 343–350 (2010). doi:10.1007/s10198-009-0171-4 CrossRefPubMed

27.

Thomson, S., Mossialos, E.: Private health insurance in the European Union. Final report prepared for the European Commission, D.G.f.E., Social Affairs and Equal Opportunities (ed.). LSE Health and Social Care, London (2009)

28.

CSO: Health status and health services utilisation. In: Quarterly National Household Survey (Quarter 3 2010). CSO, Dublin (2011)

29.

Government of Ireland: Government for National Recovery 2011–2016. Stationery Office, Dublin (2011)

30.

National Consumer Agency: Doctor and Dentists Survey. National Consumer Agency, Dublin (2010)

31.

Tussing, D.: Irish medical care resources: an economic analysis. Economic and Social Research Institute, Dublin (1985)

32.

Layte, R., Nolan, A., McGee, H., O’Hanlon, A.: Do consultation charges deter general practitioner use among older people? A natural experiment. Soc. Sci. Med. 68(8), 1432–1438 (2009)CrossRefPubMed

33.

Nolan, A.: The impact of income on private patients’ access to GP services in Ireland. J. Health Serv. Res. Policy 13(4), 222–226 (2008)CrossRefPubMed

34.

Nolan, A.: A dynamic analysis of the utilisation of GP services in Ireland: 1995–2001. Health Econ. 16(2), 129–143 (2007)CrossRefPubMed

35.

Nolan, A.: Evaluating the impact of free care on the use of GP services: a difference-in-difference matching approach. Soc. Sci. Med. 67(8), 1164–1172 (2008)CrossRefPubMed

36.

Nolan, A., Nolan, B.: Eligibility for free care, need and GP services in Ireland. Eur. J. Health Econ. 9(2), 157–162 (2008)CrossRefPubMed

37.

Nolan, A., Smith, S.: The effect of differential eligibility for free GP services on GP utilisation in Ireland. Soc. Sci. Med. 74(10), 1644–1651 (2012). doi:10.1016/j.socscimed.2012.02.007 CrossRefPubMed

38.

Nolan, B.: The utilisation and financing of health services in Ireland. Economic and Social Research Institute, Dublin (1991)

39.

Nolan, B.: Economic incentives, health status and health services utilisation. J. Health Econ. 12, 151–169 (1993)CrossRefPubMed

40.

O’Reilly, D., O’Dowd, T., Galway, K., Murphy, A., O’Neill, C., Shryane, E., Steele, K., Bury, G., Gilliland, A., Kelly, A.: Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional study. Eur. J. Gen. Pract. 13(4), 231–236 (2007)CrossRefPubMed

41.

Layte, R., Nolan, A.: Inequity in the utilisation of GP services by children in Ireland. Forthcoming report. Economic and Social Research Institute, Dublin

42.

Brick, A., Nolan, A., O’Reilly, J., Smith, S.: Conflicting financial incentives in the Irish health-care system. Econ. Soc. Rev. 43(2), 273–301 (2012)

43.

Barros, P., Machado, M., Sanz-de-Galdeano, A.: Moral hazard and the demand for health services: a matching estimator approach. J. Health Econ. 27(4), 1006–1025 (2008)CrossRefPubMed

44.

Audit Scotland: review of the new general medical services contract. Audit Scotland, Edinburgh (2006)

45.

Oxtoby, K.: The UK-wide GP contract: still fit for purpose? BMJ Careers (2012). http://careers.bmj.com/careers/advice/view-article.html?id=20007082

46.

Boyle, S.: United Kingdom (England) health system review. In: Health systems in transition. European Observatory on Health Systems and Policies, Brussels (2011)

47.

Foubister, T., Thomson, S., Mossialos, E., McGuire, A.: Private medical insurance in the United Kingdom. In: E.O.o.H.S.a. (ed.) Policies. European Observatory on Health Systems and Policies, Copenhagen (2006)

48.

Sutton, M.: Vertical and horizontal aspects of socio-economic inequity in general practitioner contacts in Scotland. Health Econ. 11(6), 537–549 (2002)CrossRefPubMed

49.

Wagstaff, A.: The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality. Health Econ. 14(4), 429–432 (2005). doi:10.1002/hec.953 CrossRefPubMed

50.

Erreygers, G.: Correcting the concentration index. J. Health Econ. 28(2), 504–515 (2009). doi:10.1016/j.jhealeco.2008.02.003 CrossRefPubMed

51.

Propper, C., Rigg, J., Burgess, S.: Child health: evidence on the roles of family income and maternal mental health from a UK birth cohort. Health Econ. 16(11), 1245–1269 (2007). doi:10.1002/hec.1221 CrossRefPubMed

52.

van Doorslaer, E., Koolman, X.: Explaining the differences in income-related health inequalities across European countries. Health Econ. 13(7), 609–628 (2004). doi:10.1002/hec.918 CrossRefPubMed

53.

Jiminez-Martin, S., Labega, J., Martinez-Granado, M.: Latent class versus two-part models in the demand for physician services across the European Union. Health Econ. 11(4), 301–322 (2001)CrossRef

54.

Deb, P., Trivedi, P.: The structure of demand for health care: latent class versus two-part models. J. Health Econ. 21(4), 601–625 (2002). doi:10.1016/s0167-6296(02)00008-5 CrossRefPubMed

55.

Robinson, R.: User charges for health care. In: Mossialos, E., Dixon, A., Figueras, J., Kutzin, J. (eds.) Funding health care: options for Europe. Open University Press, Buckingham (2002)

56.

Gorecki, P., Nolan, A., Brick, A., Lyons, S.: Delivery of pharmaceuticals in Ireland: getting a bigger bang for the buck. ESRI Research Series No. 24. Economic and Social Research Institute, Dublin (2012)

57.

Information Services Division: Prescribing and medicines: annual and quarterly update of prescription charges. Information Services Division, Scotland (2011)

58.

Royston, P.: Multiple imputation of missing values: further update of ice, with an emphasis on categorical variables. Stata J. 9(3), 466–477 (2009)

59.

Jones, A., López Nicolás, A.: Allowing for heterogeneity in the decomposition of measures of inequality in health. J. Econ. Inequal. 4(3), 347–365 (2006). doi:10.1007/s10888-005-9019-z CrossRef

Titel: Income-related inequity in the use of GP services by children: a comparison of Ireland and Scotland
verfasst von: Richard Layte
Anne Nolan
Publikationsdatum: 01.06.2015
Verlag: Springer Berlin Heidelberg
Erschienen in: The European Journal of Health Economics / Ausgabe 5/2015
Print ISSN: 1618-7598
Elektronische ISSN: 1618-7601
DOI: https://doi.org/10.1007/s10198-014-0587-3

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