Main findings
Between 2009 and 2014, the frequency of physician consultation and of hospitalization decreased in Germany, except in persons belonging to the lowest income category. In Spain, the frequency of physician consultation increased between the first and second period, whereas the frequency of hospitalization decreased. In Germany, after adjusting for age, sex and need for care, subjects in the lowest income category showed the lowest frequency of physician consultation in both periods. In contrast, no significant differences by income were seen in hospitalization in 2009, whereas subjects belonging to the lowest income category showed the highest frequency of hospitalization in 2014. In Spain, after adjusting for age, sex and need for care, no significant differences by income were observed in the frequency of physician consultation in 2009 or in the frequency of hospitalization in either of the periods, while subjects in the lower income categories showed the highest frequency of physician consultation in 2014.
Comparison with other studies and possible explanations
The reduced frequency of physician consultations in Germany stands in contrast to the increase observed in the two previous decades. The exception was the group with lowest income, which showed a slight increase in the frequency of consultations between 2009 and 2014. The elimination of copayment in 2013 probably contributed to the increased frequency of consultations in this population group. In any case, elimination of copayment did not modify the economic pattern of physician consultation, since in both periods the frequency of physician consultation was lower in the lower income groups. The economic pattern in physician consultation observed in the present study has been found in international comparative studies in various countries [
7,
16,
17]. However, some previous investigations in the German population have not found a clear relationship between income and frequency of physician consultations [
18] or a greater number of physician visits in persons with lower incomes [
19].
Although there is a medical copayment in Germany for hospitalization (10 euros per day for admission up to a maximum of 28 days a year) [
20], a previous study found a greater number of hospitalizations in subjects with lower income [
20]. In the present study, after adjusting for age, sex and need for medical care, this finding is due to an important increase in the frequency of hospitalization in this population group in 2014 with respect to 2009. The reasons for this finding are unknown. No socioeconomic differences have been found in hospitalization of children and adolescents in Germany, except for the most severe health problems, which showed a longer duration of hospitalization in those in lower socioeconomic position [
21]. The slight increase observed in the frequency of physician consultations in persons with lower incomes may be due to patients with more severe health problems, with a consequent increase in the frequency of hospitalization in this population group. In any case, it is possible that one year is not a sufficient period of time to identify changes in the behaviour of patients due to the very recent (2013) elimination of the co-payment.
In Spain, as observed in previous studies, no economic differences were found in the frequency of hospitalization in the first years of the present century [
22,
23]. These investigations also have failed to find a clear relationship between income and the frequency of physician consultations [
22,
23]. On the other hand, a surprising finding in our study is the increased frequency of physician consultations in Spain. Not only because this increase contrasts with the reduced frequency observed since the beginning of this century, but also because it occurred despite the reduction in health care expenditures and the fact that access to health care was restricted in part of the immigrant population. The increase in physician consultations was particularly notable in the lower income groups. In fact, after adjusting for all the different variables, no economic differences were observed in the frequency of consultations in 2009, while in 2014 the highest frequency of consultation was seen in the lower income groups. A previous study also found an increased frequency of general practitioner consultations in the lowest social classes between 2006 and 2012 [
24]. The increased frequency of physician consultations in our study was similar in both the native and immigrant populations, since adjustment for place of birth did not change the magnitude of the association between income and physician consultation. A previous investigation also showed a similar level of health services use by both immigrants and the native population between 2006 and 2012 [
25].
This increased frequency of physician consultation may be due primarily to an increase in visits to specialist physicians, given that the percentage of respondents who consulted a specialist in the last 4 weeks before the interview was 11.8% in 2009 and 14.2% in 2014, whereas the percentage of those who consulted a general practitioner hardly changed (28.5% in 2009 and 29.0% in 2014) [
26]. Since the increase in physician consultations was not associated with an increased frequency of hospitalization (which decreased), it may be due to a change in clinical practice on the part of general and/or specialist physicians. It is possible that there has been an increase in the rate of referral of patients from general practitioners to specialist physicians. In Spain the general practitioner is the gatekeeper to the health system, therefore patients cannot see a specialist unless referred by a general practitioner. However, an increased number of “interconsultations” (referral from one specialist to another) should not be ruled out as another explanation. According to information on health care activity in specialist care centres, the number of consultations with specialist physicians per person and year rose from 1.8 in 2010 (the first year with available data) to 2.0 in 2014 [
27].
In theory, the elimination of the co-payment in Germany would increase the frequency of the use of health services by citizens with lower incomes, while the restrictive measures in Spain would reduce the frequency of use by those citizens, because immigrants belong mostly to the population group with lower incomes. The other affected group, those who were not affiliated with the Social Security and had an annual income of over 100,000 euros, mostly used private health services and, therefore, their behaviour would not be affected by the restriction. However, the economic pattern of use of health services with these measures was not modified, even in Spain it was favourable to citizens with lower incomes. These findings are relevant for similar contexts, that is, developed countries with an important tradition of public coverage of health care. In these countries, the implementation of measures that affect the accessibility to the health system, in one way or another, may not have the desired impact.
Strengths and limitations
One strength of this study is that it compares the economic pattern in the use of health services in two countries where the economic crisis has had a different impact and which implemented different health policy measures during the crisis. Furthermore, the same data source was used in each country before and during the economic crisis, so that the variables related to the use of physician services and hospital admissions were the same. In the case of Spain, some respondents did not answer the question on household income. We do not believe that this lack of response has influenced the findings, since the percentage of non-response is similar in the categories of another socioeconomic variable, the level of education (data not shown). In addition the percentage of non-response was similar in both years of the study. On the other hand, the cut-off points for the income categories in the surveys carried out in Spain are different. However, given that the alteration in the distribution of the percentage of subjects assigned to each category in 2014 with respect to 2009 has been of small magnitude, its impact on the results must have been minimal.
It is possible that with the use of other measures of socioeconomic position, such as social class or level of education, the results obtained were not the same. However, the measures implemented in Germany and Spain affect the payment capacity of citizens and, in this sense, the measure that best reflects the economic capacity is the level of income. On the other hand, the cut-off points for the income categories in the surveys carried out in Spain are different. However, given that the alteration in the distribution of the percentage of subjects assigned to each category in 2014 with respect to 2009 has been of small magnitude, its impact on the results must have been minimal.
The increase in consultations with specialist physicians in Spain could be attributed to a greater frequency of visits to private specialists. However, the proportion of consultations with public and private specialists remained similar in the two study periods [
26]. Finally, the analyses did not include the respondents’ type of health coverage (public, private or mixed) because the European Health Surveys in Spain in 2009 did not include any question about this subject. Nevertheless, adjustment for the type of health coverage in Germany in 2009 and 2014, and in Spain in 2014 did not modify the results.