UTILISATION IN OECD COUNTRIES

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INEQUALITIES IN HEALTH CARE

UTILISATION IN OECD COUNTRIES

Marion Devaux, OECD Health Division

EU Expert Group Meeting on Social Determinants and Health Inequalities, 21-Jan-2013

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OECD framework for health system performance assessment

Health care system performance

Quality Access Expenditure

Non-health care determinants of health Health status

Equity

Efficiency

Health system design, policy and context

Source: OECD Health at a Glance 2011

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Previous work on inequalities in health care use

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• To update earlier results on inequity in health care use (van Doorslaer and Masseria, 2004) to extend the

analysis to new health care services and to new OECD countries.

• To examine inequalities in conjunction with health

systems characteristics (with focus on financial barriers)

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Objective of the study

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• 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

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• 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

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• 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 Lowest

income quintile

Average Highest income quintile

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• 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 Lowest

income quintile

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-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

Inequity in GP visits Inequity in Specialist visits

Pro-poor inequity

Pro-rich inequity

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• People with higher incomes are 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

(*) 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 Lowest

income quintile

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• 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 Lowest

income quintile

(*) Ireland: in past 12 months

Source: OECD Health Working Paper No 58.

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• Country ranking remained rather stable

• Inequities remained very stable for doctor and GP visits.

• Some discrepancies found for specialist (Finland) and dentist visits (Finland, Ireland, 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 0.04 0.08 0.12 0.16 0.2

Inequity index (HI)

2011 project Van Doorslaer & Masseria (2004)

-0.04 0 0.04 0.08 0.12 0.16 0.2

Inequity index (HI)

-0.04 0 0.04 0.08 0.12 0.16 0.2

Inequality index (CI)

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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?

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• 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

Inequity in specialist visits

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

France Belgium

Slovenia

Austria Canada

Czech Republic

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

Inequality in dental visits

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

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• PHI facilitates the use of care, with the privately

insured more likely to visit specialists and dentists.

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Private Health Insurance (PHI)

58% 38% 61% 42% 74% 78% 57% 70% 76% 41%44% 29% 51% 41% 58% 67% 46% 65% 69% 25%

0%

20%

40%

60%

80%

100%

France* New Zealand*

Switzer- land*

United Kingdom

United States*¤

France* New Zealand*

Switzer- land*

United Kingdom*

United States*

Specialist visits Dentist visits

Probability of a medical visist

Privately insured Not privately insured

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• U

pdate 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

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• Reducing financial barriers

– Targeting population the most at risk

– Increasing coverage of dental and eye care ? – Trade-off with other objectives such as

controlling public spending to reduce budgetary deficits?

• Reducing non-financial barriers

– Geographic distribution of services

– Social dimension (education level, ethnic and language)

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Possible policy action to strengthen

equal access to care

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• OECD Health Working paper No. 58 “Income-Related Inequalities in Health Service Utilisation in 19 OECD Countries, 2008-2009” Devaux, M. and M. de Looper (2012)

• OECD Health at a Glance 2011

www.oecd.org/oecd.org/health/healthataglance

• OECD Health at a Glance Europe 2012

www.oecd.org/health/healthataglance/europe

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More information

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This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on the

subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the data

included in this paper, nor does it accept responsibility for any use made thereof.