No kidding - wealth improves access to specialized services
Inequalities in access to medical care by income in developed countries
By Eddy van Doorslaer, Cristina Masseria, Xander Koolman for the OECD Health Equity Research Group
CMAJ
January 17, 2006
The member states of the Organization for Economic Cooperation and Development (OECD) represent the wealthiest and healthiest countries in the world. Most of them achieved nearly universal coverage of their populations for a fairly comprehensive package of medical services decades ago. Their governments are committed not only to pursuing the efficient delivery of high-quality medical care but also to ensuring equitable access to that care. In most OECD countries, access to good-quality physician services is ensured at relatively low and sometimes zero financial cost at the point of delivery. This is mainly the result of a variety of public insurance arrangements aimed at ensuring equitable access. The increasing tension between affordability and equity has spurred a number of countries to reconsider their public-private mix and to study reforms that may enhance efficiency while maintaining equity.
Like the World Health Organization, the OECD is committed to a watchful monitoring and comparison of the performance of its members’ health care systems, and equity in access is regarded as a key objective. In 2002, the OECD Health Project commissioned a cross-country comparative study to assess how the very diverse health care delivery systems of its members fare in terms of equitable access. This article summarizes some of the main results of this study.
Results: We found inequity in physician utilization favouring patients who are better off in about half of the OECD countries studied. The degree of pro-rich inequity in doctor use is highest in the United States and Mexico, followed by Finland, Portugal and Sweden. In most countries, we found no evidence of inequity in the distribution of general practitioner visits across income groups, and where it does occur, it often indicates a pro-poor distribution. However, in all countries for which data are available, after controlling for need differences, people with higher incomes are significantly more likely to see a specialist than people with lower incomes and, in most countries, also more frequently. Pro-rich inequity is especially large in Portugal, Finland and Ireland.
Interpretation: Although in most OECD countries general practitioner care is distributed fairly equally and is often even pro-poor, the very pro-rich distribution of specialist care tends to make total doctor utilization somewhat pro-rich. This phenomenon appears to be universal, but it is reinforced when private insurance or private care options are offered.
http://www.cmaj.ca/cgi/content/full/174/2/177
And…
Commentary (on the article above)
By Jeremiah Hurley and Michel Grignon
The international comparison carries some potentially important lessons for health care policy debates in Canada. The most important is perhaps the link between equity of utilization and a country’s system of financing. It should not be surprising that the 2 countries in the study that lack universal health care insurance coverage (Mexico and the United States) have both some of the lowest overall visit rates and the greatest income-related inequity of utilization. More subtle appears to be the effect of parallel private insurance (private insurance that covers publicly insured services) among those countries with universal public insurance coverage. Such private insurance is disproportionately purchased by the wealthy and is particularly targeted at specialist services. Countries in which parallel insurance plays an important role in financing (e.g., Ireland, Spain and Portugal) achieve equitable utilization of general practitioner services across income groups - indeed, there is a tendency toward a pro-poor bias - but utilization for specialist services displays some of the highest degrees of inequity. The results of this study do not allow any definitive conclusions in this regard, but they caution against any illusion that parallel private insurance will increase access for anyone except the higher-income people who purchase it.
http://www.cmaj.ca/cgi/content/full/174/2/187
Comment: This OECD study has some very good news, some bad news, and some terrible news.
The very good news is that nations with universal systems (all industrialized nations except the United States) have relatively equitable access to primary care services - the foundation of a well-functioning health care system.
The bad news is that access to specialized services is not equitable in most countries, but it is certainly no surprise that wealth opens doors to specialized services. This differential is exaggerated in nations with parallel private insurance systems. This is not to begrudge the wealthy their improved access to specialized services (which are not always beneficial), but rather it is to express alarm over the fact that the remaining population has even greater impairment in access to specialized services merely because of stratification of the masses into the universal public insurance program, while granting the wealthy the option of using the red-velvet-roped First Class entrance to health care.
The terrible news is that the United States, lacking universal health insurance, has amongst the lowest overall visit rates and the greatest income-related inequity of utilization. There is not much consolation in the fact that Mexico shares that honor. Mexico, a relatively poor country, spends 6 percent of its GDP on health care whereas the United States, a very wealthy nation, spends 16 percent. Where is that greater quality at lower cost that the market enthusiasts keep talking about?
A brief OECD statement on the health system of Mexico:
http://www.oecd.org/dataoecd/35/19/34685343.doc