Equity In Health Care Utilization Research Articles

PMD109 - Healthcare Expenditures and Equity in Healthcare Utilization for Lymphedema Patients in France

PMD109 - Healthcare Expenditures and Equity in Healthcare Utilization for Lymphedema Patients in France

Equity in the utilization of physician and inpatient hospital services: evidence from Korean health panel survey.

BackgroundLittle is known regarding equity in health care utilization among Koreans since 2008. This study examines the extent to which equity in the use of health care services has been achieved in Korea.MethodsDescriptive and logistic regression analysis was performed. The sample for this study was 17,035 individuals who participated in interviews.ResultsDifferences in need substantially account for the original differences observed between subgroups of Koreans. Need factors were important determinants of Koreans using physician and inpatient hospital services. Having income did not ameliorate the subgroup differences in the use of physician services. Nonetheless, having income remains an important predictor of physician utilization.ConclusionsThe Korean health care system does not yield a fully equitable distribution of physician and inpatient hospital services. Health care reforms in Korea should continue to concentrate on insuring effective universal health care, implying that all population groups with need receive effective coverage.

Erratum to: Horizontal equity in health care utilization in Brazil, 1998-2008

No abstract

How does a change in reimbursement system affect vertical and horizontal equity in healthcare utilization? Differences in GP visits before and after a change in reimbursement system in Stockholm County Council.

Background In 2008 a new health care reform was introduced in Stockholm County Council. The reimbursement system (RS) in primary care was changed from a need-weighted capitation (75%) with age and area specific socio-economic indicators used as proxies for need; to a system based more on fee-for-service (60%), less on only age weighted capitation (40%). This RS creates incentives for producing many visits and there is a risk that resources could divert from individuals with lower socioeconomic position as they often have more …

암 질환 대상 산정특례제도가 의료이용 및 의료비 부담 형평성에 미친 영향

Background: The purpose of this study is to evaluate the effect of health insurance coverage expansion for cancer patients on equity in health care utilization and catastrophic expenditure. Methods: To analyze the causal relationship between the policy to expand benefit coverage and the change in health care utilization and out-of-pocket payments of cancer patients, this study employed a difference-in-differences (DID) method. In the DID model, the change in health care utilization, such as health care expenditure, visit days and length of stay, of cancer patients was compared with that of liver disease patients, using Korea Health Panel Data in 2009 and 2010. Results: The policy of reducing cost sharing from 10% to 5% for cancer patients did not have significant effects on equity in health care utilization. The results of this study were different from those of the previous study that showed that the reduction of cost sharing from 20% to 10% significantly improved the equity in health care utilization of cancer patients. In addition, the result of catastrophic expenditures analysis showed the policy did not change the probability of catastrophic expenditures. Conclusion: The results of this study imply that payment for non-covered services account for high out-of-pocket payments, and the reduction in cost sharing for covered services alone may have a limited effect on total financial burden on patients.

Equity in health care utilization in Chile

One of the most extensive Chilean health care reforms occurred in July 2005, when the Regime of Explicit Health Guarantees (AUGE) became effective. This reform guarantees coverage for a specific set of health conditions. Thus, the purpose of this study is to provide timely evidence for policy makers to understand the current distribution and equity of health care utilization in Chile.The authors analyzed secondary data from the National Socioeconomic Survey (CASEN) for the years 1992–2009 and the 2006 Satisfaction and Out-of-Pocket Payment Survey to assess equity in health care utilization using two different approaches. First, we used a two-part model to estimate factors associated with the utilization of health care. Second, we decomposed income-related inequalities in medical care use into contributions of need and non-need factors and estimated a horizontal inequity index.Findings of this empirical study include evidence of inequities in the Chilean health care system that are beneficial to the better-off. We also identified some key factors, including education and health care payment, which affect the utilization of health care services. Results of this study could help researchers and policy makers identify targets for improving equity in health care utilization and strengthening availability of health care services accordingly.

“Can community level interventions have an impact on equity and utilization of maternal health care” – Evidence from rural Bangladesh

BackgroundEvidence from low and middle income countries (LMICs) suggests that maternal mortality is more prevalent among the poor whereas access to maternal health services is concentrated among the rich. In Bangladesh substantial inequities exist both in the use of facility-based basic obstetric care and for home births attended by skilled birth attendant. BRAC initiated an intervention on Improving Maternal, Neonatal, and Child Survival (IMNCS) in the rural areas of Bangladesh in 2008. One of the objectives of the intervention is to improve the utilization of maternal and child health care services among the poor. This study aimed to look at the impact of the intervention on utilization and also on equity of access to maternal health services.MethodsA quasi-experimental pre-post comparison study was conducted in rural areas of five districts comprising three intervention (Gaibandha, Rangpur and Mymensingh) and two comparison districts (Netrokona and Naogaon). Data on health seeking behaviour for maternal health were collected from a repeated cross sectional household survey conducted in 2008 and 2010.ResultsResults show that the intervention appears to cause an increase in the utilization of antenatal care. The concentration index (CI) shows that this has become pro-poor over time (from CI: 0.30 to CI: 0.04) in the intervention areas. In contrast the use of ANC from medically trained providers has become pro-rich (from, CI: 0.18 to CI: 0.22). There was a significant increase in the utilisation of trained attendants for home delivery in the intervention areas compared to the comparison areas and the change was found to be pro-poor. Use of postnatal care cervices was also found to be pro-poor (from CI: 0.37 to CI: 0.14). Utilization of ANC services provided by medically trained provider did not improve in the intervention area. However, where the intervention had a positive effect on utilization it also seemed to have had a positive effect on equity.ConclusionsTo sustain equity in health care utilization, the IMNCS programme needs to continue providing free home based services. In addition to this, the programme should also continue to provide funding to bear the cost to those mothers who are not able to have the comprehensive ANC from medically trained providers.

Out-of-pocket expenditures on traditional and Western medicine in Taiwan

Coexistence of traditional and modern medicine is common in Asian countries. This paper investigates out-of-pocket expenditures on traditional medicine, traditional medical service, and Western medicine by households in Taiwan. Using a national sample of 13,765 households, the three expenditure equations are estimated with a censored system procedure. Effects of socio-demographic variables are explored by calculating marginal effects on probabilities and levels of medical expenses. Different types of medical expenditures are correlated. Households with higher income and more aging members use more traditional medicine than others, as do households in agricultural sector and in urban areas. In addition, households living in rural areas relative to those in the cities are more likely to use and also spend more on traditional service. Regional disparity of health care utilization is found. Higher income households spend more on traditional medicine, likely due to the fact that patients usually pay out-of-pocket for herbal materials needed in preparation of traditional medicine. To ensure equity in health care utilization, establishment of hospitals and clinics in rural areas should be considered.

Measuring equity in disability and healthcare utilization in Afghanistan

This paper analyses equity in health and healthcare utilization in Afghanistan based on a representative national household survey. Equitable access is a cornerstone of the Afghan health policy. We measured socioeconomic-related equity in access to public health care, using disability – because people with disabilities are poorer and more likely to use health care – and a concentration index (CI) and its decomposition. The socioeconomic-related equity in healthcare utilization was measured using a probit model and compared with an OLS model providing the horizontal inequity index (HI). We found a low rate of healthcare facilities utilization (25%). Disabled persons are using more healthcare facilities and have higher medical expenses. Disability is more frequently associated with older age, unemployed heads of household and lower education. The CI of disability is 0.0221 indicating a pro-rich distribution of health. This pro-rich effect is higher in small households (CI decreases with size of the household, -0.0048) and safe (0.0059) areas. The CI of healthcare utilization is -0.0159 indicating a slightly pro-poor distribution of healthcare utilization but, overall, there is no difference in healthcare utilization by wealth status. Our study does not show major socioeconomic related inequity in disability and healthcare utilization in Afghanistan. This is due to the extreme and pervasive poverty found in Afghanistan. The absence of inequity in health access is explained by the uniform poverty of the population and the difficulty of accessing BPHS facilities (a basic package of health services), despite alarming health indicators.

Measuring change in health care equity using small-area administrative data – Evidence from the English NHS 2001–2008

This study developed a method for measuring change in socio-economic equity in health care utilisation using small-area level administrative data. Our method provides more detailed information on utilisation than survey data but only examines socio-economic differences between neighbourhoods rather than individuals. The context was the English NHS from 2001 to 2008, a period of accelerated expenditure growth and pro-competition reform. Hospital records for all adults receiving non-emergency hospital care in the English NHS from 2001 to 2008 were aggregated to 32,482 English small areas with mean population about 1500 and combined with other small-area administrative data. Regression models of utilisation were used to examine year-on-year change in the small-area association between deprivation and utilisation, allowing for population size, age–sex composition and disease prevalence including (from 2003 to 2008) cancer, chronic kidney disease, coronary heart disease, diabetes, epilepsy, hypertension, hypothyroidism, stroke, transient ischaemic attack and (from 2006 to 2008) atrial fibrillation, chronic obstructive pulmonary disease, obesity and heart failure. There was no substantial change in small-area associations between deprivation and utilisation for outpatient visits, hip replacement, senile cataract, gastroscopy or coronary revascularisation, though overall non-emergency inpatient admissions rose slightly faster in more deprived areas than elsewhere. Associations between deprivation and disease prevalence changed little during the period, indicating that observed need did not grow faster in more deprived areas than elsewhere. We conclude that there was no substantial deterioration in socio-economic equity in health care utilisation in the English NHS from 2001 to 2008, and if anything, there may have been a slight improvement.

Horizontal equity in health care utilization in Brazil, 1998–2008

IntroductionThis study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil.MethodsData are from nationally representative surveys repeated in 1998, 2003, and 2008. We apply established methods for assessing horizontal inequity in healthcare access (the principle that people with the same healthcare needs should have similar access to healthcare services). Horizontal inequity is calculated as the difference between observed healthcare utilization and utilization predicted by healthcare needs. Outcomes examined include the probability of a medical, dental, or hospital visit during the past 12 months; any health service use in the past two weeks; and having a usual source of healthcare. We use monthly family income to measure differences in socioeconomic position. Healthcare needs include age, sex, self-rated health, and chronic conditions. Non-need factors include income, education, geography, health insurance, and Family Health Strategy coverage.ResultsThe probability of having at least one doctor visit in the past 12 months became substantially more equitable over time, ending with a slightly pro-rich orientation in 2008. Any hospitalization in the past 12 months was found to be pro-poor in all periods but became slightly less so in 2008. Dental visits showed the largest absolute decrease in horizontal inequity, although they were still the most inequitably (pro-rich) distributed outcome in 2008. Service use in the past two weeks showed decreased inequity in 2003 but exhibited no significant change between 2003 and 2008. Having a usual source of care became less pro-rich over time and was nearly income-neutral by 2008. Factors associated with greater inequities include income, having a private health plan, and geographic location. Factors associated with greater equity included health needs, schooling, and enrolment in the Family Health Strategy.ConclusionsHealthcare utilization in Brazil appears to have become increasingly equitable over the past 10 years. Although this does not imply that equity in health outcomes has improved correspondingly, it does suggest that government policies aimed at increasing access, especially to primary care, have helped to make healthcare utilization in Brazil fairer over time.

A nonparametric vs. latent class model of general practitioner utilization: Evidence from Canada

Predicting health care utilization is the foundation of many health economics analyses, such as calculating risk-adjustment capitation payments or measuring equity in health care utilization. The most common econometric models of physician utilization are parametric count data models, since the most common metric of physician utilization is the number of physician visits. This paper makes two distinct contributions to the literature analyzing GP utilization: (i) it is the first to use a nonparametric kernel conditional density estimator to model GP utilization and compare the predicted utilization with that from a latent class negative binomial model; and (ii) it uses panel data to control for the potential endogeneity between self-reported health status and the number of GP visits. The goodness-of-fit results show the kernel conditional density estimator provides a better fit to the observed distribution of GP visits than the latent class negative binomial model. There are some meaningful differences in how the predicted conditional mean number of GP visits changes with a change in an individual's characteristics, called the incremental effect (IE), between the kernel conditional density estimator and the latent class negative binomial model. The most notable differences are observed in the right tail of the distribution where the IEs from the latent class negative binomial model are up to 190 times the magnitude of the IEs from the kernel conditional density estimator.

On decomposing the inequality and inequity change in health care utilization: change in means, or change in the distributions?

Health care financing arrangements not only have strong implications for income distribution, but also affect health care utilization. Therefore, a comparison of the equity in health care utilization for those health systems with different financing arrangements has important policy implications for health care policymakers. The concentration index (CI) and the horizontal inequity index (HI) are commonly used to measure inequality and inequity in health care utilization. In this paper, we propose simple methods to decompose the difference between two CIs and two HIs into two factors: one factor reflects the difference between the means, and the other factor reflects the difference between the distributions. The proposed decomposition method might be useful since the means are likely to be caused by factors that do not constitute unfair inequalities (inequities). We also present two empirical applications of the decomposition methods for the purpose of illustration.

Measurement and Explanation of Horizontal (In)Equity in Health Care Utilization Among Thais After Universal Coverage Policy Implementation

This study aimed to examine the extent to which income-related inequality and horizontal inequity in outpatient and inpatient care utilization among Thais are manifest after the country implemented the Universal Coverage (UC) policy, by using a concentration index and a horizontal inequity index, respectively. Furthermore, the study examined the determinants and their associations with the observed inequality, if any, in health care utilization through decomposition methods. The nationally representative Health and Welfare Survey 2005 was used to perform the analyses. Although there are socioeconomic gradients in health care utilization among Thais, the findings reveal that health care utilization tends to favor the poor in particular with utilization at the public facility and especially at the primary care level facility. Thailand has made impressive strides toward nearly universal health insurance coverage and improving access to and utilization of health care for its population, particularly among the poor.

A Equity in Health Care Utilization by Health Statuss

A Equity in Health Care Utilization by Health Statuss

Health equity in Lebanon: a microeconomic analysis

BackgroundThe health sector in Lebanon suffers from high levels of spending and is acknowledged to be a source of fiscal waste. Lebanon initiated a series of health sector reforms which aim at containing the fiscal waste caused by high and inefficient public health expenditures. Yet these reforms do not address the issues of health equity in use and coverage of healthcare services, which appear to be acute. This paper takes a closer look at the micro-level inequities in the use of healthcare, in access, in ability to pay, and in some health outcomes.MethodsWe use data from the 2004/2005 Multi Purpose Survey of Households in Lebanon to conduct health equity analysis, including equity in need, access and outcomes. We briefly describe the data and explain some of its limitations. We examine, in turn, and using standardization techniques, the equity in health care utilization, the impact of catastrophic health payments on household wellbeing, the effect of health payment on household impoverishment, the equity implications of existing health financing methods, and health characteristics by geographical region.ResultsWe find that the incidence of disability decreases steadily across expenditure quintiles, whereas the incidence of chronic disease shows the opposite pattern, which may be an indication of better diagnostics for higher quintiles. The presence of any health-related expenditure is regressive while the magnitude of out-of-pocket expenditures on health is progressive. Spending on health is found to be "normal" and income-elastic. Catastrophic health payments are likelier among disadvantaged groups (in terms of income, geography and gender). However, the cash amounts of catastrophic payments are progressive. Poverty is associated with lower insurance coverage for both private and public insurance. While the insured seem to spend an average of almost LL93,000 ($62) on health a year in excess of the uninsured, they devote a smaller proportion of their expenditures to health.ConclusionsThe lowest quintiles of expenditures per adult have less of an ability to pay out-of-pocket for healthcare, and yet incur healthcare expenditures more often than the wealthy. They have lower rates of insurance coverage, causing them to spend a larger proportion of their expenditures on health, and further confirming our results on the vulnerability of the bottom quintiles.

건강보험 암 중증질환 급여확대가 의료이용 형평성에 미친 영향

Government has extended the benefit coverage and reduced out-of-pocket (OOP) payment for cancer patients in 2005. This paper intends to examine the impact of the above policy on the equity in health care utilization. This paper analyzed the national health insurance data and compared the health care utilization of cancer patients before and after the policy change for people with 10 different income levels. For the equity in health care utilization, we examined the change in concentration index (CI) for visit days, inpatient days, and health expenditure. In the case of outpatient care, CI of visit days and health expenditure were positive(favoring the rich) in both regional and employee health insurance members and both 'before' and 'after' the policy change. CI values rarely changed after the policy change, and the policy change seems to have little impact on the equity of outpatient care utilization except expenditure of regional subscriber. In the case of inpatient care, CI of inpatient days was negative and CI of health expenditure was positive in both regional and work subscriber and both 'before' and 'after' the policy change. After the policy change, CI of inpatient expenditure in both groups of members decreased. CI of inpatient days changed in the direction favoring the poor in regional insurance members, but it rarely changed in employee insurance members. These results suggest that the policy of reducing OOP payment has a positive impact and reduced the inequity particularly in the utilization of inpatient care of cancer patients.

NGO facilitation of a government community-based maternal and neonatal health programme in rural India: improvements in equity

Socio-economic disparities in health have been well documented around the world. This study examines whether NGO facilitation of the government's community-based health programme improved the equity of maternal and newborn health in rural Uttar Pradesh, India. A quasi-experimental study design included one intervention district and one comparison district of rural Uttar Pradesh. A household survey conducted between January and June 2003 established baseline rates of programme coverage, maternal and newborn care practices, and health care utilization during 2001-02. An endline household survey was conducted after 30 months of programme implementation between January and March 2006 to measure the same indicators during 2004-05. The changes in the indicators from baseline to endline in the intervention and comparison districts were calculated by socio-economic quintiles, and concentration indices were constructed to measure the equity of programme indicators. The equity of programme coverage and antenatal and newborn care practices improved from baseline to endline in the intervention district while showing little change in the comparison district. Equity in health care utilization for mothers and newborns also showed some improvements in the intervention district, but notable socio-economic differentials remained, with the poor demonstrating less ability to access health services. NGO facilitation of government programmes is a feasible strategy to improve equity of maternal and neonatal health programmes. Improvements in equity were most pronounced for household practices, and inequities were still apparent in health care utilization. Furthermore, overall programme coverage remained low, limiting the ability to address equity. Programmes need to identify and address barriers to universal coverage and care utilization, particularly in the poorest segments of the population.

소득계층별 보건의료이용의 양적.질적 차이 분석 -광주.전남 지역주민을 대상으로-

The purpose of this study is to analyze the equity of health care utilization by income groups in terms of both quantity and quality of care, which is measured by expenditure, type of care, and type of health care institutions. Equity in health care utilization is measured by HIwv index, based on the survey of 1,480 Gwangju-Jeonnam residents. Health care utilization in terms of the probability and quantity of outpatient and inpatient care show equitable or pro-poor inequitable distribution, whereas the distribution of health care expenditure, which can account for the quality of care, is pro-rich inequitable, implying that the better off tend to use more expensive medical care. In terms of the types of care, simple visits for basic care show equitable distribution, whereas the distribution of the utilization of traditional tonic medicine, comprehensive health examination, CT, MRI, and ultrasound is pro-rich inequitable. Utilization of general hospitals and traditional health institutions show pro-rich inequitable distribution, hospitals and dental care institutions equitable, and physician clinics and public health centers pro-poor inequitable.

Horizontal Equity in Health Care Utilization in Canada

Even under public and universal coverage of core services with no user charges, utilization of health care services may vary among individuals with similar need depending, for example, on where the person lives, the person's income, or education status. Therefore, horizontal equity in the utilization of health care services can be influenced by health policies beyond financing, such as decisions on concentration in the hospital sector, pricing and reimbursement of non core services (drugs, home care, dental care), or physician density. We build on the well established ECuity method of income-related equity measurement to assess and interpret the changes in horizontal equity in the 10 Canadian provinces from 1990 to 2004, a period of substantial health reform in Canada. This approach uses individual-level survey data to compute a series of income-based concentration indices of need-standardized utilization of physician visits, hospital stays and dental care services. Canada provides a unique opportunity to explore the link between health policies and horizontal equity in health care utilization because provinces within Canada operate their health care system under the umbrella of the national Canada Health Act. Moreover there is a higher level of cultural and professional homogeneity than in both the US and EU, which controls for important factors of horizontal equity beyond health policies. The years 1990-2004 also provide an opportunity to study the possible impact of changes in health care policy on equity in health care utilization since they were a time of substantial changes in provincial health care systems (governance of health care, hospital sector restructuring, funding of home care services and drugs, and physicians supply). These changes differ across provinces in their qualitative nature, amplitude and year of occurrence. The project integrates a qualitative assessment of key health policy events in each province since 1990 and the quantitative measurement of equity in health care utilization over this period. First, we conduct a qualitative assessment of the co-variations in health policies in the 10 provinces on one hand and our equity measures on the other hand. We use a systematic characterization of health policy changes in Canada and take advantage of the longitudinal nature of our dataset to estimate a fixed effect model (at the province level) of the impact of changes in policy on horizontal equity. This work adds to the literature on equity measurement in the following ways: systematically links equity to health policies over time and cross-sectionally; measures equity in home care utilization, a type of services which will become more important in the future albeit still outside the set of core services in Canada; measures equity in drug expenditures using a better descriptor of drug utilization than what is available in the European Household Panel Survey; we employ a fuller and richer set of need descriptors, allowing us testing the impact of enriching the need standardization on the value of the equity measure (the more one standardizes the lower observed inequity is); in addition to income-related inequity, we assess for inequity related to degree of rurality.