Regulating Access to Health Care Providers and
Inequalities of Utilization in European Countries
Claus Wendt
Harkness/Bosch Fellow of Health Policy and Practice
Harvard School of Public Health
J.F. Kennedy Fellow
Center for European Studies, Harvard University
wendt@fas.harvard.edu
claus.wendt@mzes.uni-mannheim.de
Mannheimer Zentrum für Europäische Sozialforschung
1
From Access to Access Regulation
Access
quasi
100%

no
variance
Coverage of
the System
X
Provider Density
(OECD 1987,
Moran 2000)
Regulation
2
Dimensions of Access Regulation
Access Regulation
Gatekeeping
Inequality
Cost Sharing
Utilization
Provider Density
Costs
3
Sources of Data
 Macro-Indicators: self-coded out of WHO-country studies,
comparative studies
 Micro-Data
 Share-Survey: 1. wave 2004
 Population: people over 50
 11 countries: Belgium, Denmark, Germany, France, Greece, Italy,
Netherlands, Austria, Sweden, Switzerland, Spain.
 Number of doctor visits
 Multilevel- and country-specific logit-models
4
SHARE 2004
Country
N
Austria
1,825
Belgium
3,639
Denmark
1,583
France
2,905
Germany
2,894
Greece
2,625
Italy
2,463
Netherlands
2,772
Spain
2,274
Sweden
2,920
Switzerland
908
Total
26,808
5
Gatekeeping - Index
Country
GP
Registration
Geographic
Restriction
GPs paid by
capitation
Access to
specialist
Access to
outpatient
care in
hospital
France
--
--
--
free
free
0
0
Greece
--
--
--
free
free
0
0
Switzerland
--
--
--
free
free
0
0
Belgium
--
--
--
skip & pay
skip & pay
2
2.9
Germany
--
--
--
free
referral
2
2.9
Austria
--
--
+
skip & pay
skip & pay
3
4.3
Sweden
+
--
--
skip & pay
skip & pay
3
4.3
Netherlands
+
--
+
referral
referral
6
8.6
Spain
+
+
--
referral
referral
6
8.6
Denmark
+
+
+
referral
referral
7
10
Italy
+
+
+
referral
referral
7
10
Legal
Regulation
Index
LRI
rescaled
(0-10)
6
Overview of Regulation Indices
13.6
14
12
10.8
10
10.0
10.1
10.0
8.9
8.5
8
9.2
8.6
10.0
8.6
7.5
5.8
6
4
10.0
4.6
4.3 4.2
4.2
4.2
2.9
2
0.8
0.0
0
Austria
Belgium
Denmark
France
Access Regulation Index (ARI)
4.3
3.5
3.6
2.9
0.6
Germany
1.1
1.1
0.4
0.0
Greece
Italy
Legal Regulation Index (LRI)
Netherlands
0.6
Spain
0.0
Sweden
Switzerland
Financial Incentive Index (FII)
7
Effects on Utilization Level
RI
Country-Level
Variance
Explained
Variance
N
(1)
Any-DoctorModel
(2)
Any-GPModel
(3)
AnySpecialist
Model
(4)
AverageDoctor
Model
(5)
AverageGP
Model
(6)
AverageSpecialist
Model
0.873***
0.901**
0.921+
0.953
0.959
0.946+
(0.03)
(0.03)
(0.04)
(0.05)
(0.05)
(0.03)
0.102
(0.05)
59%
0.097
(0.04)
47%
0.156
(0.07)
26%
0.327
(0.14)
8%
0.385
(0.17)
5%
0.134
(0.06)
22%
24183
24183
24183
26808
26808
26808
8
Equity Effects: Utilization Differences across
Income Groups (Specialists)
9
Equity Effects: Utilization Differences across
Educational Groups (Specialists)
10
Equity Effects: Utilization Differences across
Groups with different health status
11
Conclusions: Level Effects
Based on multilevel analyses with the SHARE dataset including 11
countries we found that:




The overall degree of access regulation has a decreasing effect on the
overall level of service utilization
The effect was focused mainly on the probability of having any visit than
on the number of visits
This fits in the idea of patient- and provider-initiated visits which assumes
that the first visit in an illness spell is initiated by the patient, all further
visits, however, might be strongly influenced by doctors
Since cost sharing and gatekeeping are mainly patient-focused access
regulations our finding are in line with this conceptualization
12
Conclusions: Equity Effects
We investigated inequity in specialist care both across groups with different
income and educational level and health status:




Income inequity is not related to the degree of cost sharing as would be
hypothesized
Educational inequity is associated with the degree of access regulation
A higher degree of regulation decreases the probability of a doctor visit for
people with low need levels
This could be a sign for increased efficiency of these access regulations
since the take up rate of medical services by people in good health is
lower
13
What are the Policy Implications?




The results indicate that access regulations can contribute to a reduction
of health services used
However, the regulations mostly affect whether people have a first doctor
visit
This shows that an effective control of consumption levels has also to
influence provider behavior
Putting the locus of responsibility in the GP also seems to have beneficial
results in terms of increased equity across groups with different
educational level
14
Regulating Access to Health Care Providers and
Inequalities of Utilization in European Countries
Claus Wendt
Harkness/Bosch Fellow of Health Policy and Practice
Harvard School of Public Health
J.F. Kennedy Fellow
Center for European Studies, Harvard University
wendt@fas.harvard.edu
claus.wendt@mzes.uni-mannheim.de
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