Equity and utilisation of primary, specialist and dental health services in Spain

Abstract

Although public health expenditure in Spain still account for more than 70% of all health expenditures, the importance of private financing in health care has risen over the last decades. The continued growth of private health expenditures is considered to have adverse consequences for equity in the access and utilization of health care services. Regarding the increase of out-of-pocket payments for complementary to the public sector health care, the main concern is that the poor members of the society are likely to reduce (or even not use at all) their utilization of health products and services more than the better-off. This may result in violation of the principle of horizontal equity, according to which people with similar needs should be treated equally, irrespective of their income. With respect to expenditures on private health insurance premia and on other health services that are substitutes to the ones provided by the public sector, the most important consideration is that those expenditures may ensure access to health services of a different "quality".

The topics studied in this thesis follow up on the general knowledge about inequity in health and health care delivery by trying to study more in depth bow some aspects of private health care financing affect equity in the context of the mainly public Spanish Health Care System. Especially, we address the following three issues: a) the potential inequalities in the pattern of utilization of health care services due to socio-economic factors and not to differences in health; b) the determinants of the demand for private health insurance; c) the inequalities in dental health and dental care utilization.

At chapter two we try to shed light into the investigation of differential patterns of utilization of physician services by populations subgroups that is emerging in a number of studies. Using Spanish data coming from the 1997 National Health Survey, we try to explain the distinct role of the type of insurance on the choice between specialists and GPs and its intertwining with the choice between private and public providers. We estimate a two-stages probit to conclude that differences in the insurance access is the main determinant of both the choice of provider and the type of physician contacted, giving rise to very different patterns of consumption of generalists and specialists visits. People with only public insurance access goes 2.8 times to the generalist per one time that they visit a specialist; individuals with duplicate coverage have a ratio of GP/specialists visits equal to 1.4 (the combination being public GP and private specialist) and people with only private insurance access actually have an "inverted" pattern of visits: they contact specialists more often than GPs - that it is against cost control, common sense and basic epidemiological recommendations. Age, sex and health also have a distinct and interesting impact on these choices. Finally, equity concerns based on the implied assumption that specialist care is superior to generalist care are discussed.

Given that the type of insurance access appeared to be the main determinant of the choice of health care provider, we present a more comprehensive analysis of the decision to purchase voluntary health insurance in chapter three. In Spain the statutory health coverage already fulfils the basic function of health insurance, which is to smooth the financial risks associated with uncertain future health care costs. Consequently, the purchase of VHI must be motivated by other factors like inflexibilities of the public sector, private rooms in hospitals, personalised care, and different attributes of "quality". Approximately, 11% of the population buys supplemental private health insurance in Spain. The theoretical model behind the analysis is that of risk averse individuals who maximise their expected utility. We model the purchase decision based on individual and household characteristics as well as public and private health sector supply variables using data from the panel of the Spanish Family Expenditures Survey and other sources. Our results show that the decision is actually significantly influenced by a wide range of those variables. The importance of price is discussed by analysing the impact of the tax reform introduced in 1999 by which the existing tax deduction on individually bought private insurance policies was removed and employer-paid policies were instead fiscally favoured, according to our results, with success.

In chapter two we studied the utilization of health services included in the public health benefits package, but for which some people buy supplementary health coverage. In chapter four, we analyze inequalities in the utilization of health services altogether excluded from the public finance and provision, that is, dental services. We employ the concentration index approach, which although commonly used in the research of income-related inequality in health and health care, has but never been applied to analyze inequity in dental health and dental care utilization before. The data (as in the empirical analysis in chapter two) comes from the 1997 Spanish Health Survey. Our findings confirm the hypothesis of the existence of significant income-related inequity in the distribution of good dental health favouring the better­ off. Regarding the analysis of equity in the utilization of dental care, we find significant pro-rich inequity in the utilization of dental services. Finally, the results from the analysis of inequities in the utilization of specific types of dental care reveals that preventive care (like diagnostics and teeth cleanings), basic restorative care and aesthetic services are concentrated among the wealthier segments of the population, while oral surgery (tooth extractions)-the cheapest way of treating a damaged tooth besides being the only one provided by the public sector - is the only type of dental care with unequal distribution favouring the poor. The existence of inequities in dental health and dental services utilization is to be expected in a system where high treatment prices, usually paid out-of-pocket, constitute an important barrier to access care. Including dental services, or at least preventive dental care, in the package of publicly provided health services may be the right policy to adopt.