J Health Serv Res Policy 2008;13:222-226
doi:10.1258/jhsrp.2008.008048
© 2008 Royal Society of Medicine Press
The impact of income on private patients' access to GP services in Ireland
Anne Nolan
Economic and Social Research Institute, Dublin, Ireland
Correspondence to: anne.nolan{at}esri.ie
Objectives: To examine the extent to which proximity to the income threshold for free GP care results in significant differences in GP visiting. Approximately 30% of the Irish population receives free GP care (medical card patients), while the remaining 70% pays in full (private patients). Medical card eligibility exerts a significant influence on GP visiting, but how do GP visiting rates differ among private patients on differing incomes, and has the differential in visiting among private patients changed over time?
Methods: Using micro-data from three nationally representative surveys of the Irish population undertaken in 1987, 1995 and 2001, multivariate models of GP utilization are estimated.
Results: There is little evidence that proximity to the income threshold results in significant differences in GP visiting. The most significant difference is between medical card and private patients, rather than between private patients on differing incomes. There is also little evidence that the differential in GP visiting between private patients on different incomes changed over time.
Conclusions: While recent commentary has focused on the plight of individuals just above the income threshold for free GP care, these results suggest that the key difference in GP visiting is between those with, and without, eligibility for free care. If private patients are prevented from accessing GP care due to cost, this is as much an issue for those at the top of the income distribution as for those at the bottom.
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Introduction
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In Ireland, approximately 30% of the population (‘medical
card patients’) are entitled to all public health services
free of charge, including GP services and prescription medicines.
The remaining 70% (‘private patients’) must pay
out of pocket for the full cost of GP consultations. Eligibility
for a medical card is determined by an income test. Since July
2001, all individuals over 70 years old are also entitled to
a medical card. An extensive literature has analysed the differences
in GP visiting behaviour between medical card and private patients,
and has confirmed that the financial incentives inherent in
medical card eligibility strongly influence higher GP visiting
among medical card patients.
1–7
While most of the empirical work has concentrated on comparing the behaviour of medical card and private patients, there has been little analysis of the role of income in determining differences in GP visiting among private patients. An important policy question is whether the significant gap in GP visiting between medical card and private patients is more pronounced for those just above the income threshold for a medical card. The current weekly income threshold of 
184 is 25 less than the 209 level at which individuals are ‘at risk of poverty’,8 and an average GP fee of 42 amounts to 20% of weekly income at this poverty threshold. There are, therefore, very real concerns that individuals on low, but not the lowest, incomes face particular hardship in accessing GP services. Indeed, a recent study found that private patients with low or middle incomes in Ireland were four times more likely to forego a GP consultation due to cost than private patients on higher incomes.9
The income thresholds for a medical card increase annually in line with general inflation. As a result of rapid economic and employment growth, a lower proportion of the population is now eligible for medical cards (38% in 1987, 31% in 2001, 29% in 2006). Current government policy reflects widespread concern with the situation of those just above the income threshold for a medical card, favouring increasing the income thresholds, rather than any extension of medical card eligibility to the entire population. Indeed, in October 2005, the government announced a 20% increase in income thresholds, as well as the introduction of a new ‘GP only’ medical card (with income thresholds 50% higher than for the medical card). While it may be expected that a falling proportion of the population with a medical card might result in individuals just above the income threshold becoming more disadvantaged over time, the average income of those in the lowest income quintile has risen at a higher rate than that of those in the higher income quintiles. This has meant that the proportion of average weekly household income accounted for by a GP consultation has risen at a slower pace for those in the lowest income quintile, although in absolute terms, the proportion remains high (Table 1).
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Table 1 GP fees as a proportion of average weekly household income, 1987, 1995 and 2001 (private patients sample)
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The purpose of this paper is to test whether proximity to the
income threshold for a medical card results in a significant
difference in GP visiting among private patients. If the cost
of a GP consultation is indeed a substantial burden for private
patients just above the income threshold, we would expect to
see GP visiting increase as we move up the income distribution,
controlling for all other influences on visiting such as age
and health status. In addition, given the decline in medical
card coverage over the last 20 years, it is worth knowing whether
this has resulted in a change in the differential in GP visiting
between those just above the income threshold for a medical
card and those on higher incomes. The policy implications of
significantly lower levels of GP visiting concentrated among
those just above the income threshold are clearly different
to those suggested by significantly lower levels of GP visiting
across the entire income distribution.
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Methods
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The data employed in this paper come from two separate sources:
the 1987 Survey of Income Distribution, Poverty and Usage of
State Services, and the 1995 and 2001 Living in Ireland Surveys
(the Irish component of the European Community Household Panel
Survey). Excluding individuals with missing values on variables
of interest and observations with GP visits in excess of 104
per annum, complete information is available for 6721 individuals
in 1987, 7129 in 1995 and 5370 in 2001. While medical card eligibility
was extended to all individuals over 70 years old regardless
of income in 2001, this did not take effect until after the
surveys used here. Both surveys contain detailed demographic
and socioeconomic information, as well as information on health
services utilization over the previous year and various indicators
of physical and psychological health status, for each adult
respondent in the household.
In modelling GP visits, a two-step approach was used, consisting of a contact decision (where the patient initiates the visit to the GP) and a frequency decision (where the GP, in consultation with the patient, decides on the number of subsequent visits). It is commonly employed in modelling health services utilization.10,11 The two parts are estimated separately; the first using a binary probit model and the second using a truncated negative binomial model.1 Our dependent variables for the contact decision are a dummy variable indicating whether or not the individual visited their GP in the previous year, and for the frequency decision the number of GP visits in the previous year for those with positive visits. While using information on unmet need or foregone visits may provide a more accurate indication of the deterrent effect of charging for health services,9,12 no such information is available in the data available here.
The independent variables are the same for both decisions: variables intended to reflect ‘need’ for health care such as age, gender and health status; and ‘non-need’ variables that might be expected to influence visiting such as household location, education level, employment status, marital status, medical card status and private insurance status (further details on variable definition are given elsewhere3). The data do not contain variables related to the supply side of the decision, such as GP or practice characteristics, which could be important in determining the frequency decision. To identify proximity to the income threshold for a medical card, a categorical variable, with six categories representing medical card patients, and five categories representing private patients' income quintile, was constructed. For the analysis using the full sample, medical card patients are regarded as the reference category, while for the analysis of private patients, those in the lowest income quintile are regarded as the reference category.
For each of the years 1987, 1995 and 2001, a two-step model of GP visiting was estimated, firstly for the full sample, and then for the sample of private patients. The first analysis will indicate how charges influence GP visiting, while the second will indicate whether private patients on different incomes have significantly different patterns of GP utilization. In order to establish whether the gap, if any, between private patients at the top and bottom of the income distribution has changed over time, a pooled two-step model of GP visiting, using data from 1987 and 2001, was also estimated. Interaction terms were included identifying individuals in the higher income quintiles in 2001 to examine whether the effect of income had changed over the period 1987–2001.
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Results
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Table
2 presents aggregate patterns of GP visiting for
each of the three years, 1987, 1995 and 2001. The proportion
of the population with at least one GP visit per annum increased
from 62% in 1987 to 75% in 2001. However, the number of GP visits
per annum for those visiting at least once fell from 6.8 to
4.5. The reasons for this change are unclear, and while there
was a change in the manner in which GPs were reimbursed for
medical card patients in 1989 (from fee-for-service to capitation),
this would not explain the larger proportionate changes in private
patients' behaviour.
1
Medical card patients visit their GP in greater proportions,
and have a higher average number of visits than private patients.
The patterns over time are similar for medical card and private
patients, although the fall in the number of GP visits was more
marked for private patients. As expected, among private patients,
the proportion with at least one GP visit per annum increases
with increasing income, but the average number of GP visits
for those with at least one GP visit per annum falls with increasing
income. This justifies analysing the two decisions separately,
and also the use of multivariate techniques to ascertain whether
these patterns persist when other differences in characteristics
between patients on different incomes are taken into account.
Tables 3 and 4 present the marginal effects from the two-step models for 1987, 1995 and 2001. The analysis is based on the full sample of medical card and private patients, with medical card patients regarded as the reference category, and private patients differentiated by income quintile. While not presented here, the results for other independent variables such as age, health status, education level, et cetera are consistent with previous research in the area.1–7 The results for the contact decision (Table 3) suggest that in comparison with medical card patients, private patients have a significantly lower probability of visiting their GP at least once a year, with private patients in the lowest income quintiles having the lowest probability. These effects are consistent across the three years examined, with some evidence to suggest that the differential between medical card patients and private patients on high incomes has lessened over time. Similarly for the frequency decision (Table 4), GP visiting among private patients is significantly lower than for medical card patients, although the effects are larger and more significant at the top of the income distribution. The results are largely consistent across the three years.
These results confirm the significant difference in GP visiting
between medical card and private patients and are consistent
with previous Irish research as well as international evidence
on the impact of charges on the utilization of health services.
13 However, the results in Tables
3 and
4 cannot tell us how
GP visiting varies between private patients on differing incomes,
and if such a difference is statistically significant. To do
this, the same models are estimated, excluding medical card
patients, with private patients in the lowest income quintile
now the reference category. Tables
5 and
6 present the
results for the one- and two-step models for 1987, 1995 and
2001. In contrast to the results including medical card patients,
the results here are less significant and suggest that there
is little difference in the behaviour of private patients on
different incomes. For the contact decision (Table
5),
only the results for 1995 are consistently significant. Turning
to the frequency decision (Table
6), the results are largely
non-significant, with the exception of the effect for the third
income quintile in 2001, which is negative and significant.
The results presented in Tables
5 and
6 do not suggest
that there has been much change in either the probability or
level of GP visiting among private patients on different incomes
over the period 1987–2001. While not presented here, a
pooled model using data from 1987 and 2001 with interactions
between income quintile and year finds no significant effect
for the interactions, confirming that there was no significant
change in the effect of being in one quintile over another over
the period. This is not surprising given the aggregate patterns
presented in Table
2, as well as the fact that the average
GP fee as a proportion of average income increased at a slower
pace for those in the lowest income quintile over the period
1987–2001 (Table
1).
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Discussion
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The results provide little evidence that private patients on
low incomes visit their GP significantly less than their counterparts
on higher incomes. In comparison with medical card patients,
private patients on low incomes are significantly less likely
to visit their GP, and to have significantly lower levels of
GP visiting. However, these effects persist right up the income
distribution for private patients, albeit with some evidence
that the effect on the probability of having at least one GP
visit per annum is more pronounced for those in the lower income
quintiles.
Focusing solely on private patients, the analysis shows that there is little significant difference in GP visiting between private patients on different incomes. The major differential in GP visiting is between medical card and private patients, and among private patients where the usual ‘need’ factors such as age and health status are much more important in determining differences in GP visiting. Contrary to recent commentary, there has been no deterioration over time in the situation of private patients just above the income threshold for a medical card, at least in terms of access defined in terms of levels of GP visiting.
What do these results imply for public policy with regard to the medical card system in Ireland? Reforming the primary care sector, with the aim of reducing reliance on relatively costly secondary care services, is a key objective of government health policy. In terms of medical card eligibility, current government policy favours increasing the income thresholds, and the substantial increase in income thresholds as well as the introduction of the ‘GP only’ medical card in October 2005 (with income thresholds 50% higher than for the standard medical card), is consistent with this policy focus. However, examination of the behaviour of private patients suggests that the deterrent effect of charging for GP services persists even at higher incomes. Of course, the extent to which those on higher incomes are able to bypass the GP and access private outpatient care may influence this pattern, but the potential for this type of behaviour is limited as GPs act as gatekeepers for secondary care in Ireland.
On the basis of these results, the argument that there is some form of U-shaped relationship between income and GP visiting (with those on the very lowest and very highest incomes having higher levels of GP visiting compared with those in the middle of the distribution) is discounted. The results provide no guidance on the most ‘appropriate’ level of visiting for medical card or private patients, but it is certainly possible that private patients, and not just those on low incomes, are foregoing ‘necessary’ GP consultations due to cost, with unknown consequences for individuals' health and their subsequent need for more costly secondary care services. This is in agreement with a recent study which found that private patients in Ireland were significantly more likely to forego a GP consultation due to cost than medical card patients.9
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Footnotes
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Anne Nolan PhD, Research Officer, Economic and Social Research Institute, Whitaker Square, Sir John Rogerson's Quay, Dublin 2, Ireland.
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References
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- Tussing A. Physician-induced demand for medical care: Irish general practitioners. Econ Soc Rev (Irel) 1983;14:225–47
- Tussing A. Irish Medical Care Resources: An Economic Analysis. Dublin: Economic and Social Research Institute, 1985
- Combat Poverty Agency. Pre-Budget Submission 2008: Mainstreaming Poverty and Social Exclusion. Dublin: Combat Poverty Agency, 2007
- O'Reilly D, O'Dowd T, Thompson K et al. Consultation charges in Ireland deter a large proportion of patients from seeing the GP: results of a cross-sectional survey. Eur J Gen Pract 2008;13:231–6
- Pohlmeier W, Ulrich V. An econometric model of the two-part decision process in the demand for health. J Hum Resour 1995;30:339–61
- Hurd M, McGarry K. Medical insurance and the use of health care services by the elderly. J Health Econ 1997;16:129–54[Medline]
- Schoen C, Davies K, DesRoches C et al. Health insurance markets and income inequality: findings from an international health policy survey. Health Policy 2000;51:67–85[Medline]
- Keeler E. Effects of Cost Sharing on Use of Medical Services and Health. Santa Monica, CA: RAND Corporation, 1992
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Introduction
Methods
