Journal of Public Health

, Volume 18, Issue 4, pp 351–365 | Cite as

Inequality in health care utilization in Germany? Theoretical and empirical evidence for specialist consultation

  • Stefan Gruber
  • Markus KieselEmail author
Original Article



In view of increasing concern about a two-class system in the German health care sector, this study investigates the relevance of health insurance schemes and other socioeconomic characteristics to the level of specialist health care provision.

Subjects and Methods

Referring to Ronald M. Andersen’s model of health care utilization and more content-based approaches, we implement a negative binomial hurdle regression to estimate the number of specialist visits within the last 12 months. Our data source is the German sample of the first wave of the Survey of Health, Ageing and Retirement in Europe (SHARE) in 2004.


The results show that men’s number of specialist visits is markedly sensitive to predisposing and enabling factors, whereas women’s health care utilization depends less on such socioeconomic characteristics. With reference to previous findings concerning general practitioner consultation, the assumption of a bipolar health care system providing general practitioner care primarily to the statutory insured and specialist care to the privately insured is supported empirically as to men. Education, which is considered to be highly correlated with health lifestyles, has a positive effect on medical health care. Every additional year of education increases by about 10% the probability of men seeking specialist consultation. Furthermore, the results indicate an unfavorable situation for the self-employed concerning health care because of their specific employment situation and health insurance coverage.


The research results suggest the existence of relevant differences in the amount of specialist consultation according to health insurance and other socioeconomic features. Further research could concentrate on the question of whether these inequalities in utilization levels indicate overprovision or underprovision of ambulant health care. Moreover, we recommend longitudinal research that is particularly suited to detangle age and cohort effects.


Specialist consultation Health care utilization Health insurance Supply-induced demand Hurdle regression 



We wish to thank Prof. Dr. Henriette Engelhardt-Wölfler for her support and suggestions. Also, our appreciation goes to Dr. Andreas Mielck for his useful comments following the Health Inequalities III conference in Bielefeld.

The SHARE data collection has been primarily funded by the European Commission through the 5th framework program (project QLK6-CT-2001-00360 in the thematic program Quality of Life). Additional funding came from the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01 and OGHA 04-064). Further support by the European Commission through the 6th framework program (projects SHARE-13, RII-CT-2006-062193 and COMPARE, CIT5-CT-2005-028857) is gratefully acknowledged.

Conflict of interest

The authors declare they have no relevant associations that might pose a conflict of interest.


  1. Abel T, Abraham A, Sommerhalder K (2006) Kulturelles Kapital, kollektive Lebensstile und die soziale Reproduktion gesundheitlicher Ungleichheit. In: Richter M, Hurrelmann K (eds) Gesundheitliche Ungleichheit. VS Verlag für Sozialwissenschaften, Wiesbaden, pp 185–198CrossRefGoogle Scholar
  2. Allin S, Masseria C, Mossialos E (2009) Measuring socioeconomic differences in use of health care services by Wealth Versus by income. Am J Public Health 0:AJPH.2008.141499v1Google Scholar
  3. Andersen HH, Schwarze J (1997) Angebotsinduzierte Nachfrage bei zunehmendem Wettbewerb, Eine empirische Analyse der Inanspruchnahme ambulanter ärztlicher Leistungen. Berliner Zentrum Public Health, BerlinGoogle Scholar
  4. Andersen RM (1995) Revisiting the behavioral model to medical care: does it matter? J Health and Soc Behav 36:1–10CrossRefGoogle Scholar
  5. Andersen RM, Newman JF (1973) Societal and individual determinants of medical care utilisation in the Unites States. Milbank Meml Fund Q Health Soc 51:95–124CrossRefGoogle Scholar
  6. Bago d'Uva T (2006) Latent class models for utilization of health care. Health Econ 15:329–343CrossRefGoogle Scholar
  7. Bergmann E, Kalcklösch A, Tiemann C (2005) Inanspruchnahme des Gesundheitswesens. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 12Google Scholar
  8. Bisig B, Gutzwiller F (2004) Gesundheitssystem Schweiz: Gibt es eine Unter- oder Überversorgung? Rüegger, Zürich/ChurGoogle Scholar
  9. Bolin K, Lindgren B, Lundborg P (2007) Informal and formal care among single-living elderly in Europe. Health Economics 17(3)Google Scholar
  10. Börsch-Supan A, Brugiavini A, Jürges H, Mackenbach J, Siegrist J, Weber G (ed) (2005) Health, Ageing and Retirement in Europe—First Results from the Survey of Health, Ageing and Retirement in Europe. Mannheim Research Insitute for the Economics of Aging (MEA)Google Scholar
  11. Börsch-Supan A, Jürges H (2005) The Survey of Health, Ageing and Retirement in Europe—Methodology. Mannheim Research Institute for the Economics of Aging (MEA)Google Scholar
  12. Bourdieu P (1982) Die feinen Unterschiede. Kritik der gesellschaftlichen Urteilskraft. Suhrkamp, Frankfurt a MGoogle Scholar
  13. Burström B (1990) Increasing inequalities in health care utilisation across income groups in Sweden during the 1990s. Health Policy 62:117–129CrossRefGoogle Scholar
  14. Breyer F, Zweifel P, Kifmann M (2005) Gesundheitsökonomie. Springer, BerlinGoogle Scholar
  15. Busse R, Riesberg A (2005) Gesundheitssysteme im Wandel: Deutschland. WHO Regionalbüro für Europa im Auftrag des Europäischen Observatoriums für Gesundheitssysteme und Gesundheits-politik, KopenhagenGoogle Scholar
  16. Cameron AC, Trivedi PK (1986) Econometric models based on count data: comparisons and applications of some estimators and tests. J Appl Econ 1:29–53CrossRefGoogle Scholar
  17. Cameron AC, Trivedi PK (1998) Regression analysis of count data. Cambridge University Press, CambridgeGoogle Scholar
  18. Cameron AC, Trivedi PK, Milne F, Piggott J (1988) A microeconometric model of the demand for health care and health insurance in Australia. Rev Econ Stud 55:85–106CrossRefGoogle Scholar
  19. Deb P, Trivedi PK (1997) Demand for medical care by the elderly: a finite mixture approach. J Appl Econ 12:313–336CrossRefGoogle Scholar
  20. Geil P, Million A, Rotte R, Zimmermann KF (1997) Economic incentitives and hospitalization in Germany. J Appl Econ 12:295–311CrossRefGoogle Scholar
  21. Gordala J (1981) Schichtspezifische Differenzen bei der Inanspruchnahme ärztlicher Leistungen. In: Bundesministerium für Arbeit und Sozialordnung (ed) Wissenschaftlicher Preis Gesundheitsökonomie 1978/79 und 1979/80, Kurzfassungen der ausgezeichneten Arbeiten. Bonn, pp 105–130Google Scholar
  22. Gruber S, Kiesel M (2009) Wer konsultiert den Allgemeinarzt in Deutschland? Eine Analyse zum Einfluss von Versicherung und anderen sozialen Merkmalen auf die Inanspruchnahme allgemeinmedizinischer Leistungen im Alter. In: Engelhardt-Wölfler H (ed) BBzS-Band 1: Altern in Europa - Empirische Analysen mit dem Survey of Health. Ageing and retirement in Europe. University of Bamberg Press, Bamberg, pp 94–143Google Scholar
  23. Hagenaars A, de Vos K, Zaidi MA (1994) Poverty statistics in the late 1980s: research based on micro-data. Office for Official Publications of the European Communities, LuxemburgGoogle Scholar
  24. Hradil S (2006) Was prägt das Krankheitsrisiko: Schicht, Lage, Lebensstil? In: Richter M, Hurrelmann K (eds) Gesundheitliche Ungleichheit. VS Verlag für Sozialwissenschaften, Wiesbaden, pp 33–52CrossRefGoogle Scholar
  25. Jones AM, Koolman X, van Doorslaer E (2004) The impact of supplementary private health insurance on the use of specialists in European countries. Ecuity - Public PapersGoogle Scholar
  26. Long JS, Freese J (2006) Regression models for categorical dependent variables using STATA. Stata Press, TexasGoogle Scholar
  27. Lungen M, Stollenwerk B, Messner P, Lauterbach KW, Gerber A (2008) Waiting times for elective treatments according to insurance status: A randomized empirical study in Germany. International J for Equity in Health 7:1CrossRefGoogle Scholar
  28. Kohli M, Hank K, Künemund H (2009) The social connectedness of older Europeans: patterns, dynamics and contexts. J Eur Soc Policy 19(4):327–340CrossRefGoogle Scholar
  29. Mannheim Research Institute for the Economics of Aging (2007) Documentation of generated variables in SHARE 1 release 2.0Google Scholar
  30. Mannheim Research Institute for the Economics of Aging (2009) SHARE: Guide to Release 2.3.0, Waves 1 & 2. Retrieved 21/01/10, from
  31. Mielck A (2005) Soziale Ungleichheit und Gesundheit. Huber, BernGoogle Scholar
  32. Mielck A, Helmert U (2007) Das Arzt-Patienten-Verhältnis in der ambulanten Versorgung: Unterschiede zwischen GKV- und PKV-Versicherten. In: Böcken J, Braun B, Amhof R (eds) Gesundheitsmonitor 2007: Gesundheitsversorgung und Gestaltungsoptionen aus der Perspektive von Bevölkerung und Ärzten. Verl. Bertelsmann Stiftung, Gütersloh, pp 114–132Google Scholar
  33. Mielck A, Kiess R, von der Knesebeck O, Stirbu I, Kunst, AE (2009) Association between forgone care and household income among the elderly in five Western European countries—analyses based on survey data from the SHARE-study. BMC Health Services Research 1–8Google Scholar
  34. OECD (2009). What are equivalence scales? Retrieved January 21, 2010, from
  35. Pohlmeier W, Ulrich V (1995) An econometric model of the two-part decision-making process in the demand of medical care. J Hum Resour 30:339–361CrossRefGoogle Scholar
  36. Riphahn RT, Wambach A, Million A (2002) Incentive effects in the demand for health care: a bivariate panel count data estimation. J Appl Econ 18:387–405CrossRefGoogle Scholar
  37. Rückert IM, Böcken J, Mielck A (2008) Are German patients burdened by the practice charge for physician visits ('Praxisgebuehr')? A cross sectional analysis of socio-economic and health related factors. BMC Health Serv Res 8(232):1–13Google Scholar
  38. Santos Silva JMC, Windmeijer F (2001) Two-part multiple spell models for health care demand. The Institute for Fiscal StudiesGoogle Scholar
  39. Schellhorn M (2003) The demand for health care—Swiss evidence. Universität BernGoogle Scholar
  40. Schneider N, Spellerberg A (1999) Lebensstile, Wohnbedürfnisse und räumliche Mobilität. Leske+Budrich, OpladenGoogle Scholar
  41. Simon M (2005) Das Gesundheitssystem in Deutschland. Huber, BernGoogle Scholar
  42. Thode N, Bergmann E, Kamtsiuris P, Kurth B-M (2005) Einflussfaktoren auf die ambulante Inanspruchnahme in Deutschland. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 3:296–306CrossRefGoogle Scholar
  43. Thorbecke R (1975) Bewältigung von Krankheitsepisoden in der Familie. In: Ritter-Rohr D (ed) Der Arzt, Sein Patient Und Die Gesellschaft. Suhrkamp, Frankfurt am MainGoogle Scholar
  44. United Nations Educational Scientific and Cultural Organization (2006) International Standard Classification of Education: ISCED 1997. UNESCO - Institute for StatisticsGoogle Scholar
  45. Van der Heyden JHA, Demarest S, Tafforeau J, van Oyen H (2003) Socio-economic differences in the utilisation of health services in Belgium. Health Policy 65:153–165CrossRefPubMedGoogle Scholar
  46. Van Doorslaer E, Koolman X, Jones AM (2004a) Explaining income-related inequalities in doctor utilisation in Europe: a decomposition approach. Health Econ 13(7):629–647CrossRefPubMedGoogle Scholar
  47. Van Doorslaer E, Koolman X, Puffer F (2002) Equity in the use of physician visits in OECD countries: has equal treatment for equal need been achieved? In: Measuring up: Improving health system performance in OECD countries. OECD, Paris, pp 225–248Google Scholar
  48. Van Doorslaer E, Masseria C, the OECD Health Equity Research Group (2004b) Income-related inequality in the use of medical care in 21 OECD countries. In: Lafortune G (ed) The OECD health project: Towards high-performing health systems. Policy Studies. OECD, Paris, pp 109–166Google Scholar
  49. Van Doorslaer E, Wagstaff A et al (2000) Equity in the delivery of health care in Europe and the US. J Health Econ 19:553–583CrossRefPubMedGoogle Scholar
  50. Verbeek M (2004) A guide to modern econometrics. John Wiley & Sons Ltd., West SussexGoogle Scholar
  51. Weber I (2005) Mehr Patienten, weniger Ärzte und geringere Finanzmittel. Deutsches Ärzteblatt 12:540–541Google Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Institut für Arbeitsmarkt-und BerufsforschungNurembergGermany
  2. 2.Bremen International Graduate School of Social Sciences, Wiener Straße/CelsiusstraßeBremenGermany

Personalised recommendations