Abstract
Objective
Evaluate the effects of the ‘euro per prescription’ on primary health care services (number of doctor visits), through a retrospective cohort study of health care users in Catalonia (Spain). This policy, implemented in Catalonia on 23 June 2012, only lasted 6 months. This policy was introduced to improve budgetary imbalances in Spain and boost the regional and national governments’ budgets.
Methods
We used a retrospective cohort, composed of individuals who had had contact with primary healthcare services between January 1, 2005 and December 31, 2012. The econometric specification followed is a hurdle model.
Results
Our results show that from October 2012 onwards there was a decrease in the average number of overall visits, particularly for individuals aged 65 years or more. However, this decline cannot be entirely attributed to the introduction of the euro per prescription policy as in October of that same year the Spanish government introduced its pharmaceutical copayment for pensioners.
Conclusions
The policies appraised in this paper reveal a clear deterrent effect among vulnerable individuals such as those with the highest probability of being unemployed and/or those individuals with chronic conditions.
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Notes
Excluding those individuals under 16 and over 65, inactive, and therefore with a zero probability of being unemployed.
References
Aznar-Lou, I., Pottegård, A., Fernández, A., Peñarrubia-María, M.T., Serrano-Blanco, A., Sabés-Figuera, R., Gil-Girbau, M., Fajó-Pascual, M., Moreno-Peral, P., Rubio-Valera, M.: Effect of copayment policies on initial medication non-adherence according to income: a population-based study. BMJ Qual. Saf. 27, 878–891 (2018)
Beck, R.G., Horne, J.M.: Utilization of publicly insured health services in Saskatchewan before, during and after copayment. Med. Care 18, 787–806 (1980)
Craig, P., Cooper, C., Gunnell, D., Haw, S., Lawson, K., Macintyre, M., Ogilvie, D., Petticrew, M., Reeves, B., Sutton, M., Thompson, S: Using natural experiments to evaluate population health interventions: Guidance for producers and users of evidence. MRC, Medical Research Council (2011). http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC008043. Accessed 28 Dec 2013
Deb, P., Trivedi, P.K.: The structure of demand for health care: latent class versus two-part models. J. Health Econ. 21, 601–625 (2002)
Elofsson, S., Unden, A.L., Krakau, I.: Patient charges—a hindrance to financially and psychosocially disadvantaged groups seeking care. Soc. Sci. Med. 46, 1375–1380 (1998)
García-Gómez, P., Mora, T., Puig-Junoy, J.: Does €1 per prescription make a difference? Impact of a capped low-intensity pharmaceutical co-payment. Appl. Health Econ. Health Policy 16(3), 407–414 (2018)
Hernández-Izquierdo, C., González López-Valcárcel, B., Morris, S., Melnychuk, M., Abásolo-Alessón, I.: The effect of a change in co-payment on prescription drug demand in a National Health System: the case of 15 drug families by price elasticity of demand. PLoS One 14, 3 (2019). https://doi.org/10.1371/journal.pone.0213403
IDESCAT. http://www.idescat.cat/. Accessed 28 Dec 2013
Jiménez-Martín, S., Labeaga, J.M., Martinez-Granado, M.: Latent class versus two-part models in the demand for physician services across the European Union. Health Econ. 11(4), 301–321 (2002)
Jones, A.M., Rice, N.: Econometric evaluation of Health Policies. HEDG Working Paper 09/09, University of York (2009). http://www.york.ac.uk/media/economics/documents/herc/wp/09_09.pdf. Accessed 28 Dec 2013
Kiil, A., Houlberg, K.: How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011. Eur. J. Health Econ. 15, 813–828 (2014)
Law 5/2012 of March 20, on Tax, Financial and Administrative Measures and Implementation of the Tax on Stays in Tourist Accommodations [in Catalan] DOGC 6094, March 23, 2012
Morris, S., Sutton, M., Gravelle, H.: Inequity and inequality in the use of health care in England: an empirical investigation. Soc. Sci. Med. 60(6), 1251–1266 (2005)
Pinheiro, J.C., Bates, D.: Mixed-Effects Models in S and S-Plus. Springer, New York (2000)
Pohlmeier, W., Ulrich, V.: An econometric model of the two-part decision-making process in the demand for health care. J. Hum. Resour. 30, 339–361 (1995)
Puig-Junoy, J., García-Gómez, P., Mora, T.: Impacte de l’euro per recepta sobre els medicaments dispensats a les oficines de farmàcia de Catalunya segons grups de medicaments. Monogràfics de la Central de Resultats, núm. 27. Barcelona: Agència de Qualitat i Avaluació Sanitàries de Catalu-nya. Departament de Salut. Generalitat de Catalunya (2017)
Puig-Junoy, J., García-Gómez, P., Casado-Marín, D.: Free medicines thanks to retirement: impact of coinsurance exemption on pharmaceutical expenditures and hospitalization offsets in a national health service. Health Econ. 25(6), 750–767 (2016)
R Core Team. R: A Language and Environment for Statistical Computing. R Vienna, Austria: Foundation for Statistical Computing (2013). http://www.R-project.org/. Accessed 29 Dec 2013
R-INLA Project: Random Walk Model of Order 1 (RW1). http://www.math.ntnu.no/inla/r-inla.org/doc/latent/rw1.pdf. Accessed 29 Dec 2013
Roemer, M.I., Hopkins, C.E., Carr, L., Gartside, F.: Copayments for ambulatory care: Penny-Wise and Pound-Foolish. Med. Care 13, 457–466 (1975)
Royal Decree-Law 16/2012, of 20 April, on Urgent Measures to Ensure the Sustainability of the National Health System and Improve the Quality and Safety of Its Benefits [in Spanish] BOE 98, April 25, 2012
Rue, H., Martino, S., Chopin, N.: Approximate Bayesian Inference for Latent Gaussian Models by Using Integrated Nested Laplace Approximations (with Discussion). J. R. Stat. Soc. Ser. B 71:319–392 (2009). http://www.math.ntnu.no/~hrue/r-inla.org/papers/inla-rss.pdf. Accessed 29 Dec 2013
Saez, M.: Factors conditioning primary care services utilization. Empirical evidence and methodological inconsistencies” [in Spanish]. Gaceta Sanit. 17(5), 412–449 (2003)
Saez, M., Barceló, M.A., Coll de Tuero, G.: A selection-bias free method to estimate the prevalence of hypertension from an administrative primary health care database in the Girona Health Region, Spain. Comput. Methods Programs Biomed. 93(3), 228–240 (2009)
Saez, M., Saurina, C., Coenders, G., González-Raya, S.: Use of primary health care services according to the different degrees of obesity in the Girona Health Region, Spain. Health Econ. 15(2), 173–193 (2006)
Schreyoegg, G., Grabka, MM: Copayments for Ambulatory Care in Germany: A Natural Experiment Using a Difference-in-Difference Approach. Discussion Papers of DIW Berlin, German Institute for Economic Research (2008). http://mpra.ub.uni-muenchen.de/23035/1/MPRA_paper_23035.pdf. Accessed 29 Dec 2013
Scitovsky, A.A., McCall, N.: Coinsurance and the demand for physician services: four years later. Soc. Secur. Bull. 35, 4019–4027 (1977)
Winkelmann, R.: Co-payments for prescription drugs and the demand for doctor visits—evidence from a natural experiment. Health Econ. 13, 1081–1089 (2004)
Acknowledgements
This paper was developed within the project ‘COSDA’, AGAUR, Generalitat de Catalunya, 2014SGR551. The authors would like to thank Josep Maria Roca (Computing Service, IAS) for providing the IAS data; and Anna Mompart, of the ‘Servei del Pla de Salut’, ‘Subdirecció General de Planificació Sanitària’, ‘Direcció General de Planificació i Avaluació’, ‘Departament de Salut’, ‘Generalitat de Catalunya’, for having facilitated the information of the Catalan Health Survey, ESCA 2006 and 2011. We appreciate the comments of the attendees at the XXXIII Conference on Health Economics (AES) 2013, June 18–21, 2013, in Santander, Spain and at the III Research Workshop on Policy Evaluation and Health Services, the EvaluAES Group, where a very preliminary version of this work was presented. We thank the comments of Ricard Meneu that undoubtedly helped us to improve our work. Finally, we would like to thank the comments of two anonymous reviewers of a previous version of this paper who, without doubt, helped us to improve our work.
Funding
This work was partly supported by the CIBER of Epidemiology and Public Health (CIBERESP) through the strategic subprogram ‘Crisis and Health’ and by the University of Girona through the programs MPCUdG2016/69, TRANSFER2016/24 and GDRCompetUdG2017.
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Maynou, L., Coll-de-Tuero, G. & Saez, M. The effects of copayment in primary health care: evidence from a natural experiment. Eur J Health Econ 20, 1237–1248 (2019). https://doi.org/10.1007/s10198-019-01089-4
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DOI: https://doi.org/10.1007/s10198-019-01089-4