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The effects of copayment in primary health care: evidence from a natural experiment



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.


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.


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.


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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    Excluding those individuals under 16 and over 65, inactive, and therefore with a zero probability of being unemployed.


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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.


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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Correspondence to Laia Maynou.

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There are no conflicts of interest for any of the authors. All authors freely disclose any actual or potential conflict of interest including any financial, personal or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

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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).

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  • ‘Euro per prescription’
  • Cohorts
  • Hurdle model
  • Mixed models

JEL Classification

  • I18
  • C50
  • C11
  • H71