The impact of transitions in insurance coverage on GP visiting among children in Ireland

What Interventions Work to Reduce Cost Barriers to Primary Healthcare in High-Income Countries? A Systematic Review

High-income countries like Aotearoa New Zealand are grappling with inequitable access to healthcare services. Out-of-pocket payments can lead to the reduced use of appropriate healthcare services, poorer health outcomes, and catastrophic health expenses. To advance our knowledge, this systematic review asks, "What interventions aim to reduce cost barriers for health users when accessing primary healthcare in high-income countries?" The search strategy comprised three bibliographic databases (Dimensions, Embase, and Medline Web of Science). Two authors selected studies for inclusion; discrepancies were resolved by a third reviewer. All articles published in English from 2000 to May 2022 and that reported on outcomes of interventions that aimed to reduce cost barriers for health users to access primary healthcare in high-income countries were eligible for inclusion. Two blinded authors independently assessed article quality using the Critical Appraisal Skills Program. Relevant data were extracted and analyzed in a narrative synthesis. Forty-three publications involving 18,861,890 participants and 6831 practices (or physicians) met the inclusion criteria. Interventions reported in the literature included removing out-of-pocket costs, implementing nonprofit organizations and community programs, additional workforce, and alternative payment methods. Interventions that involved eliminating or reducing out-of-pocket costs substantially increased healthcare utilization. Where reported, initiatives generally found financial savings at the system level. Health system initiatives generally, but not consistently, were associated with improved access to healthcare services.

Effects of nurse visit copayment on primary care use: Do low-income households pay the price?

Nurses are increasingly providing primary care, yet the literature on cost-sharing has paid little attention to nurse visits. We employ a staggered difference-in-differences design to examine the effects of adopting a 10-euro copayment for nurse visits on the use of public primary care among Finnish adults. We find that the copayment reduced nurse visits by 9%-10% during a one-year follow-up. There is heterogeneity by income in absolute terms, but not in relative terms. The spillover effects on general practitioner (GP) use are negative but small, with varying statistical significance. We also analyze the subsequent nationwide abolition of the copayment. However, we refrain from drawing causal conclusions from this due to the lack of credibility in the parallel trends assumption. Overall, our analysis suggests that moderate copayments can create a greater barrier to access for low-income individuals. We also provide an example of using a pre-analysis plan for retrospective observational data.

Improving access to healthcare in Ireland: an implementation failure

There are significant barriers to accessing health and social care services in Ireland including high user charges, long waits and limited availability of some services. While a number of reform proposals have committed to improving access to health care, implementation of these proposals has been limited. The aim of this paper is to identify and discuss policy implementation failures concerned with improving access to health and social care services in Ireland. Four potential reasons for the repeated failure to implement stated reform proposals are identified including a failure to identify and address the practicalities of implementation, competing health care demands, the political cycle and stakeholder resistance. While there has been a shift in Irish health care policy documents in the last 10 years with increasing emphasis on ensuring access to health care based on need rather than ability to pay, a repeated failure to implement the proposed reforms raises questions as to whether there is a real commitment to improving access to health care.

Policy of free GP care for children under 6 years: The impact on emergency department attendance

Universal health coverage (UHC) aims to improve child health. Ireland, the only country in the European Union without universal access to primary care, introduced general practitioner (GP) care at no charge for children aged under six in 2015. This paper aims to evaluate the impact of this policy on attendance at the emergency department (ED). A difference-in-difference (DiD) analysis was applied to visit records of 367,000 paediatric patients at five hospitals over a period of five years, with treatment and control differentiated by age. DiD was also used to assess if GP referrals and the severity of presentations altered as a consequence of this policy. While existing research estimates that this policy increased attendance by children aged under six at general practice by over 25%, this policy did not lead to a reduction in ED attendance. Hospital level effects on attendance varied from no impact to increased attendance by children aged under six of 28.9%. While increased GP referrals, particularly for injury and medical reasons, indicated more patients presented to their GP prior to ED attendance, walk-ins without referral did not decrease. Attendance increased at both regional hospitals, which also had the highest proportion of GP referred visits. While the marginal probability of a visit being GP referred increased at four of the five hospitals in this study, only in two of these can the entire effect be attributed to the introduction of this policy (effects 1.4 and 1.8 percentage points). Previous unmet need, capacity constraints in general practice, regional variability in the GP to population ratio, restricted hours of access to GPs, coupled with faster access to diagnostics in the ED setting, may explain variability in the effect and why the expected reduction in ED attendances did not occur.

Children's unscheduled primary and emergency care in Ireland: a multimethod approach to understanding decision making, trends, outcomes and parental perspectives (CUPID): project protocol

INTRODUCTION

The aim of this project is to determine the patterns, decision-making processes and parental preferences associated with unscheduled paediatric healthcare utilisation in Ireland. Unscheduled paediatric healthcare is outpatient care provided within primary care settings by general practitioners (GPs), emergency departments (EDs) located in paediatric and general hospitals, and out-of-hours services provided by cooperatives of GPs operating on a regional basis. This project will take a multimethod approach to analysing the utilisation of unscheduled paediatric healthcare nationally within the context of a significant change to the provision of healthcare for young children in Ireland-the introduction of free at the point of delivery GP care for all children aged under 6.

METHODS AND ANALYSIS

A multimethod approach consisting of three work packages will be employed. Using patient-level data, work package 1 will describe patterns of attendance at primary care, out-of-hours medical services and at EDs. Applying a difference-in-difference methodology, the impact of the introduction of free GP care for children under 6 on attendance will be assessed. Work package 2 will explore geospatial trends of attendance at EDs, identifying disparities in ED attendance by local area and demographic characteristics. Work package 3 will employ two discrete choice experiments to examine parental preferences for unscheduled paediatric healthcare and GP decision making when referring a child to the ED. The insights gained by each of the work packages individually and collectively will inform evidence-based health policy for the organisation of paediatric care and resource allocation.

ETHICS AND DISSEMINATION

Ethical approval for this research has been granted by University College Dublin, The Irish College of General Practitioners and the five participating hospitals. Results will be disseminated via publication in peer-reviewed journals, national and international conferences, and to relevant stakeholders and interest groups.

Healthcare consumption after a change in health insurance coverage: a French quasi-natural experiment

BACKGROUND

Compared with the number of studies performed in the United States, few studies have been conducted on the link between health insurance and healthcare consumption in Europe, likely because most European countries have compulsory national health insurance (NHI) or a national health service (NHS). Recently, a major French private insurer, offering voluntary complementary coverage in addition to the compulsory NHI, replaced its single standard package with a range of offers from basic coverage (BC) to extended coverage (EC), providing a quasi-natural experiment to test theoretical assumptions about consumption patterns.

METHODS

Reimbursement claim data from 85,541 insurees were analysed from 2009 to 2018. Insurees who opted for EC were matched to those still covered by BC with similar characteristics. Difference-in-differences (DiD) models were used to compare both the monetary value and physical quantities of healthcare consumption before and after the change in coverage.

RESULTS

As expected, the DiD models revealed a strongly significant, though transitory (mainly during the first year), increase after the change in coverage for EC insurees, particularly for costly care such as dental prostheses and spectacles. Surprisingly, consumption seemed to precede the change in coverage, suggesting that one possible determinant of opting for more coverage may be previous unplanned expenses.

CONCLUSION

Both catching-up behaviour and moral hazard are likely to play a role in the observed increase in healthcare consumption.

An investigation of the effect of accessibility to General Practitioner services on healthcare utilisation among older people

Equity in access to healthcare services is regarded as an important policy goal in the organisation of modern healthcare systems. Physical accessibility to healthcare services is recognised as a key component of access. Older people are more frequent and intensive users of healthcare, but reduced mobility and poorer access to transport may negatively influence patterns of utilisation. We investigate the extent to which supply-side factors in primary healthcare are associated with utilisation of General Practitioner (GP) services for over 50s in Ireland. We explore the effect of network distance on GP visits, and two novel access variables: an estimate of the number of addresses the nearest GP serves, and the number of providers within walking distance of a person's home. The results indicate that geographic accessibility to GP services does not in general explain differences in the utilisation of GP services in Ireland. However, we find that the effect of the number of GPs is significant for those who can exercise choice in selecting a GP, i.e., those without public health insurance. For these individuals, the number of GPs within walking distance exerts a positive and significant effect on the utilisation of GP services.