The Roles of Health Insurance and Its Interactions with Provider’s Characteristics in Addressing Inequity of Access to Outpatient Care

Pungkas Bahjuri Ali(pungkas.ali@bappenas.go.id)

2nd Indonesia Health Economics Association Conference – Jakarta 9 April 2014

Head of Public Health DisivionNational Development Planning Agency (Bappenas) - Jakarta

A. Motivation, data & methodsB. Inequity of access to outpatient careC. Roles of health insuranceD. Roles of provider’s attributeE. Conclusion

Inequity to Access of High Quality Healthcare

2

A. Motivation, Data & Methods

C. Determinants of demand for healthcare

3

Responses to sickness: Indonesian ways

56%44%

A. Motivation and Data dan Methods

1. Is there inequity of access to outpatient care?

2. Does health insurance reduce this inequity?

3. How do health provider attributes influence the decision?

4

Response to sicknessAbout 33.7 % of population experiences sickness (Susenas, 2007)

Who are they?

Seeking medical

care44%

Not seeking a medical

care56%

What is role of health providers ?

Health Centre

Physician

Nurse/Midwife

Hospital

Traditional

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Main data sources

1. IFLS (Indonesia Family Life Survey): depth, providers characteristics2007 wave, covers 83% population, 13 provinces , 44,103 individuals

2. Susenas (National Social Economic Survey): coverage & trend2007 survey, national coverage, approx 250,000 households

Scope and terms

Outpatient services

Sick: experiencing any of sickness symptoms in the past 4 weeksIFLS : headache, runny nose, cough, breathing difficulty, fever, stomach ache, nausea, swollen

legs, skin infections, eye infections, toothache, cold soresSusenas : cough, fever, flu/cold, asthma/breathing difficulty, diarrhoeas, headache, toothache, others

A. Motivation and Data dan Methods

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Methods of determinant analysisAnalysis Statistical

ModelsVariables Data source

A. Decision to visit

Logistic regression

DV: Whether visited health provider if sick (Yes or No)

IV: Demographic, social structure, personal/family, community, health needs

2007 SusenasChildren: 110.954Adult:212.225Elderly: 9.175

B. Choice of Provider

Multinomial Logistic Regression

DV: Type of health provider visited

IV: Demographic, social structure, personal/family, community, health needs

2007 SusenasChildren:18.968Adult:74.154Elderly: 9.175

C. Role of ProviderCharacteristics

Random Parameter Logit

DV: Type of health provider visited

IV: community (cost of service,distance, number of doctors, drug availability)

2007 IFLSAdult=2,564

A. Motivation and Data dan Methods

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B. Inequity of Access to Outpatient Care

B. Inequity of Access to Outpatient Care

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People from poorer income groups use healthcare less than do people from higher income groups

The effect is small but statistically significant

• All age gropus • Urban and rural residents

0

20

40

60

80

100

0 20 40 60 80 100

Cum

ulat

ive

% h

ealth

care

util

isatio

n

Cumulative % ill people, ranked by income quintiles

Children

Adult

Eldelry

0

20

40

60

80

100

0 20 40 60 80 100

Cum

ulat

ive

% h

ealth

care

util

izatio

n

Cumulative % ill people, ranked by income quintiles

Urban

Equity

Rural

B. Inequity of Access to Outpatient Care

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Differences in the quality of services

• Type of provider is systematically related to quality of services, indicated by:– structural quality (number of doctors) (Donabedian, 1980)

– quality in diagnostic and treatment (Barber et al. ,2007) and Rokx et al.,2010)

• Paramedic, nurse and midwife practices are associated with lower quality of care as compared to health centres and hospitals, physicians and clinics

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Inequity : children, adult and elderly

B. Inequity of Access to Outpatient Care

0

20

40

60

80

100

0 20 40 60 80 100

Cum

ulat

ive

% h

ealth

care

ut

ilizat

ion

Cumulative % ill people, ranked by income quintiles

Children(CI: 0.28)

0

20

40

60

80

100

0 20 40 60 80 100Cum

ulat

ive

% h

ealth

care

util

izat

ion

Cumulative % ill people, ranked by income quintiles

Adult(CI: 0.15)

0

20

40

60

80

100

0 20 40 60 80 100

Cum

ulat

ive

% h

ealth

care

ut

ilizat

ion

Cumulative % ill people, ranked by income quintiles

Elderly(CI: 0.18)

Health centre

Paramedic/nurse/midwifeHospital

Notes: Concentration index (CI) indicates how large concentration of utilization (inequities). Negative = concentrated to the poor, positive = concentrated to the rich. All CIs are significant at 1% level

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Inequity to high quality outpatient care:

B. Inequity of Access to Outpatient Care

• The use of paramedics, nurses and midwives is concentrated to the lower income groups

• The probability of visit to hospitals, physicians and clinics for the poor is lower

• Health centres provide a safety net to balance out the lack of access to high-quality healthcare (hospitals, clinics and physicians) for low-income groups

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C. The Roles of Health Insurance on utilizations

C. The Roles of Health Insurance

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Health insurance (all types) increase outpatient utilization

0.10

0.15

0.20

0.25

Pred

icte

d Pr

obab

ility

Insured (mean)Uninsured (mean)

Q1 (lowest) Q2 Q4 (highest)Q3

Probability of utilization by insurance types and income levels

• The increase is all across the board

• It may not reduce utilization gaps between poor and non-poor

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0.0

0.2

0.4

0.6

0.8

1.0

No

Insu

ranc

e

Aske

s

Aske

skin

Priv

ate

No

Insu

ranc

e

Aske

s

Aske

skin

Priv

ate

Q1 Q4

Cum

ulat

ive

prob

abili

ty Paramedic,nurse, midwife

Physician

Hospital

Health Centre

Traditional

Health insurance (by types) increase outpatient utilization

• For the poor, health insurance increases utilization

• The change depends on the the type of health insurance

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0.0

0.2

0.4

0.6

0.8

1.0

No

Insu

ranc

e

Aske

s

Aske

skin

Priv

ate

No

Insu

ranc

e

Aske

s

Aske

skin

Priv

ate

Q1 Q4

Cum

ulat

ive

prob

abili

ty Paramedic,nurse, midwife

Physician

Hospital

Health Centre

Traditional

Health insurance (by types) increase outpatient utilization

• For the poor, health insurance increases utilization

• The change depends on the the type of health insurance

• Askeskin improves the use of health centre but may reduce the use of physician

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D. Providers characteristics:How do they interact with user’s characteristic?

Traditional

Public

Private

Random Parameter

Logit:

C. Determinants of demand for healthcare

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Random Variable Mean coefficientStandard deviation

of parameter distribution

by preference (%)

Dislike Like

Price -0.018100*** 0.007834 99.0 1.0Distance 0.146665*** 0.081269*** 3.6 96.4Doctors 1.868.851*** 1.316.148*** 7.8 92.2Drug -0.560102*** 0.989279*** 71.4 28.6

• All four provider’s characteristics have a significant influence on choice of provider

• The distribution of individual preference is also significant (except for price)

• On average, people dislike provider with higher price and more drugs but like farther provider but wth more number of doctors

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Random Variable Mean coefficientStandard deviation

of parameter distribution

by preference (%)

Dislike Like

Price -0.018100*** 0.007834 99.0 1.0Distance 0.146665*** 0.081269*** 3.6 96.4Doctors 1.868.851*** 1.316.148*** 7.8 92.2Drug -0.560102*** 0.989279*** 71.4 28.6

• All four provider’s characteristics have a significant influence on choice of provider

• The distribution of individual preference is also significant (except for price)

• On average, people dislike provider with higher price and more drugs but like farther provider but wth more number of doctors

The taste (preference) is not the same for everyone

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Heterogeneity of mean parameters and distribution of the estimated preference of users to provider characteristics

Provider characteristics

Users characteristics

HeterogeneityCoefficient SE

Price Rural 0.017093*** 0.004303Income 0.000089 0.000702Severity of illness -0.008467** 0.003273Insured -0.008001* 0.003953

Distance Rural -0.029237* 0.028329Income -0.002044 0.004967Severity of illness 0.039677 0.025380Insured -0.001010 0.289668

Doctor Rural 0.181891 0.289668Income 0.053967 0.043171Severity of illness 0.029069 0.244569Insured -0.191291 0.240950

Drug Rural -0.173555* 0.074813Income -0.098621*** 0.019858Severity of illness -0.103880 0.070223Insured 0.330583*** 0.080285

N=2563; Log likelihood function = -2505.268; McFadden Pseudo R-squared =0.1102641

Probability [Chi-squared > value] = .000 Notes: ***=significance at 0.001; **=significance at 0.01; *=significance at 0.05

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Roles of providers and its interaction w/users characteristics:• Quality and price are important but accessibility and indirect cost may

not be major problems (relatively small?)

• Health insurance may reduce burden of cost (out of pocket expenditure), but not completely.

• Insured persons react differently to provider characteristics, for example:

– Price of service matters more for insured patients than for uninsured patients

– Drugs availability matters less for insured patients than for uninsured patients

– Insured persons react in te same manners for number of doctors and distance to of provide

C. Determinants of demand for healthcare

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E. Conclusion

E. Discussion and Conclusion

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1. Inequities of access to outpatient care is small (but significant)

2. Inequities of access to high quality care is more profound

3. Price of service deters the use of service, but the effects vary by patient’s characteristics

4. Health insurance increased utilization but does not necessarily reduce inequities

5. The role of provider characteristics on choice of provider is not homogenous, but it is dependent to insurance subscription status

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THANK YOU

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ADDITIONAL INFORMATION(NOT TO BE PRESENTED)

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Inequity to high quality outpatient care:

B. Inequity of Access to Outpatient Care

1. is observed among all population groups: children, adult and elderly

Concentration Index

Health Centre

Hospital/Physician/

Clinic

Paramedics/Nurses/ Midwives

Children -0.11 0.28 -0.06

Adult -0.11 0.15 -0.02

Elderly -0.13 0.18 -0.14

Notes: Concentration index (CI) indicates how large concentration of utilization (inequities). Negative = concentrated to the poor, positive = concentrated to the rich. All CIs are significant at 1% level

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If people do seek care, which provider do they choose?Share of provider utilization for outpatient care, 2007

Calculated from Susenas, 2007

Health Centre27%

Physician21%

Paramedic practice

29%

Public Hospital

5%

Private hospital

3%

Clinic5%

Traditional10%

• Main differences : ownership, health worker, price, geographical reach

D. The Roles of Health Provider

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Healthcare utilization: what determine* a health visit?

Children Adult Elderly

Demographic: Younger, less children in household

Older, female, married, educated

-

Social economic higher income higher income, insured, working, higher income,

higher income

Community Living in urban, in Java or in Bali

living in rural, in Java or in Bali

Health need poorer health & severe illness

poorer health & severe illness

Poorer health & severe illnesscontracted with chronic diseases

Parents educated carer - -

Notes: *) Significance p<0.001. Other variables such as religion, ethnicity, headship status are not significantly influential to all groups

C. Determinants of demand for healthcare

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Exploring male and female response

Model

VariableAdult

(15-69 yrs)Male Model Female Model

DemographicAge +++ +++Marital Status 0 +++Householder status 0 +++

Social EconomicEducation

No education Ref RefPrimary +++ 0Secondary +++ 0Tertiary +++ 0

Facility knowledge ++ +++Working 0 ++Insured + +++Economic status:

1st Quartile (lowest) Ref Ref2nd Quartile 0 03rd Quartile 0 +++4th Quartile (highest) 0 ++

Region of residence 0 ++Island of residence 0 +

Health needSelf rated health +++ +++Severity of illness +++ +++

Variables: religion, ethnicity, household size are not significant for both sexes

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