Anne Nolan

The effect of differential eligibility for free GP services on GP utilisation in Ireland

Internationally, there is extensive empirical evidence that a strong primary care-led health system is associated with improved health outcomes, increased quality of care, decreased health inequalities and lower overall health-care costs. Within primary care, factors influencing access to, and utilisation of, general practitioner (GP) services have been widely examined and this paper focuses on the role of user financial incentives. In particular, user charges for health care have been observed to deter health-care utilisation. Relative to other countries, the Irish health-care system is unusual in that the majority of the population are required to pay out-of-pocket for GP care. However, in 2005 the Irish government extended eligibility for free GP care to a further small subset of the population. Using micro-data from a nationally representative survey of the population in 2007, this paper analyses the impact of differential coverage of free GP services on GP utilisation in Ireland. Results from multivariate regression analysis indicate that GP utilisation is significantly more likely in the context of free GP care, controlling for a range of demographic, socio-economic and health factors. Interpretation of the results for the new category of coverage is complicated by possible pent-up demand and selection effects.

Eligibility for free GP care, “need” and GP visiting in Ireland

The determinants of general practitioner (GP) visiting patterns in Ireland, in particular the role of eligibility for free GP care, are examined using microdata from a nationally representative survey of the population in 2001. Whereas most studies find that need factors such as age and health status are most important in determining GP visiting rates, the Irish situation is complicated by the distinction between medical card patients, who receive free GP visits, and private patients, who must pay for each visit. Controlling for a variety of need-related and other factors, the results show that health status and medical card eligibility are consistently most important in explaining differences in GP visiting patterns. The medical card result is particularly noteworthy; even when differences in age and other observable characteristics between medical card and private patients are taken into account, medical card patients are both more likely than private patients to visit their GP, and they visit more frequently when they do. In addition, we investigated whether individuals just above the income threshold for a medical card are disadvantaged in terms of accessing GP services in comparison with other private patients on higher incomes. We found that there is little significant difference among private patients in GP visiting rates as we move up the income distribution.

The impact of income on private patients' access to GP services in Ireland

Objectives: To examine the extent to which proximity to the income threshold for free GP care results in significant differences in GP visiting. Approximately 30% of the Irish population receives free GP care (medical card patients), while the remaining 70% pays in full (private patients). Medical card eligibility exerts a significant influence on GP visiting, but how do GP visiting rates differ among private patients on differing incomes, and has the differential in visiting among private patients changed over time? Methods: Using micro-data from three nationally representative surveys of the Irish population undertaken in 1987, 1995 and 2001, multivariate models of GP utilization are estimated. Results: There is little evidence that proximity to the income threshold results in significant differences in GP visiting. The most significant difference is between medical card and private patients, rather than between private patients on differing incomes. There is also little evidence that the differential in GP visiting between private patients on different incomes changed over time. Conclusions: While recent commentary has focused on the plight of individuals just above the income threshold for free GP care, these results suggest that the key difference in GP visiting is between those with, and without, eligibility for free care. If private patients are prevented from accessing GP care due to cost, this is as much an issue for those at the top of the income distribution as for those at the bottom.

Eligibility for free GP care and the utilisation of GP services by children in Ireland

The majority of the Irish population pay the full out-of-pocket price of a GP visit, with only those on low incomes exempt. While there is an extensive literature analysing the impact of the Irish system of eligibility for free GP care on GP visiting rates among adults, there is a lack of evidence for children. Given the importance of socio-economic health inequalities in shaping the future outcomes of children, it is important to analyse the extent to which the current system of eligibility leads to inequities in access to GP services among Irish children. In addition, some private health insurance plans have started to offer cover for GP expenses, which adds an additional layer of complexity to the existing system of eligibility, and to date, this has not been studied. Using a large, nationally-representative data-set covering two cohorts of Irish children (9-month olds and 9-year olds), we examine the role of eligibility for free GP care in determining GP visiting rates among children. As with the adult population, the results show that, even with controls for child health, and parental and family characteristics, eligibility for free GP care is a significant determinant of GP utilisation among Irish children.

Income-related inequity in the use of GP services by children: a comparison of Ireland and Scotland

Abstract Equity of access to health care is a key component of national and international health policy, with most countries subscribing to the principle that health care should be allocated on the basis of need, rather than ability to pay or other criteria. The issue of health care entitlements for children is particularly pertinent given the strong causal links that have been demonstrated between eligibility for free care, utilisation and health outcomes. The Irish health care system is unusual in requiring the majority of the population to pay the full out-of-pocket cost of GP care. In contrast, all Scottish residents are entitled to free GP care at the point of use. This difference in public health care entitlements between Ireland and Scotland allows us to examine the impact of differences in financing structures on equity in GP care. In this paper, we use data from two nationally representative surveys of children in Ireland and Scotland to examine the degree of income-related inequity in the utilisation of GP services in both countries. We find that while the distribution of GP care is significantly pro-poor in Ireland, even after adjustment for health need, there is little or no significant inequity in GP utilisation among Scottish children. However, focusing just on children who pay the full price of GP care in Ireland, we find some evidence for a significant pro-rich distribution of GP visits. These results reflect the particular structure of health care entitlements that exist in two systems.

Health and Health Care

Health plays a central role in people’s perceptions of their quality of life, and access to good health care is a key ingredient in an overall sense of security and well-being. This chapter examines how health and health care have evolved over the course of Ireland’s economic boom. Media coverage highlights the negatives: increasing suicide, road deaths, binge drinking and obesity, together with over-crowded accident and emergency departments and the perception that the health-care system is a ‘black hole’, absorbing ever-increasing resources for no return. Our aim is to assess the more complex reality, where some aspects of health and health care have been improving and others standing still or deteriorating, and to examine the role that public perceptions of those trends play in attitudes towards quality of life in Ireland. We look first at trends in health, and then how the health services and their use have evolved.

Urban green space and obesity in older adults: Evidence from Ireland

We examine the association between living in an urban area with more or less green space and the probability of being obese. This work involves the creation of a new dataset which combines geo-coded data at the individual level from the Irish Longitudinal Study on Ageing with green space data from the European Urban Atlas 2012. We find evidence suggestive of a u-shaped relationship between green space in urban areas and obesity; those living in areas with the lowest and highest shares of green space within a 1.6 km buffer zone have a higher probability of being classified as obese (BMI ⩾30). The unexpected result that persons in areas with both the lowest and highest shares of green space have a higher probability of being obese than those in areas with intermediate shares, suggests that other characteristics of urban areas may be mediating this relationship.

Public Healthcare Entitlements and Healthcare Utilisation among the Older Population in Ireland.

The use of direct out-of-pocket payments to finance general practitioner (GP) care by the majority of the population in Ireland is unusual in a European context. Currently, approximately 40% of the population have means-tested access to free GP care, while the remainder must pay the full out-of-pocket cost. In this paper, we use data from The Irish Longitudinal Study on Ageing (TILDA) to examine the impact of the current system of public healthcare entitlements on GP utilisation among the older population. Using difference-in-difference propensity score matching methods, we find significant effects of changes in public healthcare entitlements on GP utilisation (i.e. introducing user fees reduces utilisation, while removing them increases utilisation). There is limited evidence of offset effects on other types of healthcare utilisation. The results have direct implications for current Irish health policy, and add to the international literature on the effects of insurance on healthcare utilisation. Copyright

Usage of generics in Ireland: Recent trends and policy developments

In 2011, the Irish State spent €1.9bn on pharmaceuticals, amounting to approximately 13% of total public health expenditure. Over the period 2000–2010, Ireland experienced one of the fastest growth rates in per capita pharmaceutical expenditure in the OECD. Concern over pharmaceutical expenditure in Ireland has led to a number of policy changes, targeting primarily the price of pharmaceuticals. More recently, there has been much concern over the low rates of generic usage in Ireland. In 2009, 34% of multiple-source off-patent pharmaceuticals dispensed under the main State pharmaceutical reimbursement schemes in Ireland were generics, in comparison with 71% in the UK. Up to now, the potential for significant savings through the increased use of generics in Ireland has been limited as the price of off-patent pharmaceuticals (including generic pharmaceuticals) was set at a small discount to the patent-holder price. Legislation to introduce a system of reference pricing and generic substitution for 20 leading off-patent pharmaceuticals has recently been enacted. However, reference prices have yet to be set, and so the full scale of any potential savings under the Health (Pricing and Supply of Medical Goods) Act 2013 has yet to be determined. In advance of the new legislation, there has been evidence of a substantial increase in the use of generics in Ireland, although the precise reasons driving this increase are unclear.

Coastal blue space and depression in older adults

&NA; This paper tests whether higher exposure to coastal blue space is associated with lower risk of depression using data from The Irish Longitudinal Study on Ageing (TILDA), a nationally representative longitudinal study of people aged fifty and over in Ireland. We contribute to the literature on blue space and health by (i) using scores from the Center for Epidemiologic Studies Depression Scale (CES‐D) to measure depression outcomes (ii) using new measures of coastal blue space visibility (iii) studying the association in an older population (iv) using data from Ireland. Our results indicate that exposure to coastal blue space is associated with beneficial mental health outcomes: TILDA respondents with the highest share of sea view visibility have lower depression (CES‐D) scores, while distance from coastline is not statistically significant when views and proximity are both included in the model. This finding supports the idea that the primary channel through which coastal blue space operates to reduce depression scores is visual rather than related to physical proximity. HighlightsWe examine links between coastal blue space and depression in older age.Exposure to coastal blue space is associated with positive mental health effects.Individuals with the most sea view visibility have lower depression (CES‐D) scores.Distance from coastline does not have a significant independent association.