Nadine Reibling

Healthcare systems in Europe: towards an incorporation of patient access:

The core of existing healthcare typologies is the public—private mix in the three areas of funding, provision and regulation of healthcare services. This article aims to contribute to the debate by adding ‘healthcare access’ as an important dimension for comparing healthcare systems. In contrast to previous analyses, I extend the concept of access by looking at regulative aspects and financial incentives that shape entry and reception of care. Based on empirical indicators for three different dimensions of healthcare access — gatekeeping, cost sharing and supply — a cluster analysis is performed that yields four access regime types: financial incentive states; strong gatekeeping/low supply states; weakly regulated/high supply states; and mixed regulation states. The countries clustered in the access regimes show a different pattern than typologies based on other system indicators. This suggests that previously used dimensions for comparison do not sufficiently capture patients’ access to healthcare.

Bildungsniveau und Zugang zu Gesundheitsleistungen

Equal access to health care is a central goal of all European health-care systems. International studies, however, show that this goal has not been accomplished yet. The aim of this study is to investigate if there are inequalities across patients with different levels of education and if these differences vary with the institutional set-up of health-care systems. The test of this hypothesis is based on a comparison of eleven European countries using data from the SHARE survey (Survey of Health, Ageing and Retirement in Europe). Our results show that in countries with institutionalised gatekeeping systems differences of utilisation between educational groups are rather low. In countries with free access to specialists, patients with higher levels of education show a higher probability of specialist visits than their counterparts with lower levels of education.

Confidence in receiving medical care when seriously ill: a seven-country comparison of the impact of cost barriers.

Objective  This paper examines how negative experiences with the health‐care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

Gatekeeping and provider choice in OECD healthcare systems

Gatekeeping and provider choice have become central in health policymaking within the last two decades. This article contributes to the debates in two ways: first, it provides an extended review of evidence on the impact of gatekeeping and provider choice on efficiency, costs, quality, equality and patient empowerment; and second, it empirically analyses regulations and identifies common trends in healthcare reforms in OECD countries since 1990. More than half of the countries analysed have established gatekeeping systems, while a smaller number provides free access to secondary care. The study discovers a trend towards strengthening gatekeeping regulations within free access countries. Free choice of provider is the standard in the OECD, where only a small number of countries restrict provider choice. The article identifies a diverging trend of reforms, with some traditionally restrictive countries offering more provider choice and other countries limiting the choice of providers as a result of managed care reforms.

Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? Findings from the European Social Survey (2014) special module on the determinants of health

Background: Economic crises constitute a shock to societies with potentially harmful effects to the mental health status of the population, including depressive symptoms, and existing health inequalities. Methods: With recent data from the European Social Survey (2006–14), this study investigates how the economic recession in Europe starting in 2007 has affected health inequalities in 21 European nations. Depressive feelings were measured with the CES‐D eight‐item depression scale. We tested for measurement invariance across different socio‐economic groups. Results: Overall, depressive feelings have decreased between 2006 and 2014 except for Cyprus and Spain. Inequalities between persons whose household income depends mainly on public benefits and those who do not have decreased, while the development of depressive feelings was less favorable among the precariously employed and the inactive than among the persons employed with an unlimited work contract. There are no robust effects of the crisis measure on health inequalities. Conclusion: Negative implications for mental health (in terms of depressive feelings) have been limited to some of the most strongly affected countries, while in the majority of Europe persons have felt less depressed over the course of the recession. Health inequalities have persisted in most countries during this time with little influence of the recession. Particular attention should be paid to the mental health of the inactive and the precariously employed.

The international performance of healthcare systems in population health : Capabilities of pooled cross-sectional time series methods

This paper outlines the capabilities of pooled cross-sectional time series methodology for the international comparison of health system performance in population health. It shows how common model specifications can be improved so that they not only better address the specific nature of time series data on population health but are also more closely aligned with our theoretical expectations of the effect of healthcare systems. Three methodological innovations for this field of applied research are discussed: (1) how dynamic models help us understand the timing of effects, (2) how parameter heterogeneity can be used to compare performance across countries, and (3) how multiple imputation can be used to deal with incomplete data. We illustrate these methodological strategies with an analysis of infant mortality rates in 21 OECD countries between 1960 and 2008 using OECD Health Data.

The (Missed) Potential of the Patient-centered Medical Home for Disparities.

Background:Disparities in health care and health outcomes are a significant problem in the United States. Delivery system reforms such as the patient-centered medical home (PCMH) could have important implications for disparities. Objectives:To investigate what role disparities play in current PCMH initiatives and how their set-up might impact on disparities. Research Design:We selected 4 state-based PCMH initiatives (Colorado, Massachusetts, Pennsylvania, and Rhode Island), 1 regional initiative in New Orleans, and 1 multistate initiative. We interviewed 30 key actors in these initiatives and 3 health policy experts on disparities in the context of PCMH. Interview data were coded using the constant comparative method. Results:We find that disparities are not an explicit priority in PCMH initiatives. Nevertheless, many policymakers, providers, and initiative leaders believe that the model has the potential to reduce disparities. However, because of the funding structure of initiatives and the lack of adjustment of quality metrics, health policy experts do not share this optimism and safety-net providers report concerns and frustration. Conclusion:Even though disparities are currently not a priority in the PCMH community, the design of initiatives has important implications for disparities.

Regional inequalities in self-reported conditions and non-communicable diseases in European countries: Findings from the European Social Survey (2014) special module on the social determinants of health

Background: Within the European Union (EU), substantial efforts are being made to achieve economic and social cohesion, and the reduction of health inequalities between EU regions is integral to this process. This paper is the first to examine how self‐reported conditions and non‐communicable diseases (NCDs) vary spatially between and within countries. Methods: Using 2014 European Social Survey (ESS) data from 20 countries, this paper examines how regional inequalities in self‐reported conditions and NCDs vary for men and women in 174 regions (levels 1 and 2 Nomenclature of Statistical Territorial Units, ‘NUTS’). We document absolute and relative inequalities across Europe in the prevalence of eight conditions: general health, overweight/obesity, mental health, heart or circulation problems, high blood pressure, back, neck, muscular or joint pain, diabetes and cancer. Results: There is considerable inequality in self‐reported conditions and NCDs between the regions of Europe, with rates highest in the regions of continental Europe, some Scandinavian regions and parts of the UK and lowest around regions bordering the Alps, in Ireland and France. However, for mental health and cancer, rates are highest in regions of Eastern European and lowest in some Nordic regions, Ireland and isolated regions in continental Europe. There are also widespread and consistent absolute and relative regional inequalities in all conditions within countries. These are largest in France, Germany and the UK, and smallest in Denmark, Sweden and Norway. There were higher inequalities amongst women. Conclusion: Using newly available harmonized morbidity data from across Europe, this paper shows that there are considerable regional inequalities within and between European countries in the distribution of self‐reported conditions and NCDs.

The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care.

Cost barriers reduce confidence in receiving medical care when seriously ill.

People need to trust that necessary care will be provided in the case of serious illness or injury, but negative experiences with the healthcare system reduce confidence. In this article, we discuss the effect of cost barriers on peoples confidence in receiving safe and quality medical care when falling seriously ill in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States.