Waiting times for elective treatments according to insurance status: A randomized empirical study in Germany
Lungen M, Stollenwerk B, Messner P, Lauterbach KW, Andreas G
Int J Equity Health. 2008 Jan 9;7:1. doi: 10.1186/1475-9276-7-1.
Background
Many countries consider universal health insurance to be a requisite for reducing disparities in access to health care. Germany is among those countries, covering 90% of its population through compulsory statutory health insurance (SHI). The remaining 10% - only those who are self-employed or are high income earners – are permitted to opt out and purchase private health insurance (PHI) as a substitute for social health insurance.
Some claim that patients with SHI face longer waiting times for outpatient appointments because physicians are paid 20%–35% more to treat patients with private health insurance. This study assesses outpatient waiting times according to type of health insurance.
Methods
In 2006, researchers telephoned 189 practices in five specialties in the regions of Cologne, Leverkusen, and Bonn. Excluded from the study were 61 practices in which the treatments under study were not offered; the practice was closed for vacation; the line was busy after three attempts; they did not offer fixed appointment times; they exclusively treated PHI patients; or the practice was no longer in service. Using standard conversation guidelines, researchers requested an appointment date for one of five elective treatments provided by a specialist: allergy test plus pulmonary function test (Allergist or Pulmonologist); pupil dilation (Ophthalmologist); gastroscopy (Gasteroenterologist); hearing test (ENT); and MRI of the knee (Radiologist). Each practice was only called for one appointment, and the caller did not request an expedited appointment. Each caller was randomly assigned the status of either a PHI or SHI insuree. Insurance status was mentioned during each phone call. If asked for the name of the private health insurer, the caller named a leading health insurer. If asked to name the referring physician, a fictitious physician from a distant region was identified, with the explanation that the caller had recently moved to the area.
Both univariate analysis (one specialist field at a time) and multivariate regression analysis were performed. For univariate analysis, the Wilcoxon rank sum test, also known as Mann-Whitney test, was performed.
Limitations
The study was performed in only one geographic region, without assessing whether that area was representative of other areas. The study sites were cities, which typically have a higher percentage of PHI policyholders than do rural areas. It is unclear whether this may have increased or decreased waiting times for those with private insurance. It may be that a higher percentage of PHI patients in an area leads to less competition between practices to attract such patients, which could lead to them waiting longer. It may also be that a higher percentage of PHI patients permits more practices to serve only these patients, shortening their wait times. Since practices exclusively serving PHI patients were excluded, it remains uncertain whether wait times would have been even longer for SHI patients had the exclusively PHI practices been included.
Results
Waiting time difference between SHI and PHI policyholders was 17.6 working days.
(SHI 26.0 vs. PHI 8.4) for allergy test plus pulmonary function test; 17.0 days (SHI 25.2 vs. PHI 8.2) for pupil dilation; 24.8 days (SHI 36.7 vs. PHI 11.9) for gastroscopy; 4.6 days (SHI 6.8 vs. PHI 2.2) for hearing test; and 9.5 days (SHI 14.1 vs. PHI 4.6) for MRI of the knee. In relative terms, the difference in working days amounted to 3.08 (95% CI 1.88 – 5.04) and proved significant.
Comment
Discrepancies in physicians’ reimbursement are associated with disparities in patients’access to treatment. Even with comprehensive health insurance coverage for almost 100% of the population, Germany shows clear differences in access to care, with SHI patients waiting 3.08 times longer for an appointment than PHI patients. Different levels of physician reimbursement - even in the case of identical treatments - is associated with discrepancies in access to health services, with privately insured patients getting preferential access. This has provoked a lively political and legal debate in Germany about possibly harmonizing reimbursement for SHI and PHI.
In Canada, health care is funded by a single payer in each province, and all provinces either prohibit private insurance outright or employ economic disincentives to discourage it. A constitutional challenge underway in British Columbia’s supreme court threatens to unravel the prohibitions on private insurance in that province, paving the way for the sale of private duplicative health insurance to those who could afford to buy it, and for similar legal challenges in other provinces. The experience in Germany offers a cautionary tale about what Canadians might expect to see here if the plaintiffs were to be successful: higher reimbursement rates to physicians who serve those with private health insurance, and, logically, preferential access to care for privately insured patients.