Beca AES 2023: ¿Qué hay detrás de las desigualdades en los tiempos de espera de la sanidad pública?

Waiting times in public health have usually been a rationing tool in many health systems, allowing demand to be managed according to available resources. This method, adopted with the intention of promoting equity in access, aims to prevent financial and social factors from conditioning the care patients receive. However, recent research reveal persistent inequality: patients from higher socioeconomic levels often experience shorter wait times compared to those of lower economic ability. This inequality, especially observable in services such as specialized consultations and the elective surgeryposes a significant challenge to equity in universal healthcare systems. Known as the “socioeconomic gradient in waiting times”, this phenomenon suggests that, far from being equitable, the current system may be aggravating health inequalities based on the socioeconomic level of patients.

The Research Scholarship in Health Economics and Health Services 2023granted by the Association of Health Economics (AES) in collaboration with Novartis, finances a project that addresses this problem. This study seeks to understand the mechanisms behind these inequalities and explore how both demand- and supply-side factors could be contributing to this inequality in access. Among the demand-side factors, the patient’s abilities to “navigate” the health system are considered, while on the supply side, the possibility of unconscious biases in prioritization by health professionals is explored.

A two-way approach

To investigate the socioeconomic gradient in waiting times, the study uses a two-pronged approach that considers both the demand and supply of health services.

1.Analysis from the demand side:

The first approach examines how freedom of choice of provider by patients could benefit those with greater resources and skills to navigate the health system. In 2009, the Community of Madrid implemented a reform that allows citizens to freely choose their specialist doctor and hospital throughout the province. This reform, which introduces free choice, provides an ideal context to analyze how a provider choice policy can affect patients of different socioeconomic levels. Using this policy as a natural experiment, the study evaluates whether the introduction of free choice more benefits wealthier patients, who may have an easier time taking advantage of these options as they have lower information and transportation costs for switching providers.

2.Analysis from the supply side:

The second approach, still in development, explores whether it exists. unconscious biases by doctors who contribute to inequalities in waiting times. The hypothesis is that doctors could show greater empathy or affinity with patients with similar characteristics, which could result in favorable prioritization for patients with a high socioeconomic level. To investigate this hypothesis, a discrete choice experiment (DCE) will be designed to identify patient attributes that influence their prioritization by primary care physicians. The goal is to discover whether doctors tend, even unconsciously, to prioritize certain patients based on their socioeconomic status, which could lead to differences in access to care and, ultimately, unequal health outcomes. .

First results and first impressions.

In May 2024, the first findings of this study were presented in the XIII EvaluaAES Workshopheld at the Faculty of Nursing, Physiotherapy and Podiatry of the University of Seville. During the presentation, Juan David García Corchero (University of Granada) presented under the title “The socioeconomic gradient in waiting times: evaluating the impact of the choice of providers in a universal health system.the first results of the project. These preliminary results indicate that the free choice policy in Madrid managed to reduce waiting times, with notable benefits for patients from lower socioeconomic levels. This conclusion suggests that the free choice reform could have acted as a mechanism to reduce inequalities in access to care.

The analysis, based on difference-in-differences techniques, revealed that the reduction in waiting times was particularly significant among patients from low socioeconomic levels, measured through educational level, as can be seen in graph 1, confirming that free choice policy has the potential to reduce inequalities in access to care.

Graph 1. Evolution of the differences in waiting times between Madrid (treatment region) and the rest of the regions before and after implementing the free choice policy in 2009 depending on educational level (A: Patients without university studies. B: Patients with university studies)

Grades: (1) this event study analyzes the impact of the choice of supplier in Madrid for the year 2009 (year 0). Point estimates are shown along with their 95% confidence intervals. The base period (omitted) is the year of the reform in each region treated. Controls are included for clinical need, such as age or gender. (2) Panel A shows the heterogeneous effect for those patients without tertiary education using the difference-in-differences method. Panel B shows the heterogeneous effect for those patients with tertiary education (University or Vocational Training) using the difference-in-differences method.

In the Workshop, Myriam Soto Gordoa (Mondragon Unibertsitatea) congratulated the team for the relevance of the topic and suggested that they delve deeper into the explanation of the free choice policy and its impact on the system. He also proposed evaluating the effect of the proportion of patients with private insurance in Madrid, who could be combining private and public services to reduce waiting times.

The results of the study were also presented in the XLIII Health Economics Conference (AES)held in Tenerife in June 2024. During this event, it was discussed how the free choice policy in Madrid has impacted the reduction of socioeconomic inequalities in waiting times. In addition, the methodological aspects were delved into and the challenges of implementing policies of this type in decentralized health systems such as the Spanish one were addressed.

Next steps

The findings suggest that free choice could be a useful tool to improve equity in the system, but also raise the need to consider the costs associated with these policies. The experience of England, where the introduction of greater competition between hospitals has helped to reduce slightly Inequalities in waiting times indicate that policies of this type can have positive effects, but require a significant commitment of resources. In addition, the study plans to analyze the long-term effects of free choice in the Madrid health system and incorporate into the analysis other free choice experiences implemented throughout the country, including as an analysis the impact on the use of public services and in the financial burden for the system. Based on these first results, the study will focus on further evaluating the impact of supply-side services and how these can contribute to inequality in access to public health services.

The research funded by the AES 2023 Grant offers a great opportunity to understand how free choice policies and biases in care can influence equity of access in the healthcare system. The first results suggest that, at least in the case of Madrid, free choice has contributed to reducing inequalities, especially for patients with lower educational levels. However, these benefits must be weighed against the costs, as free-choice policies can require significant resources. While free choice may improve efficiency and equity, it is also crucial that policymakers carefully evaluate their economic and social impact before implementing policies in a broader context.