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6 Urgences KCE reports vol. 19B
The amount of demand reduction is measured by the price elasticity of demand. The
lower the price elasticity, the weaker the effect on expenditures will be. What
determines this price elasticity?
3.1.2. Health effects
The most obvious factor is the behavioral reactions of the patients. These will
be stronger if treatments are less urgent or if substitutes are readily available.
Reactions will be weaker if patients are more ill (or consider themselves
more at risk). They may be higher for low income people, because a change
in the relative prices will have a relatively larger effect on their purchasing
power. All this presumes that patients are sufficiently informed about prices.
A second element is the so-called supply-induced demand. In the health care
sector suppliers can directly influence the quantities consumed. It is not easy
to predict the final result of these provider reactions. On the one hand, one
may think that providers will counteract possible demand reductions, if these
threaten their income position. In that case the supply-induced demand may
counteract the immediate behavioral reactions of the patients. There may
then be a difference between the short-term and the long-term effect of the
introduction of cost-sharing. On the other hand, it may also be the case that
supply-inducement becomes less pronounced after the introduction of patient
cost-sharing. Patients may be more alert and exert more pressure on
providers; ethically motivated providers may worry about the effects of
increased expenditures on the economic position of their patients. In general,
it is obvious that one should not only focus on the incentives for the patients
but also bring the provider incentives into the picture.
A distinction has to be made between on the one hand first contacts, and on
the other hand referrals and prescriptions. While decisions about the former
are taken in the first place by the patients themselves, the latter are more
strongly influenced by the providers.
The behavioral effects of cost-sharing will depend on the specific form of
cost-sharing considered. Co-payments and co-insurance raise the price of the
service (with a fixed amount or in a fixed proportion respectively) for all
possible quantities. A deductible only has effects once the threshold has been
passed, because from that point onwards the price of the service becomes
zero.
Very important is that the final outcome of these various effects depends on
specific contextual factors (and can only be estimated through empirical
work).
The absence of user charges may lead to moral hazard and excess demand. Most policy
measures introducing user charges intend to reduce unnecessary services. However,
taking such a policy measure is not always hitting the target of consumption of
unnecessary services. To be an effective instrument, the price signal should indeed
provide incentives for cost-conscious care and selectively discourage the use of
unnecessary services. However, if patients not only stop obtaining unnecessary care but
also effective care defined by clinical criteria cost-sharing may set up barriers to
needed care and health effects may be expected.
Health effects can only be measured through empirical work, although some important
factors are already known 6, 7, 1 :
Cost-sharing will be most efficient if it can be applied to relatively inefficient
services, for which more efficient substitutes (alternatives) are available. Such
substitution will indeed compensate the effects on health.
The previous argument only works if patients are sufficiently informed about
the appropriateness of alternative services for their health care needs. They
must be aware of the existence of alternative more effective or more costefficient
treatments. Providers are probably the main source of information in