Effects of “Free” Medical Care on Medical Practice — The Quebec Experience

Enterline, Philip E.; McDonald, J. Corbett; McDonald, Alison D.; Davignon, L; Salter, Vera

doi:10.1056/nejm197305312882204

Cited by 29 publications

(11 citation statements)

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“…There is only one published study we are aware of- Enterline, McDonald, and McDonald (1973)-that directly examines the effects of a major coverage expansion on physician work patterns. That study measured physician work hours and practice patterns immediately before and after the introduction of universal coverage for physician services in Quebec in 1970.…”

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confidence: 99%

The Effect of the Children’s Health Insurance Program on Pediatricians’ Work Hours

White

2013

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Objective: Our study examines changes in physicians' work hours in response to a coverage expansion. Methods: We use as a natural experiment the Children's Health Insurance Program (CHIP), which was established in 1997 and significantly expanded children's eligibility for public health insurance coverage. The magnitude of the CHIP expansion varied across states and over time, allowing its effects to be identified using a state-year fixed effects model. We focus on pediatricians, and we measure their selfreported work hours using multiple waves (pre-and post-CHIP) of the physician survey component of the Community Tracking Study. To address endogeneity concerns, we instrument for CHIP enrollment using key program features (income eligibility cutoffs and waiting times). Results:We find a large negative relationship between the magnitude of a state's CHIP expansion and trends in pediatricians' work hours. This relationship could be due to key supply-side features of CHIP, including relatively low provider reimbursements and heavy use of managed care tools. He, F., White, C. Keywords: E2 IntroductionThe Congressional Budget Office (CBO) has estimated that providing insurance coverage for all of those who are currently uninsured would increase the demand for health care services by 2 to 5 percent (Congressional Budget Office, 2008). But, for the quantity of services to actually increase, providers have to supply the additional care, and it is not clear whether, or how, they will do so. Based on a purely demand-driven model of physician labor supply, the CBO and other researchers have hypothesized that a large coverage expansion could lead, in the short run, to physicians working longer hours to accommodate such an influx of patient demand. On the other hand, a supply-driven model hypothesizes that physicians could choose to work fewer hours with a large coverage expansion, due to constraints on the supply side. To test between the two hypotheses, we analyze the impact of the Children's Health Insurance Program (CHIP), a public health insurance program for children in low-and middle-income families.Established in 1997, CHIP has several features that make it well suited to our purposes. First, the CHIP expansion was large, resulting in almost one in five children becoming newly eligible for public coverage-that expansion in eligibility is roughly similar in magnitude to the expansion for adults that will occur under the Affordable Care Act (ACA). Second, states play a central role in designing and financing their CHIP programs, and have some latitude to determine eligibility criteria. As a result, eligibility criteria and other key program features vary widely from state to state, which we exploit in our analysis. Third, CHIP was established relatively recently. This allows access to fairly rich and recent data sources, and also makes it more plausible that any findings would be relevant to upcoming reforms.We use a state-year level panel data analysis, with observations spanning the period before and after the establi...

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confidence: 99%

The Effect of the Children’s Health Insurance Program on Pediatricians’ Work Hours

White

2013

MMRR

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“…De l'année précédant l'instauration du régime jusqu'à l'année qui Ta suivie, il y a eu peu ou pas de changement dans les taux de visite à un médecin pour l'ensemble de la population montréalaise et le nombre moyen d'heures travaillées par les médecins a diminué (13). L'implantation du système a provoqué beaucoup de tensions et de perturbations dans le monde médical.…”

Section: Discussionunclassified

“…Même en 1971-72, une période de mécontentement chez plusieurs médecins, les rapports concernant des abus du système par des patients ont été très peu nombreux (13). Les taux d'utilisation plus élevés en 1974 qu'en 1971-72 pourraient refléter un degré d'abus plus élevé, une meilleure utilisation, une offre de services plus élevée ou une combinaison de ces divers éléments.…”

Section: Discussionunclassified

Statut socio-économique et utilisation des services de santé à Montréal

Siemiatycki

Richardson

2009

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National health insurance was implemented in Quebec in late 1970. Previously reported surveys carried out in Montreal in 1969-70 and 1971-72 showed that while there was no change in overall volume of services, there was a redistribution, with increases among the poor and decreases among the wealthy. We conducted a survey in late 1974 to determine the "steady-state" impact of l’assurance-maladie on social class differences in health care utilization. In a socially heterogeneous area of Montreal 1,559 households were surveyed. When reported morbidity status was taken into account, physician visit rates in the past two weeks were 21.6 per cent, 20.2 per cent, and 20.4 per cent in low, middle and high economic classes respectively, confirming the disparity of access has been reduced. However, relative to the non-poor, the poor still made considerable use of hospital clinics and emergency rooms for primary care and more of their visits entailed prescriptions and physician-initiated requests to return. The latter may indicate that the poor still consult the doctor for more advanced conditions than the non-poor. There is no evidence of abuse of "free" medical care by the poor. In contrast to the equalization in use of physician services, dental services are still unequally distributed, although compared with the 1969-70 and 1971-72 surveys, utilization rates were higher in 1974 in all social classes. The overall increase in per capita physician visits was confirmed by statistics of the Régie de l’assurance-maladie du Québec. A parallel increase in the supply of physicians kept the workload of the average physician at a constant level.

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“…(For historical examples of that type of reallocation, see Stewart and Enterline [1961] and .) It is improbable that physicians' work schedules would expand proportionally with the increase in patient demand (Enterline, McDonald, and McDonald, 1973;He and White, 2013), particularly among the half of physicians practicing in Oregon who were employees in 2015 (Oregon Health Authority, 2016). In the long run, providers might delegate larger roles to ancillary staff to increase output (Buchmueller, Miller, and Vujicic, 2016) or develop enhanced triage strategies to prioritize the provision of services to patients with the greatest clinical need (Aaron and Schwartz, 1984).…”

Section: Congestionmentioning

confidence: 99%