Cost barriers reduce confidence in receiving medical carewhen seriously ill

Trust, which according to Mechanic, is ‘the expecta-

tion that individuals and institutions will meet their

responsibilities to us’ (1), has been analysed from

different perspectives. Authors have, for instance,

studied trust in one’s own medical doctor (2),

patient preferences (3) and satisfaction with the

healthcare system (4,5). The question of confidence

in receiving safe and quality medical care when fall-

ing seriously ill, in contrast, has been neglected in

previous comparative research (6). We expect that

this ‘feeling of security’ is influenced by past experi-

ences with the healthcare system, and we therefore

ask in what respect negative experiences influence

confidence in the healthcare system.

The analysis is based on data from the Common-

wealth Fund International Health Policy Survey 2007

(6). Negative experiences are captured by the ques-

tion: ‘During the past 12 months, was there a time

when you had a medical problem but did not visit a

doctor because of cost?’ The lack of confidence in

receiving good medical care in the

future is measured by the question:

‘How confident are you that if you

become seriously ill, you will get

quality and safe medical care?’ In

our analysis, we focused on those

respondents who reported to be ‘not

very’ or ‘not at all confident’. We

conducted pairwise comparisons of

group percentages using the Scheffe

method (7) for the dependent vari-

able (confidence).

In the US, 25% of respondents

have experienced cost barriers, 20% in New Zealand,

more than 13% in Australia and 12% Germany. In

the Netherlands, the UK and Canada, only a small

minority of the population has had the experience of

not going to the doctor because of costs (Figure 1).

When discussing the impact of cost barriers on con-

fidence in receiving medical care, the very low num-

ber of individuals facing cost barriers in the latter

three countries must be taken into account.

Women are less confident than men in their abil-

ity to receive safe and quality healthcare when ill in

Germany, the UK, Australia and Canada. Education

matters in the US, Australia, New Zealand and

Canada, with groups with lower education being less

confident. In all countries, people with below-average

incomes are less confident in receiving good medical

care than are those with above-average incomes (Fig-

ure 2). Being in poor health significantly reduces

confidence. In Germany, New Zealand, the UK and

the US, about 40% of those who consider their own

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 people’s 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.

1.5 1.8

4.1

11.713.5

19.9

24.6

0

5

10

15

20

25

30

Netherlands UK Canada Germany Australia NewZealand

USA

Not

goi

ng to

doc

tor b

ecau

se o

f cos

ts (i

n pe

rcen

t)

Figure 1 Experience of not going to the doctor because of costs, 2007. Source: Wendt et al. (6)

PERSPECT IVE

ª 2011 Blackwell Publishing Ltd Int J Clin Pract, November 2011, 65, 11, 1115–1117doi: 10.1111/j.1742-1241.2011.02770.x 1115

In the US, New

Zealand,

Australia, and

Germany many

patients

experience

cost barriers

health to be fair or poor are either not very or not at

all confident that they will receive safe and quality

medical care when seriously ill. The gap between

groups with better and poorer health is greatest in

the US (22 percentage points), followed by New Zea-

land (20), Australia (18) and the UK (17). In most

countries, the experience of cost barriers has the

strongest negative effect on confidence in the health-

care system. In the US, the gap between patients with

and without the experience of cost barriers is almost

30 percentage points. This gap is also high in the UK

and in Canada (in both countries, however, cost bar-

riers play a minor role). In Germany, the gap

between patients with and without the experience of

cost barriers amounts to 17 percentage points.

Among those who experienced difficulties related to

costs for taking up necessary healthcare services, con-

fidence in receiving safe and quality medical care is

lower (Figure 2).

The bivariate results were generally confirmed in

logistic regressions that included gender, age,

income, education, health status and the experience

of cost barriers (not shown; see ref. 6). Although

gender (except in Canada and Germany) and educa-

tion (except in the US) seem to be of lesser impor-

tance, income still matters after controlling for other

factors (in Canada, Germany and the UK). In addi-

tion to poor health, the experience of not going to

the doctor has a strong negative effect on confidence

in the overall system’s capacity to deliver health care

services when necessary (not significant in Australia

and the Netherlands).

The data show major disparities among social

groups in all included countries regarding the confi-

dence in receiving medical care when in need. Given

the high emphasis of equality, particularly in the

British NHS, these differences in confidence require

further elaboration. Even if only a few patients in the

British NHS have experienced cost barriers at all,

those who have had this negative experience have

less trust in future healthcare provision. Further-

more, poor health and low income reduce confidence

not only in countries with serious access barriers,

such as the US but also in countries where access to

acute care is free, such as the British NHS.

The findings do not provide direct lessons as to

how the disparities among education and health

groups could be reduced; however, the fact that the

experience of financial barriers considerably lowers

confidence has important health policy implications.

Although those who did not go to the doctor

because of costs have less confidence in all countries,

035202510150

USANetherlands

CanadaAustralia

New ZealandUK

GermanyNetherlands

UKGermany

CanadaNew Zealand

AustraliaUSA

NetherlandsCanada

GermanyUK

New ZealandAustralia

USANetherlands

CanadaGermany

UKAustralia

New ZealandUSA

AustraliaNetherlands

New ZealandGermany

CanadaUK

USA

Gen

der:

dist

ance

fem

ale-

mal

eE

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tion:

dis

tanc

elo

wes

t-hig

hest

Inco

me:

dis

tanc

elo

wes

t-hig

hest

Hea

lth: d

ista

nce

poor

-go

od

Cos

t bar

riers

:di

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ce w

ith-w

ithou

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arrie

rs

Diffferences between social groups (in percentage points)

*****

******

*****

*****

***

******

**********

******

******

***

***

***

*****

****

**

Figure 2 Differences in the lack of confidence in receiving medical care, 2007. Source: Authors’ calculations using the

2007 Commonwealth Fund International Health Policy Survey (6). Data weighted. Only significant group differences

shown (*p £ 0.05, **p £ 0.01, ***p £ 0.001)

Low income,

poor health,

and the

experience of

cost barriers

reduce

confidence in

receiving safe

and quality

healthcare

when ill

1116 Perspective

ª 2011 Blackwell Publishing Ltd Int J Clin Pract, November 2011, 65, 11, 1115–1117

we could show that not only in the UK but also in

the Netherlands only a few people have experienced

cost barriers. This phenomenon could be partly

related to the fact that visits to a doctor are free and

that other private out-of-pocket payments have also

been particularly low for many years in both coun-

tries while remaining at a high level in the US, Aus-

tralia and New Zealand. The type of co-payment, as

well as the time of the introduction of co-payments,

also plays a role in establishing cost barriers. In Ger-

many, for instance, a payment of ten Euros per quar-

ter for a doctor’s visit was introduced in 2004. This

fee seems to have a stronger impact on patients’

decision to not see a doctor, as patients can be sure

that these costs will apply as soon as they visit a doc-

tor (in contrast, for instance, to co-payments for

pharmaceuticals).

The trend towards increased cost-sharing for

patients in healthcare systems therefore has more

unintended consequences than previously realised.

Beside the risk of an increased burden on low-

income groups and those with a lower health status,

experienced cost barriers also affect trust in the

healthcare system. As trust is not only important for

the legitimacy of the healthcare system but also for

treatment outcomes, we suggest that policy makers

consider the negative impact on trust when dealing

with cost-sharing instruments. Guaranteeing access

to necessary healthcare services for those who fall

seriously ill can be considered the single most impor-

tant task of healthcare systems in modern societies,

and patients therefore need ‘markers of certainty’

(8), which indicate that this promise will be fulfilled.

Being able to go to a doctor with a minor symptom

seems to represent such a ‘marker of certainty’, indi-

cating that quality healthcare will be provided when

facing a serious disease.

Disclosures

None.

Acknowledgements

The research reported here has received financial

support from the Harkness Program of Health Policy

& Practice of the Commonwealth Fund and the

Bosch Foundation.

C. Wendt,1 M. Mischke,1 M. Pfeifer,1 N. Reibling2

1Department of Sociology, University of Siegen,Siegen, Germany

2MZES, University of Mannheim, Mannheim, GermanyEmail: wendt@soziologie.uni-siegen.de

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