Health care inequality in free access health systems: The impact of non-pecuniary incentives on diabetic patients in Danish general practices
Indicators of deprivation based on income and education might offer a blunt tool for inequality analysis in universal health systems with free access to care and thereby preventing the identification of groups experiencing the largest inequality. Also, analysis methods based on ranking the population by income or education, such as concentration curves and indices, are unsuitable for evaluating the impact of a health programme on inequality. This paper uses a new method for inequality analysis based on the Health Care Deprivation profiles’ approach, allowing for: (1) considering multi-dimensional aspects of deprivation in the inequality analysis, (2) a graphical representation of the distribution of inequality, and (3) a range of additive decomposable inequality indices consistent with dominance. We apply this method and a Difference in Differences approach to evaluate the impact of a disease management programme aiming at reducing underutilisation of GP services for diabetic patients in Denmark. The programme introduced a set of non-pecuniary incentives empowering GPs with feedback reports on their performance and comparisons with other peers. Our study population includes 93,849 diabetic patients aged 18 + registered in 563 GP practices in Denmark; a total of 246 of these practices joined the programme, and 317 are used as control. The results show that patients experiencing the largest inequality in the top quintile of the distribution are characterised by deprivation in multiple socio-economic and morbidity dimensions that are not captured fully by income and education. The programme significantly reduced inequality in access to pivotal services, such as blood tests and preventive visits, for all patients and, with greater magnitude, for the most-deprived patients. Non-pecuniary incentives may be an effective tool for GPs to improve access to care in the most vulnerable patients.