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The Impact of An Increase in User Costs on the Demand For Emergency Services: The Case of Portuguese Hospitals


  • Pedro Ramos

    () (Faculdade de Economia, Universidade do Porto)

  • Álvaro Almeida

    () (CEF.UP and Faculdade de Economia, Universidade do Porto)


Evidence on the impact of user costs on healthcare demand in “universal” public National Health Service (NHS) systems is scarce. The changes in copayments and in the regulation of the provision of free patient transportation, introduced in early 2012 in Portugal, provide a natural experiment to evaluate that impact. However, those changes in user costs were accompanied with changes in the criteria that determine which patients are exempt from copayments, implying that changes to the underlying populations made simple comparisons of user rates meaningless. The aim of this paper is to evaluate the impact of increases in direct and indirect user costs on the demand for emergency services (ES), in the context of changes to the underlying populations of exempt and non-exempt patients. Our contributions are twofold: we develop a new methodology for analyzing ES demand changes following user cost increases when the underlying population is not constant, and we measure the relative impact of copayments and distance costs on ES demand, in NHS-countries, with “almost free” access to healthcare. Our results show that the increase in copayments did not have a significant effect in moderating ES demand by paying users. On the other hand, we find a significant effect of the change in transport regulation in the demand for ES, especially in the more general polyvalent ES and for older patients. Thus, our results support the conclusion that indirect costs may be more important than direct costs in determining healthcare demand in NHS-countries where copayments are small and wide exemption schemes are in place, especially for older patients.

Suggested Citation

  • Pedro Ramos & Álvaro Almeida, 2014. "The Impact of An Increase in User Costs on the Demand For Emergency Services: The Case of Portuguese Hospitals," FEP Working Papers 531, Universidade do Porto, Faculdade de Economia do Porto.
  • Handle: RePEc:por:fepwps:531

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    References listed on IDEAS

    1. Chiappori, Pierre-Andre & Durand, Franck & Geoffard, Pierre-Yves, 1998. "Moral hazard and the demand for physician services: First lessons from a French natural experiment," European Economic Review, Elsevier, vol. 42(3-5), pages 499-511, May.
    2. Barros, Pedro Pita & Machado, Matilde P. & Sanz-de-Galdeano, Anna, 2008. "Moral hazard and the demand for health services: A matching estimator approach," Journal of Health Economics, Elsevier, vol. 27(4), pages 1006-1025, July.
    3. Rainer Winkelmann, 2004. "Co-payments for prescription drugs and the demand for doctor visits - Evidence from a natural experiment," Health Economics, John Wiley & Sons, Ltd., vol. 13(11), pages 1081-1089.
    4. Acton, Jan Paul, 1975. "Nonmonetary Factors in the Demand for Medical Services: Some Empirical Evidence," Journal of Political Economy, University of Chicago Press, vol. 83(3), pages 595-614, June.
    5. Óscar D. Lourenço & Pedro L. Ferreira, 2005. "Utilization of public health centres in Portugal: effect of time costs and other determinants. Finite mixture models applied to truncated samples," Health Economics, John Wiley & Sons, Ltd., vol. 14(9), pages 939-953.
    6. Jaume Puig‐Junoy & Marc Saez & Esther Martínez‐García, 1998. "Why do patients prefer hospital emergency visits? A nested multinomial logit analysis for patient‐initiated contacts," Health Care Management Science, Springer, vol. 1(1), pages 39-52, September.
    7. Dor, Avi & Gertler, Paul & van der Gaag, Jacques, 1987. "Non-price rationing and the choice of medical care providers in rural Cote d'Ivoire," Journal of Health Economics, Elsevier, vol. 6(4), pages 291-304, December.
    8. Manning, Willard G. & Marquis, M. Susan, 1996. "Health insurance: The tradeoff between risk pooling and moral hazard," Journal of Health Economics, Elsevier, vol. 15(5), pages 609-639, October.
    9. Babu Nahata & Krzysztof Ostaszewski & Prasanna Sahoo, 2005. "Rising Health Care Expenditures: A Demand Side Analysis," Journal of Insurance Issues, Western Risk and Insurance Association, vol. 28(1), pages 88-102.
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    More about this item


    Copayments; Indirect costs; healthcare demand;

    JEL classification:

    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private

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