Copayments and the evidence-base paradox

In reply: I thank Lexchin for citing the Saskatchewan natural experiment, but we do need to exercise caution when extrapolating the findings of this study to the current copayment debate.

The Saskatchewan copayments were higher ($10 to $13 in today's money1), and broader (covering general practice, emergency department and outpatient visits). The study population was “essentially agrarian”,2 life expectancy was less than 70 years for men,3 and information-sharing technology was completely different from what we have today. The study analysed the effect of a copayment only on the poorest of families,2 defined as having incomes (in 2014 dollars1) of up to $11 500 for individuals and $32 000 for a family of five. People on such incomes might be holders of concession cards today in Australia, and would be exempt from the proposed copayment.

Furthermore, “It is, of course, not possible to infer whether the reduction in these services represents a decline in ‘abuse' through overservicing or overutilization, or an increase in ‘unmet needs'.”2 This is a recurring theme in the copayment debate, but could not be determined in the Saskatchewan analysis.2

We also have to recognise there is an opportunity cost to any health care expenditure. Using Canada as an example, there has been a doubling in the time Canadians wait to receive specialist treatment since 1993.4 This represents reduced access to health care. Therefore it can't be assumed that a reduction in use of general practitioner services, even among the poor, is necessarily a bad outcome if it contributes to a more effective allocation of health resources. We just don't know.