Socioeconomic inequalities in waiting times for planned and cancer surgery: Evidence from Spain.

Waiting times act as a non-price rationing mechanism to bring together the demand for and the supply of public healthcare services and ensure equal access independently of ability to pay. This study tests for the presence of socioeconomic inequalities in waiting times for ten publicly-funded planned and cancer surgeries in Catalonia (Spain) in 2015-2019. Socioeconomic status (SES), measured by four categories (very low, low, middle, high), is based on co-payment levels for medicines which depend on patient's income. Using administrative data, we estimate the association between SES and waiting times controlling for patient characteristics and hospital fixed effects. Compared to patients with low SES, patients with middle SES wait 2-6 fewer days for hip replacement, cataract surgery, and hysterectomy, and less than a day for breast cancer surgery. These inequalities arise within hospitals and are not explained by patient nor hospital characteristics. For some surgeries, the results also show that patients with higher SES are more likely to voluntarily exit the waiting list and have a lower probability of having a surgery canceled for medical reasons and dying while waiting.

The association between bed occupancy rates and hospital quality in the English National Health Service.

We study whether hospitals that exhibit systematically higher bed occupancy rates are associated with lower quality in England over 2010/11-2017/18. We develop an economic conceptual framework to guide our empirical analysis and run regressions to inform possible policy interventions. First, we run a pooled OLS regression to test if high bed occupancy is associated with, and therefore acts as a signal of, lower quality, which could trigger additional regulation. Second, we test whether this association is explained by exogenous demand-supply factors such as potential demand, and unavoidable costs. Third, we include determinants of bed occupancy (beds, length of stay, and volume) that might be associated with quality directly, rather than indirectly through bed occupancy. Last, we use a within-between random-effects specification to decompose these associations into those due to variations in characteristics between hospitals and variations within hospitals. We find that bed occupancy rates are positively associated with overall and surgical mortality, negatively associated with patient-reported health gains, but not associated with other indicators. These results are robust to controlling for demand-supply shifters, beds, and volume. The associations reduce by 12%-25% after controlling for length of stay in most cases and are explained by variations in bed occupancy between hospitals.