Are Turkish patients treated differently by German physicians? What role does health insurance play? A corresponding testing study by the Johannes Kepler University Linz and the Vienna University of Economics and Business provides answers.

Minority group members face many challenges in the healthcare system. Does discrimination in the healthcare system add to the challenges? A correspondence testing study explores whether or not German physicians in private practice treat members of an ethnic minority differently. Conducted under the scientific and academic direction of Prof. Martin Halla (Department of Economic Policy at the JKU) and Prof. Rupert Sausgruber (Institute of Public Economics and Finance at WU Vienna), researchers sent an e-mail to 3,224 medical practices (in different areas of specialty) in 79 major German cities to request an appointment. The e-mail contained random attributes of the fictitious patients. The focus was on ethnicity (German vs. Turkish) and type of health insurance (private, PKV vs. public, GKV).

Christian Schmidt versus Ahmet Yilmaz
The fictitious e-mail sender names were "Christian Schmidt" and "Ahmet Yilmaz". Researchers contacted dentists, ophthalmologists, dermatologists, and orthopedists. The response rate of 74% was high, showing that e-mails are an acceptable way to make an appointment. In order to minimize the physicians’ workload, the appointments were canceled right after receiving confirmation of the appointment. This also ensured other patients were not impacted because of the study and were able to make an appointment.

Public vs. Private Health Insurance
It is crucial to stress that physicians are paid more for treating patients who have private health insurance. This means that it is more lucrative to give appointments to privately-insured (PKV) patients than publicly insured (GKV) patients. Germany’s institutional environment is an ideal testing ground in lieu of ethnic discrimination since the type of patient insurance determines the doctor’s revenue; ethnicity should not be an influencing factor. If, nonetheless, physicians showed they were more inclined to give "Christian Schmidt" an appointment rather than to "Ahmet Yilmaz" (who has the same insurance), this would be a strong indication of ethnic discrimination.

Appointment Scheduling & Wait Time
The study focused primarily on whether or not the rate of appointments scheduled differs between the fictitious patients. The study also looked at and analyzed how long it took to get a response to the e-mail, how long of a period before the scheduled appointment, and if information about the expected waiting time was provided.

On average, "Ahmet Yilmaz" (who had the same type of insurance) was treated equally.
The study showed that ethnicity per se has no effect on getting an appointment or on the wait times. This holds true for both types of patient insurance and specialists. However, as other studies have shown, insurance is a strong determining factor. Those holding public health insurance received an appointment in 41% of cases. Those holding private health insurance experienced a 32% higher probability of receiving an appointment and amounts to 54% (see chart below). There are additional differences between those insured by the GKV or PKV with regard to basic e-mail response (72% vs. 75%), the wait time for an appointment (plus 8 hours), and the frequency with which patients were told they would have to wait for a longer time at the doctor’s office (22% vs. 15%).

Competition Among Physicians, However, Plays a Role
Economic theory suggests that (when prices are regulated) the quality of healthcare improves as competition intensifies. Accordingly, the study found that in low-competition market sectors, those insured by the GKV experience ethnic discrimination. In regions where there are fewer medical practices, compared to "Christian Schmidt", "Ahmet Yilmaz" is less likely to get an appointment. In contrast, the regional share of AfD voters or the share of Turks in the overall population does not matter.

Is the Finding Surprising?
The result that German-Turks are not discriminated against may come as a surprise as other studies have shown German-Turks experience discrimination in other areas of life, including the job and housing market. This new study shows that there is little room for (statistical) discrimination in the German healthcare system. The structural differences in physician compensation (GKV vs. PKV), however, create barriers for those who are economically disadvantaged, and that includes German-Turks to an above-average degree.

Additional information about the study

Title:

Testing for Ethnic Discrimination in Outpatient Health Care: Evidence from a Field Experiment in Germany

Authors:

Martin Halla (JKU Linz)

Christopher Kah (Mercedes-Benz AG)

Rupert Sausgruber (WU Vienna)

Abstract:

To test for ethnic discrimination in access to outpatient health care services, we carry out an email-correspondence study in Germany. We approach 3,224 physician offices in the 79 largest cities in Germany with fictitious appointment requests and randomized patients' characteristics. We find that patients' ethnicity, as signaled by distinct Turkish versus German names, does not affect whether they receive an appointment or wait time. In contrast, patients with private insurance are 31 percent more likely to receive an appointment. Holding a private insurance also increases the likelihood of receiving a response and reduces the wait time. This suggests that physicians use leeway to prioritize privately insured patients to enhance their earnings, but they do not discriminate persons of Turkish origin based on taste. Still, their behavior creates means-based barriers for economically disadvantaged groups.

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http://www.economics.jku.at/papers/2021/wp2115.pdf, opens an external URL in a new window

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