Cream skimming by health care providers and inequality in health care access: Evidence from a randomized field experiment

Using a randomized field experiment, we show that health care specialists cream-skim patients by their expected profitability. In the German two-tier system, outpatient reimbursement rates for both public and private insurance are centrally determined but are significantly higher for the privately insured. In our field experiment, following a standardized protocol, the same hypothetical patient called 991 private practices in 36 German counties to schedule appointments for allergy tests, hearing tests and gastroscopies. Practices were 4% more likely to offer an appointment to the privately insured. Conditional on being offered an appointment, wait times for the publicly insured were twice as long than for the privately insured. We also find smaller access differences when reimbursement rate differences are smaller. Our findings show that structural differences in reimbursement rates lead to structural differences in health care access. (c) 2021 Elsevier B.V. All rights reserved.

Automated summary

In the German two-tier healthcare system, privately insured patients are more likely to get appointment offers from clinics and experience shorter wait times. The study also shows that smaller differences in reimbursement rates result in smaller disparities in healthcare access.