High income is strongly associated with elderly people seeing a specialist in the U.S., but not in Canada — where poor health is a much stronger predictor of who sees a specialist. Those are the findings of a new study published in the January issue of the International Journal of Health Services, according to a recent press release. The study found that elderly Americans in the top 40 percent of the income distribution were nearly twice as likely as those in the bottom 20 percent to visit a specialist. The study found that in Canada, there was no statistically significant association between income and specialist visits.

“This study points out an inequity between the U.S. and Canadian health care systems,” says David Feeny, Ph.D., co-author of the study and Professor Emeritus, University of Alberta. “Both systems have government financed health insurance for the elderly, but in the U.S. the likelihood of visiting a specialist appears to be related to income, while in Canada it appears to be related to need or burden of illness.”

“This finding is especially important in the context of national healthcare reform,” says Mark Kaplan, DrPH, lead author and professor of community health at Portland State University. “Even though they have Medicare coverage, some of the sickest Americans may not be able to afford the extra out-of-pocket expenses associated with seeing a specialist.”

The study used data collected in 2002/2003 survey conducted by Statistics Canada and the U.S. National Center for Health Statistics. Seven-hundred 55 elderly Canadians and 1,151 elderly Americans were asked if they had seen a doctor in the past 12 months, and if their most recent visit was with a family doctor (general practitioner) or a medical specialist.

The survey also collected demographic, socioeconomic, and health status information. The authors used statistical modeling to determine which factors were strongly associated with doctor visits. In the U.S., respondents with household incomes of $50,000 or more (top 40 percent of income distribution) were nearly twice as likely (1.74) as those with household incomes of less than $30,000 (bottom 20 percent of income distribution) to have seen a specialist. In Canada, but not in the U.S., poor health (as measured by HUI) was strongly associated with having seen a specialist. The Health Utilities Index (HUI) is a survey tool that asks people to rate their abilities in eight categories, including vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain. The lower their score the more likely Canadians were to have seen a specialist.

Nearly the same percentage of elderly people in the U.S. (81.6 percent) and Canada (78.8 percent) had seen any type of physician in the past year, but a greater percentage of U.S. respondents (25.6 percent) had seen a specialist, compared to (16.4 percent) of Canadians. The authors suggest that this might be explained by the gatekeeper system in Canada, where a referral from a general practitioner or family doctor is required to see a specialist. In Canada, there are also nearly an equal number of specialists and general practitioners, in the U.S. more than 2/3 of doctors are specialists.

Study limitations include a lower response rate in the U.S. than Canada and that the study relied on self-reported data that could have been influenced by socially desirable responses.