title: Increased cost sharing and changes in noncompliance with specialty referrals in The Netherlands.
abstract: BACKGROUND
  The compulsory deductible, a form of patient cost-sharing in the Netherlands, has more than doubled during the past years. There are indications that as a result, refraining from medical care has increased. We studied the relation between patient cost-sharing and refraining from medical care by evaluating noncompliance with referrals to medical specialists over several years.
  
  
  METHODS
  Noncompliance with specialty referrals was assessed in the Netherlands from 2008 until 2013, using routinely recorded referrals from general practitioners to medical specialists and claims from medical specialists to health insurers. Associations with patient characteristics were estimated using multilevel logistic regression analyses.
  
  
  RESULTS
  Noncompliance rates were approximately stable from 2008 to 2010 and increased from 18% in 2010 to 27% in 2013. Noncompliance was highest in adults aged 25-39 years. The increase was highest in children and patients with chronic diseases. No significantly higher increase among patients from urban deprived areas was found.
  
  
  CONCLUSIONS
  Noncompliance increased during the rise of the compulsory deductible. Our results do not suggest a one-to-one relationship between increased patient cost-sharing and noncompliance with specialty referrals. In order to develop effective policy for reducing noncompliance, it is advisable to focus on the mechanisms for noncompliance in the groups with the highest noncompliance rates (young adults) and with the highest increase in noncompliance (children and patients with chronic diseases).
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands. Electronic address: T.vanEsch@nivel.nl.
authors.forename: Thamar E M
authors.initials: TE
authors.lastname: van Esch
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands. Electronic address: a.brabers@nivel.nl.
authors.forename: Anne E M
authors.initials: AE
authors.lastname: Brabers
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands. Electronic address: christelvdijk@hotmail.com.
authors.forename: Christel E
authors.initials: CE
authors.lastname: van Dijk
authors.affiliation: Vektis, P.O. Box 703, 3700 AS Zeist, The Netherlands. Electronic address: l.gusdorf@vektis.nl.
authors.forename: Lisette
authors.initials: L
authors.lastname: Gusdorf
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands; Utrecht University, Department of Sociology, Department of Human Geography, The Netherlands. Electronic address: p.groenewegen@nivel.nl.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Groenewegen
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, The Netherlands. Electronic address: j.dejong@nivel.nl.
authors.forename: Judith D
authors.initials: JD
authors.lastname: de Jong
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002908:Chronic Disease; D017047:Cost Sharing / Q000191:economics*; D005260:Female; D006801:Humans; D007345:Insurance Claim Review; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D013038:Specialization
keywords: Cost sharing; Longitudinal studies; Netherlands; Patient compliance; Primary health care; Referral and consultation