SELECTED FOR YOU... APRIL 2012:
books of the month
site of the month
working papers

All the Selected for you

BOOKS OF THE MONTH

Evidence-based policy : a realist perspective.
Politique fondée sur les preuves : une perspective réaliste.

Pawson R.
Londres : Sage : 2011 : 11 p.+196 p.

Author Ray Pawson presents a devastating critique of the dominant approach to systematic review - namely the 'meta-analytic' approach as sponsored by the Cochrane and Campbell collaborations. In its place is commended an approach that he terms 'realist synthesis'. On this vision, the real purpose of systematic review is better to understand program theory, so that policies can be properly targeted and developed to counter an ever-changing landscape of social problems (4e de couverture).

Handbook of survey research.
Manuel de recherche par enquête.

Marsden P.V., / éd., Wright J.D. / éd
Bingley : Emerald Group Publishing Company : 2010 : 14 p.+ 886 p.

This book is divided into three parts. Part 1 provides a general background for what follows; it includes both a discussion of the substantive importance of dynamic analyses is sociology and a review of models and methods previously used by sociologists interested in the empirical study of social dynamics. Part 2 contains eight chapters on models and methods for analyzing change in qualitative outcomes; it concentrates mainly on methods based on analyses of event-history data. Part 3 contains six chapters on comparable models and methods for analyzing change in quantitative outcomes; it focuses primarily on methods based on analysis of panel data.

WORKING PAPERS

Health Economics

What drives Health Care Expenditure in France since 1950? A time-series study with structural breaks and non-linearity approaches.
Qu'est-ce qui motive les dépenses de soins de santé en France depuis 1950 ? Une étude de séries temporelles avec des ruptures structurelles et des approches non linéaires.

Barnay T., Damette O.
Paris : TEPP : 2012 : 30 p.

Using the French annual database (1950-2009), we conducted a time-series analysis to explain the role of GDP per capita on HCE (Health Care Expenditure) per capita taking into account structural breaks and non-linearity in the long-term economic relationship between HCE and GDP, controlling for price effect, population ageing, innovation proxy and medical density. We show that the non-linearity of the long-run relationship between HCE and GDP comes from both the presence of a structural break and non-linearity explained by a transition variable (by constructing a smooth transition cointegrating regression). More precisely, lower GDP elasticity is explained by an exogenous shock linked to health system policies in the mid 1980's (break analysis) and endogenously driven changes in the health care system via medical density in France.

Is There Too Much Inequality in Health Spending Across Income Groups?
Y-a-t-il trop d'inégalités en matière de dépenses de santé parmi les groupes de revenus ?

Alesci L., Hosseini R., Jones L.E.
Cambridge : NBER : 2012/03 : 64 p.

This paper studies the efficient allocation of health resources across individuals. It focuses on the relation between health resources and income (taken as a proxy for productivity). In particular it determines the efficient level of the health care social safety net for the indigent. It assumes that individuals have different life cycle profiles of productivity. Health care increases survival probability. It adopts the classical approach of welfare economics by considering how a central planner with an egalitarian (ex-ante) perspective would allocate resources. It shows that, under the efficient allocation, health care spending increases with labor productivity, but only during the working years. Post retirement, everyone would get the same health care. Quantitatively, it finds that the amount of inequality across the income distribution in the data is larger that what would be justified solely on the basis of production efficiency, but not drastically so. As a rough summary, in U.S. data top to bottom spending ratios are about 1.5 for most of the life cycle. Efficiency implies a decline from about 2 (at age 25) to 1 at retirement. It finds larger inefficiencies in the lower part of the income distribution and in post retirement ages.

Hospital

Do High-Cost Hospitals Deliver Better Care? Evidence from Ambulance Referral Patterns.
Les hôpitaux les plus chers sont-ils ceux qui offrent les meilleurs soins ? Résultats issus de l'orientation des patients par les ambulances.

Doyle J.J., Graves J.A., Gruber J., et al.
Cambridge : NBER : 2012/03 : 44 p.

Endogenous patient sorting across hospitals can confound performance comparisons. This paper provides a new lens to compare hospital performance for emergency patients: plausibly exogenous variation in ambulance-company assignment. Ambulances are effectively randomly assigned to patients in the same area based on rotational dispatch mechanisms. Using Medicare data from 2002-2008, we show that ambulance company assignment importantly affects hospital choice for patients in the same zip code. Using data for New York state from 2000-2006 that matches exact patient addresses to hospital discharge records, it shows that patients who live very near each other but on either side of ambulance-dispatch boundaries go to different types of hospitals. Both strategies show that higher-cost hospitals have significantly lower one-year mortality rates compared to lower-cost hospitals. It finds that common indicators of hospital quality, such as indicators for "appropriate care" for heart attacks, are generally not associated with better patient outcomes. On the other hand, it finds that measures of "leading edge" hospitals, such as teaching hospitals and hospitals that quickly adopt the latest technologies, are associated with better outcomes, but have little impact on the estimated mortality-hospital cost relationship. It also finds that hospital procedure intensity is a key determinant of the mortality-cost relationship, suggesting that treatment intensity, and not differences in quality reflected in prices, drives much of our findings. The evidence also suggests that there are diminishing returns to hospital spending and treatment intensity.

Hospital competition with soft budgets.
Concurrence entre hôpitaux ayant des budgets réduits.

Brekke K., Siciliani L., Straume O.
Braga : NIPE : 2011/12 : 26 p.

This article studies the incentives for hospitals to provide quality and expend cost-reducing effort when their budgets are soft, i.e., the payer may cover deficits or confiscate surpluses. The basic set up is a Hotelling model with two hospitals that differ in location and face demand uncertainty, where the hospitals run deficits (surpluses) in the high (low) demand state. Softer budgets reduce cost efficiency, while the effect on quality is ambiguous. For given cost efficiency, softer budgets increase quality since parts of the expenditures may be covered by the payer. However, softer budgets reduce cost-reducing effort and the profit margin, which in turn weakens quality incentives. We also find that profit confiscation reduces quality and cost-reducing effort. First best is achieved by a strict no-bailout and no-profit-confiscation policy when the regulated price is optimally set. However, for suboptimal prices a more lenient bai lout policy can be welfare improving.

Social Health Inequalities

Education, Health and Mortality: Evidence from a Social Experiment.
Niveau d'éducation, état de santé et mortalité : résultats d'une expérimentation sociale.

Meghir C., Palme M., Simeonova E.
Cambridge : NBER : 2012/03 : 55 p.

This paper studies the effect of a compulsory education reform in Sweden on adult health and mortality. The reform was implemented by municipalities between 1949 and 1962 as a social experiment and implied an extension of compulsory schooling from 7 or 8 years depending on municipality to 9 years nationally. It uses detailed individual data on education, hospitalizations, labor force participation and mortality for Swedes born between 1946 and 1957. Individual level data allow us to study the effect of the education reform on three main groups of outcomes: (i) mortality until age 60 for different causes of death; (ii) hospitalization by cause and (iii) exit from the labor force primarily through the disability insurance program. The results show reduced male mortality up to age fifty for those assigned to the reform, but these gains were erased by increased mortality later on. It finds similar patterns in the probability of being hospitalized and the average costs of inpatient care. Men who acquired more education due to the reform are less likely to retire early.

Medicines

The Use of Pay-for-Performance for Drugs: Can It Improve Incentives for Innovation?
L'utilisation du système de paiement à la performance pour les médicaments : peut-elle améliorer les incitations à l'innovation ?

Towse A., Garrison L.P., Puig-Peiro R.
London : OHE : 2012/02 : 14 p.

Interest is growing in schemes that involve “paying for pills by results”, that is, “paying for performance” rather than merely “paying for pills”. Despite its intuitive appeal, this approach is highly controversial and is disliked by many health care providers, policy makers, and pharmaceutical companies. In this paper, the authors define pay-for-performance and the related terms used in discussions about such schemes; set out a framework for understanding and interpreting them; explore existing schemes, providing examples; discuss the benefits and weaknesses of such schemes; and consider their value as an incentive for innovation. In the literature to date, the authors note, identified benefits are countered by significant costs and challenges. As a result, the overall balance remains unclear, despite strong opinions regarding one specific scheme (the UK's risk sharing scheme for multiple sclerosis drugs). They find that sentiment is strong against outcomes based schemes. Two related problems are identified by the authors as being behind the hesitation to make use of pay-for-performance schemes. The first is a tendency to focus on the negatives of experience to date, despite the lack of good evidence; the second is the predominance of rather naïve views about the feasibility of the alternatives. Rewarding those products that do deliver performance (in the form of health gain and other benefits) is very important in stimulating innovation. The authors conclude that “pay-for-performance” offers an important way forward to both handle uncertainty around expected value in routine clinical practice and provide the rewards essential for continued innovation.

How Can European Reference Price Systems Influence Drugs Innovations?
Comment les systèmes européens de prix de référence influencent-ils l'innovation ?

NGuyen T., Rohlf K.
Lahr : Wissenschaftliche Hochschule : 2012 : 15 p.

In this essay, the authors have modified a model from the literature about the monopoly quality in order to explain different drug provision decisions of the European states. They analyze particularly the effects of different population sizes as well as per capita incomes in a two country model. It turns out that different drug prices are not necessarily a proof for an inefficient provision in the examined countries. It can rather be efficient from the pan-European point of view that high-income countries grant in-creased subsidies in order to make the provision of innovative drugs possible for the low-income, new countries of the EU. Contrary to the intention of its introduction, a European system of reference prices or parallel imports do not increase the welfare but lead rather to a lower efficiency of the supply with innovative drugs.

Twenty Years of Using Economic Evaluations for Reimbursement Decisions. What Have We Achieved?
Vingt années d'utilisation des évaluations économiques pour les décisions de remboursement. Qu'avons-nous accompli ?

Drummond M.
York : University of York : 2012/02 : 16 p.

The objective of this paper is to examine the impact of economic evaluation on the reimbursement process for pharmaceuticals. Before the introduction of economic evaluation, a range of arrangements existed across different jurisdictions, varying from reimbursement based on clinical criteria alone and price controls, to a total absence of controls over price or reimbursement. The changes in the structure of reimbursement policies necessary to incorporate economic evaluation have been accomplished without major difficulty in most jurisdictions. However, several methodological differences in international guidelines for economic evaluation exist, only some of which can easily be justified. A number of beneficial changes in reimbursement processes have also been observed, such as a trend towards requiring the measurement of more meaningful clinical endpoints and increased engagement between manufacturers, drug regulators and payers. A consistent finding in studies of reimbursement decisions is that economic considerations have been influential, second only to the strength of the clinical evidence for the drug of interest. The impact of economic evaluation on the allocation of healthcare resources is hard to ascertain because of the difficulties in specifying the counterfactual and the fact that little is known about the extent to which reimbursement decisions actually lead to changes in healthcare practice. However, there is evidence that economic evaluation has assisted price negotiations and enabled reimbursement agencies to target drugs to those patients who will benefit the most. In publicly financed healthcare systems, an evidence-based system of pricing and reimbursement for drugs, considering societal willingness-topay, is a reasonable policy objective to pursue.

Health prevention

The Effectiveness of Health Screening.
L'efficacité de la prévention en santé.

Hackl F., Halla M., Hummer M., et al.
Bonn : IZA : 2012/02 : 34 p.

Using a matched insurant-general practitioner panel data set, we estimated the effect of a general health-screening program on individuals' health status and health care cost. To account for selection into treatment, we used regional variations in the intensity of exposure to supply-determined screening recommendations as an instrumental variable. We found that screening participation substantially increased inpatient and outpatient health care costs for up to two years after treatment. In the medium term, we found cost savings in the outpatient sector, whereas in the long run, no statistically significant effects of screening on either health care cost component could be discerned. In summary, screening participation increases health care costs. Since we did not find any statistically significant effect of screening participation on insurants' health status at any point in time, we do not recommend a general health-screening program. However, given that we found some evidence for cost-saving potentials for the sub-sample of younger insurants, we suggest more targeted screening programs.

Primary health care

The Effect of Physician Fees and Density Differences on Regional Variation in Hospital Treatments.
L'influence des honoraires des médecins et des disparités de densité sur la variation régionale des traitements à l'hôpital.

Douven R., Mocking R.
Utrecht : NZA: 2012 : 52 p.

This working paper uses a panel data set of about 1.7 million hospital records in 4,000 Dutch zip code regions for the years 2006-2009. Its estimates the effect of physician fees and physician density on regional variation in hospital care for nine different treatments. The results show that a 1 percent increase in the total number of physicians, if these extra physicians are all paid according to an output-based reimbursement scheme, would increase the number of treatments on average by 0.40 percent. For salaried physicians we find a significantly lower average effect of 0.15 percent. We find no or weak effects for hip fractures, which is included in the analysis as a control treatment. Our data allows us to deal with reverse causality, excess demand, border crossing, and availability effects. The findings lend support to the existence of supplier induced demand for the majority of the analyzed treatments.

Health care system

The Relationship between Self-reported Unmet Need for Health Care and Health Care Utilization.
La relation entre la perception de besoin en soins non satisfaits et l'utilisation des services de soins de santé.

Mhurley J., Jama T., Grignon M. et al.
Hamilton : McMaster Research Data Centre : 2011 : 35 p.

This study builds on the work of Allin, Grignon, and Le Grand (2008) to investigate the relationship between self-reported unmet need and a variety of measures of health care utilization. It exploits a linked Ontario Canadian Community Health Survey-administrative data that includes individual-level information on self-reported unmet needs and a person's actual use of physician and hospital services, which permits a number of improvements over existing research. It measures utilization using the dollar value of services received, which: provides a more accurate measure of volume of care obtained (because it is not subject to recall error and because it adjusts for the nature of the services received); allows us to combine general practitioner, specialist physician services and hospital services to examine the relationship between unmet need and total service use; and allows us to study both inpatient services and day procedures, the latter of which constitute an increasing proportion of hospital utilization (CIHI 2007).

Roadblocks to Reform: Beyond the Usual Suspects.
Les obstacles à la réforme : aller au-delà des raisons habituellement avancées.

Grignon M.
Hamilton : McMaster University : 2012/01 : 22 p.

Real reforms attempt to change how health care is financed and how it is rationed. Three main explanations have been offered for why such reforms are so difficult: institutional gridlock, path dependency and societal preferences. The latter posits that choices made regarding the health care system in a given country reflect the broader societal set of values in that country and that, as a result, public resistance to real reform may more accurately reflect citizens' personal convictions, self-interest or even active social choices. “Conscientious objectors” may do more to derail reform than previously recognized.

Are Health Care ‘Choice – and – Competition' Reforms really Efficiency Driven?
Les réforme en matière de soins de santé et de concurrence sont-ils réellement menés de manière efficace ?

Costa-Font J., Zigante V.
London : London School of Economics and Political Science : 2012/01 : 30 p.

Are choice and competition reforms only a route to improving economic efficiency or, do other goals buttress the so-called choice agenda? We here examine evidence of alternative explanations for drivers of choice reforms. More specifically, we explore whether there is evidence consistent with political incumbents' aspirations to satisfy middle (median) classes (voters), alongside providers capture and service modernisation agendas as potential drivers. We concentrate on health care sector reforms given its central role as a reference universal welfare service - and focus on eight European countries where there has been heterogeneous experimentation with choice and competition reforms. Our findings suggest that whilst competition and choice reforms are primarily driven by the attainment of micro-efficiency and modernisation goals, middle class politics and to a some extent provider interests, appear to also prompt choice reforms. Hence, we conclude that allocative efficiency is not the sole driver of choice reforms.

Productivity of the English National Health Service 2003-4 to 2009-10.
Productivité du service national de santé anglais de 2003-4 à 2009-10.

Bojke C., Castelli A., Goudie R., et al.
York : University of York : 2012/03 : 45 p.

The objectives of this research is to estimate output, input and productivity growth for the English NHS for the period 2003/4 to 2009/10 using the most detailed and comprehensive information at its disposal. It reveals that the productivity of the NHS in England has been broadly constant over the last seven years, increasing by an average of 0.1 per cent per year. The research shows that between 2003/4 to 2009/10 the number of staff has increased by 18 per cent, buildings and equipment by 24 per cent and all other inputs, such as clinical supplies and energy costs, by 76 per cent. There has also been a corresponding increase in both the quantity and quality of output. The number of patients treated in hospital increased from 12.1m to 15.6m; outpatient attendances from 50m to 77m; community care contacts from 76m to 92m; and primary care consultations from 262m to 300m. Over the same period, hospital survival rates improved from 99.4 per cent to 99.8 per cent for elective patients and from 95 per cent to 96 per cent for non-electives. Average inpatient waiting times fell from 78 to 57 days, reaching a low of 51 days in 2008/9. Outpatient waiting times fell from 58 days to 24 days. All in all, growth in activity and changes in quality have tracked the growth in inputs, implying that productivity has been flat over the seven year period.