Issues in Health Economics

Issues in Health Economics (in French : Questions d’économie de la santé) is a monthly publication presenting syntheses of latest Irdes research on health economics. Benefiting from a high public visibility, this publication is systematically translated in English.

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Improving the geographical distribution of health professionals: What the literature tells us
Questions d'Úconomie de la santÚ n° 116. December 2006.
Bourgueil Y., Mousquès J., Tajahmadi A.

The ability of health systems in developed countries to guarantee access to health services throughout the country will be severely stretched in years to come, given the expected reduction in the number of health professionals, particularly doctors. The geographical distribution and productivity of health professionals will also be affected by already discernible trends – poor investment in general medicine, difficulties in setting up practice in some areas, the desire to work in group practices or in institutions, which trends are related in particular to the changing work-life balance.
Most studies do no more than describe inequalities in geographical distribution using essentially demographic and professional criteria, and look more rarely at policies designed to improve the geographical distribution of health professionals, and their impact. With regard to the latter there is no “miracle remedy” in the international literature. Nevertheless, while taking into account the huge range of measures implemented at different points in the professional career, the literature highlights the limits of the two measures most frequently used: on one hand increasing the total number of doctors, which is considered to be ineffective, and on the other, financial incentives, which are thought to be insufficient.

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Company supplementary health insurance: Compulsory or voluntary schemes, avoiding adverse selection and its effect on employees
Questions d'Úconomie de la santÚ n° 115. November 2006.
Francesconi C., Perronnin M., Rochereau T.

Company supplementary sickness insurance is offered to 72% of employees, according to the Company Supplementary Social Protection survey (PSCE), and is by no means uniform. Many different schemes exist: compulsory schemes offered to all employees or to a proportion of them, voluntary schemes with or without options etc.. These schemes are not all exposed to the same degree of adverse selection. Adverse selection exists where young persons in good health choose not to insure themselves, which leads people in poor health to finance their own risk. According to our survey, insurers protect themselves against this risk by proposing for the most part compulsory group schemes, or voluntary schemes with options. Voluntary schemes without options are most exposed to this risk, and affect at most 15% of employees. In these cases, employees who delay signing up to the scheme may face increased premiums.
Compulsory group schemes and voluntary schemes do not offer the same levels of benefit to employees. The first, which are not exposed to adverse selection and enjoy a range of advantages in terms of costs, offer on average higher levels of cover. The voluntary schemes give employees more freedom, particularly that of whether to subscribe, and would appear, in the service sector, to be offered most often by companies which delegate management of the scheme to the employees.

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Differences between reported and diagnosed morbidity The examples of obesity, arterial hypertension and hypercholesterolemia
Questions d'Úconomie de la santÚ n° 114. November 2006.
Dauphinot V., Naudin F., Gueguen R.(CETAF), Perronnin M., Sermet C. (Irdes)

Using a sample of persons who both responded to a health survey by interview and agreed to have a medical examination, this study compares the prevalence rates reported from these two sources for three cardiovascular risk factors: obesity, arterial hypertension and hypercholesterolemia. Individuals under-report poor health whatever the health problem; in general, very few report a problem although the results of medical examination is negative. We note that,
- one person in three declared their height and weight incorrectly, resulting in an underestimation of the prevalence of obesity;
- almost one in two persons suffering from arterial hypertension did not report this at the time of the survey
In the case of obesity, under-reporting seems to result from a problem of self evaluation, whether deliberate or not. However the significant under-reporting of arterial hypertension and hypercholesterolemia is of more concern because it probably indicates poor understanding of the problem due to inadequate screenning. The results of this study show that prevalence rates established on the basis of self-reporting must be interpreted carefully, as for example in prevention campaigns. This is a serious issue for cardiovascular mortality, which with 180 000 deaths per year, is the leading cause of mortality in France.

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Why patients attending free health centres seek care Precalog Survey 1999-2000
Questions d'Úconomie de la santÚ n° 113. October 2006.
Collet M. (Drees), Menahem G. , Picard H.

One in two persons living in social exclusion reports having suffered pain which is difficult to endure during the year preceding the survey. Yet more than half refuse or delay seeking treatment. It appears that some of them are reluctant to seek medical care: they put off seeking a consultation or attend haphasardly, while others do not adhere to the prescribed treatment or even refuse to treat their health problems. Why is there this resistance or denial? While it does not completely answer this question, our survey shows the importance of people’s relationship with the health system and the important influence of the particularly difficult lives which people living in social exclusion have endured (serious family problems during their youth, prolonged unemployment etc.). <
This new exploration of the survey of persons consulting free health centres, carried out in 1999/2000, enables us to analyse the variety of motives for seeking care of the socially excluded population. It completes the recent study of Médecins du monde by looking again at a bigger sample.

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Workplace provided supplementary health insurance: Levels of cover in contracts by type of employee and sector of activity
Questions d'Úconomie de la santÚ n° 112. September 2006.
Francesconi C., Perronnin M., Rochereau T.

On the basis of a survey of companies carried out at the end of 2003, this study shows that managers enjoy a range of benefits related to group health insurance: more managers than non-managers have access to these schemes, and they benefit from higher levels of cover. Thus:
- companies employing high proportions of managers on average offer contracts with better cover;
- and where they offer different contracts to different groups of employees, the cover is almost always better for managers.
And finally, for those services least well-reimbursed by public health insurance, dental and optical services, one manager in three has access through his employer to a contract with a good level of cover, compared to one in five non-managers.
If, on average, the levels of cover vary little by sector of activity, there are big differences between companies in the same sector, depending on their size and the status of employees. Hence employees of small companies in the services sector and to an even greater extent in the manufacturing sector, are for the most part excluded from group health insurance schemes; whereas the construction sector, in contrast to the manufacturing sector, makes little distinction between managers and non-managers in terms either of access to company schemes or the levels of cover offered.

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Expenditure on prevention and care by disease in France
Questions d'Úconomie de la santÚ n° 111. July 2006.
Fénina A., Geffroy Y., Minc C., Renaud T., Sarlon E, Sermet C.

This study is based on the 2002 National Health Accounts, and presents an estimation of the distribution of health expenditure by curative and preventive care, and distribution of curative expenditure by the main disease groups.
In 2002, France spent 10,5 billion Euros on prevention, i.e. 6.4% of current health expenditure, half of this on preventing disease or undesirable states, one quarter on disease screening and the remaining quarter on intervention in risk factors or early stage disease. Expenditure on prevention related to the Consumption of care and medical goods was 54.7 billion Euros. Consumption of care and medical goods excluding prevention has been allocated by disease. Thus, expenditure on cardiovascular disease is the highest (12.6%), greater than mental illness and musculoskeletal disease (10.6% and 9% respectively).
Infections of the mouth and teeth account for most ambulatory care expenditure (28.3%) and circulatory disease and mental illness together represent more than a quarter of hospital expenditure.

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Health, Health Care and Insurance Survey 2004: First results
Questions d'Úconomie de la santÚ n° 110. July 2006.
Allonier C., Guillaume S., Rochereau T.

The Health, Health Care and Insurance survey (ESPS) depicts how health care and health insurance cover are distributed among the French population.
The 2004 survey provides new results on health status. Women are less likely than men to report good health (29.6% compared to 22.5%). They also declare more illnesses (3.9 compared to 2.7 for men), but these are less severe. Men, whose life expectancy is lower, declare more serious illnesses.
Acces to supplementary health insurance on health care appear to be a issue for a non negligeable part of the French population.
Nearly one in ten persons report neither CMU supplementary health insurance. 13% report almost one not sought care for financial reasons during the previous twelve months. Almost half of not sought care concern dental care, 18% medical optics, and 9% specialist care.
The survey confirms the strong social gradient in health Insurance and health care status: blue collar households and those of employees report poor health status most frequently, are least likely to have supplementary health insurance cover and are most likely to forego care.

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Effects of health on the labour force participation of older persons in Europe
Questions d'Úconomie de la santÚ n° 109. June 2006.
Barnay T., Debrand T.

The health status of older Europeans has a major influence on the probability of being in employment, according to a study based on the SHARE 2004 survey. At the European level the employment rate of persons aged 50 or more is much lower for persons self-reporting a disease or severe restrictions in activities of daily living. For example it is half the average for persons who have suffered a cerebrovascular accident (CVA). Similarly, for persons suffering from cancer, the employment rate falls from 43% to 34% for women and from 63% to 42% for men.
After controlling the effects of age, educational level, marital status and country of residence on health status, the analysis shows that the diseases which are most detrimental to employment for men are: hip fractures, cerebrovasular accidents, heart disease and diabetes.
Finally the study shows that health status does not explain the differences in employment rate for men between European countries. This varies from a little over 40% in Austria to 80% in Switzerland. These differences are more likely to relate to differences in national economic circumstances and to regulations governing the legal age of retirement and mechanisms for leaving employment.

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July 26th 2007