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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Asthma in France in 2006: Prevalence and Control of Symptoms
Questions d'économie de la santé n° 138. December 2008.
Afrite A., Allonier C., Com-Ruelle L., Le Guen N., with the collaboration of Annesi-Maesano I. (Inserm Unity 707), Delmas M.-C. (InVS), Furhman C. (InVS), Leynaert B. (Inserm Unity 700)

In 2006, 6.25 million people in metropolitan France reported having had asthma at least once during their lifetime, and among these, 4.15 million, i.e. 6.7% of the population, continued to live with it. Overall, men were as much concerned by asthma as women, but with differences according to age. Less than half of asthmatics were administered controller medications
to control and reduce the intensity of symptoms related to the bronchial hyperresponsiveness which is a characteristic of this chronic disease.
Asthma symptoms were inadequately controlled for six out of ten asthmatics: 46% of asthmatics are partly controlled and 15% completely uncontrolled. Among the completely uncontrolled asthmatics, one quarter did not follow any long-term daily treatment.
Ceteris paribus, being obese, current smoking, living in a low-income or single-parent household increases the risk of having uncontrolled asthma.
These results are drawn from the French Health, Health Care and Insurance survey (ESPS*) which is carried out on the general population. The 2006 Survey included a specific set of questions on asthma designed to identify asthmatics and assess the level of control of symptoms.

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SHARE, the Survey of Health, Ageing, and Retirement in Europe goes longitudinal - Data from wave 2 is now available
Questions d'économie de la santé n° 137. December 2008.
Barangé C., Eudier V., Sirven N.

The Survey of Health, Ageing, and Retirement in Europe (SHARE) is an international, multidisciplinary and longitudinal survey, developed to address research issues on ageing.
Wave 2 data, collected in 2006-07, provides panel data from respondents already interviewed in 2004-05. Since ageing should be seen as a process, rather than a state, longitudinal dimension is of foremost importance to put a stress on evolutions and transitions, as well as generation effects and causality.
This issue presents some preliminary results from wave 2 of SHARE. These results deal with health and labour market dynamics. They show the influence of working conditions and institutional differences – especially concerning disability assurance enrolment, on early exits from the labour force and retirement decisions. Moreover, the new data confirms first wave analyses in terms of health disparities, and gives new insight about changes in health services utilization.

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GPs teamed up with nurses: a skill mix experiment improves management ot type 2 diabetes patients - Main results of the ASALEE experiment.
Questions d'économie de la santé n° 136. November 2008
Bourgueil Y., Le Fur P., Mousquès J., Yilmaz E.

ASALEE, French acronym for Health Action by Teams of Self-employed Health Professionals, associates 41 GPs and 8 nurses in the Deux-Sèvres department (FRANCE) in view to improve the quality of healthcare, especially for patients suffering from chronic disease. Launched in 2004, it is the only natural experiment on healthcare professionals skill mix with focus given to primary care use. In accordance with a specific protocol, the doctors entrust the nurses with the computerized management of certain patient data and therapeutic education consultations.
This medico-economic evaluation of the ASALEE natural experiment focused specifically on type 2 diabetes patients, which represents a third of nurses activity. The study shows that the improvement of the glycemic control of patients treated in the ASALEE experiment is better than that of a control group. They also perform more systematic follow-up examinations without significant additional cost for Health Insurance. Nontheless, the methods used in the study require that these results be validated by further analyses.

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The volume-outcome relationship in hospitals - Lessons from the literature
Questions d'économie de la santé n° 135. September 2008
Com-Ruelle L., Or Z., Renaud T.

Concentrating the supply of hospital care is often presented as a means to improve the quality of care, but the extent of the relationship and the direction of causality between hospital volume and health outcomes is still a matter for debate. The systematic literature review carried out by the Irdes shows that for certain procedures and interventions, particularly complex surgery, there is a real possibility of improving outcomes by increasing activity volumes. The presence of a learning curve at both the individual level (surgeon) and hospital level (transfer of knowledge, organisation of work) appear to explain a large part of this correlation. In certain cases, however, the alternative hypothesis of selective referral, according to which patients are directed towards the hospitals with the best outcomes, cannot be disproved.
Moreover, this causal link between volume and outcome should be interpreted with caution: the results are sensitive to the nature of the procedures analysed and to the activity thresholds used. The more complex and specific the procedure, the stronger the correlation between volume and outcome. For most procedures, there is no single minimum volume threshold which emerges from the literature. In addition, some studies show that the volume-outcome relationship becomes marginal above what may be a relatively low threshold.

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Referral to specialist consultations in France in 2006 and changes since the 2004 Health Insurance reform - 2004 and 2006 Health, Health Care and Insurance surveys
Questions d'économie de la santé n° 134. August 2008
Le Fur P., Yilmaz E.

The August 2004 Health Insurance reform seemed to have had substantial impacts on the patients' access to and use of specialist care. According to data published in the Health, Health Care and Insurance Surveys in 2004 and 2006, the proportion of consultations obtained by patients through direct access fell considerably, especially for dermatology and ENT, which both had high levels of consultation in 2004. Concurrently, for many specialties, there was a rise in referral access to specialists by general practitioners (most usually the Preferred Doctor), the number varying according to specialty. Lastly, the number of consultations advised by the specialists themselves remained fairly stable.
All other things being equal, the determinants of direct access to specialist care (other than gynaecologists and ophthalmologists) changed slightly between 2004 and 2006. The influence of social environment and level of education appeared to decline slightly, while household size became significant. The proportion of direct access consultations with specialists was lower for persons living in households with three members and higher than for those living alone.

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Self assessed health of immigrants in France - Analysis of the 2002-03 decennial health survey
Questions d'économie de la santé n° 133. July 2008
Dourgnon P., Jusot F., Sermet C., Silva J.

Data from the decennial health survey conducted by Insee in 2002-2003 show that people of foreign origin living in France report worse health status than native French. Immigrants worse self assessed health is partly explained by poorer socio-economic status and working conditions. But self assessed health status also varies according to the country of origin, and more specifically according to the country's level of development. Thus, immigrants from the richest countries report a better health status than those from intermediate developed countries, suggesting that the social and health situation in countries of birth has a long-term effect on health status. Immigrants from the poorest countries also report better health status than those from intermediate developed countries. This can be explained by a health selection effect in the migration process in the poorest countries. Lastly, the fact of acquiring French nationality doesn't appear to make any difference to the health status of immigrants.

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Complementary Health Insurance in France in 2006: Access is Still Unequal
Results of the 2006 French Health, Health Care and Insurance Survey (ESPS 2006)

Questions d'économie de la santé n° 132. May 2008
Kambia-Chopin B., Perronnin M., Pierre A., Rochereau T.

In 2006, more than 9 out of 10 people in France reported being covered by complementary health insurance. Of those not covered, more than one in two reported financial difficulties. Access to complementary health insurance therefore remains difficult and expensive for low income households and, indeed, these households declare the lowest rate of coverage. On the contrary, households with the highest incomes, especially those of managers, benefit from easier access to complementary insurance due to higher financial resources and more frequent access to group health insurance contracts.
For the first time, the data of the French Health, Health Care and Insurance Survey (ESPS*) have been used to calculate the effort rate, i.e. the share of income that households devote to complementary insurance coverage. This effort rate varies from 3% for the wealthiest households to 10% for the poorest (excepting the beneficiaries of supplementary universal health insurance*). However, in spite of an effort rate three times higher, the contracts covering the poorest households provide lower levels of guarantee on average than the contracts of the wealthiest households.
In addition, for 14% of the population the lack of complementary coverage was a major factor for foregoing healthcare for financial reasons in 2006.

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The 2006 Health, Health Care and Insurance Survey, a panel for health policies analysis, public health and health economics research
Questions d'économie de la santé n° 131. April 2008
Allonier C., Dourgnon P., Rochereau T.

Since 1988, the Health, Health Care and Insurance Survey (Enquête santé protection sociale, ESPS) provide information on French population's health status, utilization of healthcare services and health insurance. Thanks to its frequency, scope and longitudinal dimension, the survey participates in evaluating health policies, monitoring of public health problems in general population and research in the field of health economics.
In 2006, the Health, Health Care and Insurance Survey interviewed 8,100 households and 22,000 individuals. A oversample of households covered by public means tested complementary insurance was added, in order to better describe the health status access to health care of this population.
The 2006 survey incorporates new questions. In particular it is intended to participate in the evaluation of the “preferred doctor” reform and the coordinated treatment pathway scheme. Besides, questions on respiratory health and asthma will permit monitoring the evolution of the disease, studying its social and environmental determinants, and evaluating the adequacy of the treatments effectively dispensed as referred to medical guidelines. A module on living conditions during childhood and parent's health status will permit deepening studies on the intergenerational mechanisms at play in the construction of unequal health status, especially the transmission of risk behaviours.

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Explaining the strong disparities observed in the CMU-C clientele of independent practitioners?
Questions d'économie de la santé n° 130. March 2008
Cases C., Lucas-Gabrielli V., Perronnin M., To M.

The proportion of beneficiaries of supplementary universal health insurance (CMU-C) treated by general practitioners (GPs), specialists and dentists varies greatly from one practitioner to another. In addition to the geographic distribution of CMU-C beneficiaries, the variability can be partly explained by the nature of this population's health-care needs. This is a relatively young, female population, characterised by specific health problems (notably mental and sleep disorders and illnesses of the nervous system and the ear). The socio-economic environment and particularly the average income of the commune (local administrative district) in which the doctors practise also plays a role. Doctors in the most deprived communes appear to be relatively ‘specialised', attracting CMU-C beneficiaries from richer neighbouring communes.
A degree of discrimination against CMU-C patients by certain professionals cannot be excluded: there is indeed a lower proportion of CMU-C patients among the clientele of ‘sector 2' doctors (who set their own fees, but have to apply the agreed Social Security fee to CMU-C patients ) and dentists. But it is difficult to distinguish between a choice freely made by CMU-C patients (on the basis of their characteristics and preferences) and a choice constrained by a doctor's refusal to treat.

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Alcohol consumption in France: one more glass of French paradox
Questions d'économie de la santé n° 129. January 2008
Com-Ruelle L., Dourgnon P., Jusot F., Lengagne P., January 2008

In France, excessive drinking is essentially an issue among men. More than four men vs. one woman out of ten are affected. Moreover, one in every two men between the age of 25 and 64 is an excessive drinker.
Excessive drinking is less common among people living in a family, except when another member of the family drinks excessively.
The links between excessive alcohol consumption and socio-economic status appear to be complex. Among women, the risk is significant for executives only, while among men it affects executives as well as blue collar workers, but is less frequent among employees. Persons who have experienced periods of social disadvantage during their lives, men working in intermediate professions, self employed, salespersons, executives and men with low income are more likely to have a chronic rather than an episodic consumption pattern. Finally the least well-off are most likely to be non-drinkers.
These results are based on a general population survey which for the first time in France enables to identify excessive, moderate and non-drinking behaviours.

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July 22nd, 2011