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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The Health of Older Workers in Europe: Results of SHARE 2006
Issues in Health Economics (Questions d'économie de la santé) n° 160. 2010/12.
Lenormand M.-C., Sermet C., Sirven N.

An ageing population and the extension of working life are confronting most countries with the challenge of healthy ageing. Using data from the Survey of Health, Ageing and Retirement in Europe (SHARE), this study focuses on the state of health of Europeans aged 50 to 59 and its determinants.
If we note a notable increase in health problems from the age of 50, we equally note considerable situational differences between European countries. Although France has one of the highest life expectancy rates, its position is inversely rather poor regarding the health status of workers in their fifties.
After comparing the health status of older workers with that of the unemployed and inactive population in the same age group, creating the ‘healthy worker’ effect, particular attention is given to the analysis of the determinants of health in older employed Europeans.

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Arammis Microsimulation Model Contribution: an Analysis of the Redistributive Effects of an OOP Maximum on Ambulatory Care Expenditures
Issues in Health Economics (Questions d'économie de la santé) n° 159. 2010/11.
Debrand T., Sorasith C.

In France, although the Compulsory Health Care Insurance scheme reimburses a large part of health expenditures, patients may still be faced with high out-of-pocket payments (difference between actual health expenditure and the amount reimbursed).
Within the framework of IRDES commitment to exploring ways of reducing ‘excessive’ out-ofpocket (OOP) payments, we tested two possible ways of introducing OOP maximums using the Arammis microsimulation model. We simulated substituting the current long-term illness scheme (ALD), covering registered patients’ expenditures at 100%, for two OOP threshold models restricted to ambulatory health care expenditures (excluding hospital stays and charges exceeding statutory fees) and applicable to all Compulsory Health Care Insurance beneficiaries (excluding CMU beneficiaries). The first model introduces a fixed uniform threshold for all beneficiaries; the second an income-related threshold.
Using a microsimulation model based on individual data, the study outlines two OOP threshold mechanisms with a neutral effect on the health insurance scheme’s financial equilibrium.

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Has the Introduction of Mandatory Deductibles Modified Patients’ Prescription Drug Purchasing Behaviour?
Issues in Health Economics (Questions d'économie de la santé) n° 158. 2010/10.
Kambia-Chopin B., Perronnin M.

Introduced on January 1st 2008, the 0.5€ deductible levied on every prescription drug package purchased was an incentive measure essentially aimed at regulating individuals’ drug consumption. Applicable independently of drug category, individuals’ financial resources or health status, this deductible essentially increases the financial burden borne by individuals especially those with low income or in poor health. As a result, some individuals may be constrained to forego necessary treatment. In order to provide a first indication of this hypothesis, an analysis using declarative data from the 2008 Health, Health Care and Insurance Survey (Enquête Santé et Protection Sociale, ESPS) was conducted.
12% of respondents declared a modification in their prescription drug purchasing behaviour following the introduction of the 0.5€ deductibe. This behaviour change is mainly influenced by income level and health status: with a 7 point increase, the probability of declaring a change in drug purchasing behaviour almost doubles among individuals earning less than 870€ per month compared with those earning over 1,167€ per month. Among individuals suffering from a chronic disease, the probability increases by two points compared to the others and a similar gap is observed between individuals reporting average, poor or very poor health and those reporting good health.

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Group Practice Dynamics Among Private General Practitioners from 1998 to 2009
Issues in Health Economics (Questions d'économie de la santé) n° 157. 2010/09.
Baudier F. (ARS), Bourgueil Y. (Irdes), Evrard I. (Irdes), Gautier A. (Inpes), Le Fur P. (Irdes), Mousquès J. (Irdes)

Based on the Inpes 1998, 2003 and 2009 General Practitioners’ Health Barometer surveys conducted on representative national samples, this joint Inpes/Irdes study analyses group practice trends, its characteristics and evolution among private general practitioners.
Today, group practices are in the majority. The percentage of private GPs declaring to work in a group practice has risen from 43% in 1998 to 54% in 2009. This increase is particularly apparent among GPs aged below 40 with eight out of ten working in a group practice.
Three quarters of group practice GPs share premises exclusively with other GPs and/or specialists. These office-based practices are in the majority made up of two or three practitioners.
The group practice structure appears to alter GPs’ weekly work patterns without for as much altering their weekly volume of activity: group practice GPs more frequently declare working less than five days a week but carry out more medical acts per day than GPs working alone. Group practice is equally associated with more available time for training, supervising students and the greater use of computerised patient files.

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Drug-prescription Management in Patients with Multiple Chronic Conditions
Issues in Health Economics (Questions d'économie de la santé) n° 156. 2010/07-08.
Clerc P., Le Breton J., Mousquès J., Hebbrecht G., de Pouvourville G.

In a context where the prevalence of chronic diseases is constantly rising, drug-related risks confronting patients suffering from multiple chronic conditions (MCC) remains poorly documented. Although certain undesirable adverse effects are inherent to the use of a drug and therefore inevitable, certain adverse effects could be prevented as they result from noncompliance with indications and recommendations.
The experimental Polychrome study provides some answers. On the one hand, it reveals that the treatment of MCC patients is a predominant aspect of general medicine and inevitably results in polypharmacy (multiple drug prescriptions) and, on the other, that the concurrent use of multiple drugs is not without iatrogenic risk. Serious adverse drug reactions are nevertheless relatively rare. More generally, the study reveals that drug prescription quality could be improved; notably by reducing prescription imprecisions and inappropriate dosage, but equally in reducing the number of drugs prescribed.
If the Polychrome study remains experimental, it nevertheless reveals the difficulties facing general practitioners in prescribing drug treatments for MCC patients. It also provides interesting perspectives for the optimal use of pharmaceutical drugs and their use in combination with alternative, drug-free therapies.

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Employer-sponsored Complementary Health Insurance:
Variable Situations According to Company

Issues in Health Economics (Questions d'économie de la santé) n° 155. 2010/06.
Guillaume S., Rochereau T.

Preliminary results from Irdes new wave of the Employer-sponsored Complementary Health Insurance survey (PSCE) conducted in 2009 reveals that over two in five establishments (excluding the public services and agricultural sectors) offer their employees a complementary health insurance (CHI) scheme. The PSCE survey is conducted at establishment level as the specificities of the offercan vary between establishments belonging to the same company. Thus, only 32% of very small companies (VSC with less than 10 employees) offer CHI compared to 91% in establishments belonging to companies of over 250 employees. Similarly, the higher the percentage of executives employed within the company, the higher the percentage of establishments offering CHI, and the higher the guarantees offered by the contracts proposed.
Furthermore, the 2003 Fillon Act incited companies to change CHI contract garantees so as to maintain their tax and social security deductions. In 2009, a third of contracts were subscribed to within the previous two years. Over three out of four establishments offered a compulsory enrolment contract (or contracts) exclusively; 15% of establishments declared having converted from voluntary to compulsory schemes in conformity with the legislation.
On average, 57% of the cost of the contract is financed by the employers and in 85% of establishments where employee participation is obligatory, employees pay a fixed-rate contribution.

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Lifestyles: a Channel of Intergenerational Transmission of Health Inequalities?
Issues in Health Economics (Questions d'économie de la santé) n° 154. 2010/05.
Bricard D., Jusot F., Tubeuf S.

In France, several recent studies have highlighted inequalities of opportunity in health directly related to social background. In order to better understand the long-term effects of childhood living conditions, specific questions were introduced in the Health, health care and insurance survey conducted by Irdes in 2006.
The results reveal the extent of inequalities of opportunity in health in France: having a poor social background, parents with a low education level, who also are in poor health or adopt risky health behaviours, are the factors explaining health inequalities in adulthood.
Risky behaviours adopted by the parents, mother’s education level as well as difficult material conditions during childhood influence descendant’s future lifestyles which in turn have an impact on her long-term health status. Adult health is thus influenced by a indirect effect of social background combined with a direct effects of living conditions during childhood.
Beyond government interventions aimed at improving equality of opportunities in education, or more globally, in living conditions, specific prevention and health promotion policies targeting underprivileged populations are potential avenues to reduce inequalities of opportunity in health.

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What Would be the Optimal Subsidy to Encourage Subscription to Supplementary Health Insurance?
Issues in Health Economics (Questions d'économie de la santé) n° 153. 2010/04.
Grignon M.,Kambia-Chopin B. (McMaster University, Irdes)

Health insurance reduces financial risk and plays an important role in low income households’ access to care. However, these same households are the least likely to benefit from supplementary health insurance coverage. The average monthly income in households without supplementary coverage is 844€ against 1,382€ in households with supplementary coverage. Encouraging low income households to purchase supplementary health insurance can be achieved by subsidising part of the premium, an approach favoured by the ACS scheme introduced in France. The question is then to determine the optimal amount of financial assistance that will ensure an effective improvement in access to supplementary health insurance.
The aim here is to simulate the impact of different subsidy levels on the decision to purchase supplementary health insurance among households situated just above the CMU-C income threshold. To carry out this simulation, individual supplementary health insurance purchase behaviours were observed. According to our results, three quarters of potential ACS beneficiaries would accept paying a monthly premium of 50 Euros if the subsidy covered 80% of the premium.

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Asthma Patients’ Ambulatory Care Expenditures in 2006
Issues in Health Economics (Questions d'économie de la santé) n° 152. 2010/03.
Com-Ruelle L., Da Poian M.-T., Le Guen N.

In France, asthma patients’ total ambulatory medical expenditures is one and a half times higher than for non-asthmatics, according to data matching of IRDES’ “Health, Health Care and Insurance” survey (ESPS) with Health Insurance claims. This is due to the condition itself, the level of asthma control and co-morbidities more frequently affecting asthma sufferers (allergies...).
The level of control is, however, insufficient for 6 out of 10 asthmatics and only 12.5% of them consulted an office-based pneumologist (10 % of asthma patients as a whole). General practitioners remain on the front line in asthma monitoring for all patients.
Medication is the highest item in all asthma-related ambulatory care expenditures but is concentrated among a percentage of varying consumers according to therapeutic class. A third of asthmatics receive no anti-asthma treatment. This suggests that health professionals can still improve asthma management in terms of education programs and risk-factor reduction (environmental measures).

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Who Took out Additional Supplementary Health Insurance? A dynamic Analysis of Adverse-Selection
Issues in Health Economics (Questions d'économie de la santé) n° 150. 2010/01.
Franc C. (Cermes, Inserm U988, CNRS UMR8211), Perronnin M. (Irdes), Pierre A. (Irdes), in collaboration with Cases C. (Ined)

According to economic theory, individuals choose their insurance cover levels in virtue of anticipated health expenditures. Thus, they partially reveal their health risks. Yet, on the French health insurance market this hypothesis, known as ‘adverse-selection’, has only been tested on the supplementary health insurance purchase decision. However, the supplementary health insurance market is extremely heterogeneous, at least in the same way as beneficiaries’ health risk levels.
Between July 1st 2003 and December 31st 2006, a mutual insurance fund for state employees (Mutuelle générale de l’équipement et des territoires) offered existing holders of its supplementary cover (‘MGET basic’) an additional health coverage (‘MGET+’). This particular context, where individuals covered from the same supplementary health insurance decide to purchase additional cover, provides an opportunity to test the adverse-selection hypothesis. Using an approximated health risk calculated from a policyholder’s age and past health expenditures, the determinants of purchasing MGET+ are analysed and compared through time.
At the end of 2005, around 20 % of the individuals covered by ‘MGET basic’ had purchased ’MGET+’ cover, and the majority from its outset in 2003. Initial purchasers tended to be older with higher healthcare needs, notably in physician, optical and dental care. From 2004, policyholders with more modest incomes tended to defer purchasing MGET+ and did so in anticipation of optical care expenditures, the only expense item that maintains its positive influence through time.

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July 26th, 2011