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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Excess Costs of Adverse Events in Hospitals in France
First estimations using nine patient safety indicators

Issues in Health Economics (Questions d'économie de la santé) n° 171. 2011/12.
Nestrigue C., Or Z. (Irdes)

Based on routine hospital data, this study provides the first estimations at the national level of excess costs incurred by a number of selected adverse events in hospitals. The nine patient safety indicators chosen correspond to avoidable adverse events which require attention.
The results indicate that 0.5% of hospital stays are associated with one of these nine adverse events. The excess costs generated, vary considerably ranging from a little over 500 € for obstetric traumas to almost 20,000 € for postoperative sepsis. The excess costs are closely correlated with length of hospital stay and intensity of care. In 2007, the total cost of care incurred by these nine adverse events was estimated near 700 million Euros. Four adverse events (postoperative physiologic and metabolic derangement, postoperative sepsis, decubitus ulcers and post-operative pulmonary embolism) represented 90% of the costs.
Adverse hospital events examined in this study represent a substantial burden in terms of cost and length of stay. It is necessary to invest in these areas with a perspective of improving both the quality of patient care and care cost-efficiency in hospitals.

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Giving up on Health Care for Economic Reasons: an Econometric Approach
Issues in Health Economics (Questions d'économie de la santé) n° 170. 2011/11.
Desprès C. (Irdes), Dourgnon P. (Irdes ; Paris-Dauphine University, Leda-Legos), Fantin R. (Irdes), Jusot F. (Paris-Dauphine University, Leda-Legos ; Irdes)

Despite extensive public health insurance coverage, France faces social inequalities in access and use of health care services. In this research we study self assessed unmet needs (SUN) as an alternative approach to standard measures of health consumption, such as expense or number of visits, so as to cast new light on social inequalities in access to health care services issues.
SUN is measured in a short questionnaire on having given up on health care for financial reasons within the last twelve months. The questionnaire is introduced in the ESPS survey, a French general population survey on health, health care and insurance. We focus on SUN for financial reasons since French ambulatory care is grounded on private practice, fee for service, some of it unregulated, and upfront payment.
In 2008, 15.4% of the adult population declared having given up on medical care for financial reasons over the last twelve months. Economic barriers to accessing care are essentially concentrated on dental care (10% declared having foregone dental care for financial reasons) and to a lesser extent, eyewear (4.1%) and physician visits (3.4%, GPs and specialists altogether).
These difficulties in accessing care are partially explained by limits in Insurance coverage. Indeed, the lack of complementary health insurance (CHI) coverage appears to reduce significantly access to health services whereas means tested CHI (CMU-C) facilities access. This study also brings to light explanatory factors related to life course episodes, in particular past and present socio-economic conditions and perspectives. Our study also confirms that prices do matter. The level of the fees in the unregulated ambulatory sector (in 2008, 40.7% of specialists and 8.5% of GPs belong to the so-called unregulated “secteur 2”) has an impact on access to health care as measured through SUN.
A socio-anthropological study published simultaneously by the authors (Desprès et al., 2011) supports the use of SUN data in quantitative multivariate approaches to study access to health care services.

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Healthcare Renunciation: a Socio-anthropological Approach
Issues in Health Economics (Questions d'économie de la santé) n° 169. 2011/10.
Desprès C. (Irdes), Dourgnon P. (Irdes ; Paris-Dauphine University, Leda-Legos), Fantin R. (Irdes), Jusot F. (Paris-Dauphine University, Leda-Legos ; Irdes)

Although the concept of healthcare renunciation is regularly employed in health surveys and increasingly called into the French public debate, it has never been subject to methodological questioning to analyse the term’s underlying significations. If health surveys frequently refer to healthcare renunciation for economic reasons, a socio-anthropological approach using in-depth interviewing permits a broader analysis of its signification for the individuals concerned and establishes the social, economic and cultural determinants involved.
This study shows that there are two main forms of healthcare renunciation: barrier-renunciation and refusal-renunciation. In the first case, individuals are confronted with an environment of constraints, more notably budgetary constraints, preventing access to the desired care. The second case is an expression of patient autonomy with regard to conventional medicine. It is characterized by the refusal of certain specific therapies or a more radical, definitive form of refusal when seeking treatment is perceived as being unnecessary. These two forms of healthcare renunciation (barrier and refusal) are often interrelated: the economic factor is rarely isolated and is frequently combined with other reasons leading individuals to forego treatment.
An econometric analysis, based on the results of a survey on healthcare renunciation for economic reasons, is being published simultaneously (Desprès et al., 2011).

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The Effects of Welfare State Intervention on the Living Condition of Europeans Aged 50 and Over
First Results of SHARELIFE on Life Histories

Issues in Health Economics (Questions d'économie de la santé) n° 168. 2011/09.
Briant N., Lenormand M.-C., Sirven N.

SHARELIFE, the third wave of the Survey of Health, Ageing, and Retirement in Europe (SHARE), interviewed senior citizens aged 50 and over on their life histories from childhood to the present day. The aim of the survey was to fill an information gap common to surveys on health and economic and social conditions: the lack of retrospective data. By collecting standardized retrospective data on individuals’ life histories, SHARELIFE permits, for example, a better understanding of the effects of welfare state intervention on individuals’ past and present lives.
The first results from SHARELIFE presented here have been summarised from a selection of articles taken from the multi-authored book The Individual and the Welfare State, edited by A. Börsch-Supan, M. Brandt, K. Hank and M. Schröder. If the positive short-term effects of social protection systems are confirmed, unexpected and sometimes pernicious long-term effects, both in terms of public expenditures and individual benefits, are equally observed.

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Analysis of the Impact of Drug Delisting in France between 2002 and 2011
Issues in Health Economics (Questions d'économie de la santé) n° 167. 2011/07-08.
Pichetti S., Sermet C.

Between 2002 and 2011, the continuous increase in pharmaceutical expenditures prompted the public authorities to delist drugs with low therapeutic values. Of the 486 drugs considered inefficient in terms of medical services rendered (SMR, ‘service médical rendu’) still on the market in March 2011, 369 were delisted whereas 117 are still reimbursed, for the majority at the rate of 15%.
These successive waves of drug delisting have an immediate impact on drug prescription rates for the pharmaceuticals concerned, resulting in a significant drop in sales volumes. The subsequent increase in over-the-counter sales of delisted drugs for self-medication purposes does not compensate for sales volume loss. Patients who continue to take these drugs are faced with an average 43% price increase shortly after delisting.
An evaluation of delisting measures must equally take into account the tendency towards prescribing substitute classes of therapeutic drugs that are still reimbursed. If the substitute drugs are inappropriate from a medical point of view, the consequences both in terms of public health and National Health Insurance savings can be damaging; the greater the tendency toward prescribing reimbursable therapeutic alternatives, the lower the savings.
If drug delisting produces immediate savings, its long-term effectiveness can be put into question and would benefit from being accompanied by piloting tools enabling the impact of future exclusions from the reimbursable drugs basket to be anticipated and monitored.

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Relationship between Perceived Labour Market Rewards and the Health of Senior Workers
Issues in Health Economics (Questions d'économie de la santé) n° 166. 2011/06.
Lengagne P.

According to Siegrist’s effort-reward imbalance (ERI) model, the feeling that one’s laboureffort is inadequately rewarded generates a psychological risk factor with an adverse effect on health. On the basis of the European SHARE survey carried out in 2004 and 2006 among individuals aged 50 and over, this study attempts to measure the effects of ERI on elderly workers’ health status and identify work-related factors that could explain this imbalance.
According to our results, the probability of self-reporting activity limitations increases by 8 points among older workers experiencing ERI in 2004 and 2006, and the probability of selfreporting joint pain or backache by over 12 points.
The perceived imbalance between the effort expended at work and the rewards received, more prevalent among blue-collar workers and clerks than executives, is equally associated with physically demanding work, workload and perceived job insecurity. The effort-reward imbalance at work is less frequently experienced by employees working in small companies (less than 15 employees) and self-employed workers than those working in medium-sized companies (25 to 199 employees). Finally, the results reveal significant disparities between European countries in the perceived rewards in exchange for effort. This reflects the differences between northern European countries with higher employment performance in the employment of seniors and those with lower employment performance such as France.

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Do Individuals Using the 21 Health Care Centres Participating in the EPIDAURE-CDS Study Have a Lower Socio-Economic Status?
Issues in Health Economics (Questions d'économie de la santé) n° 165. 2011/05.
Afrite A., Bourgueil Y., Dufournet M., Mousquès J.

The exploratory project EPIDAURE-CDS aims at analysing the specificity of 21 polyvalent health care centers (HCC) in the supply of health care and evaluating their role in the reduction of health inequalities, notably in terms of access to primary care. Preliminary results show that compared to general medicine patients within the population as a whole, HCC patients are more socio-economically disadvantaged and self-report poorer health.
The level of individual socio-economic deprivation is assessed using the EPICES score which takes into account the broader, multidimensional aspects of socio-economic conditions, contrary to traditionally used socio-administrative indicators. This score shows that over 60% of HCC patients have a low socio-economic status against less than 40% within the population as a whole. Individual deprivation is associated with a lower probability of self-reporting good health and a higher consumption of general medicine. Furthermore, socio-economic deprivation appears to be concentrated among beneficiaries of a complementary health insurance (CHI) other than the state-funded CHI for low-income individuals.
If these results indicate that HCCs supply care to a more vulnerable population thereby contributing to facilitate access to health care, the quality of care delivered needs to be evaluated, and more generally whether the services supplied effectively correspond to the health care needs of socio-economically deprived populations.

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Travel Distances and Travel Times to Nearest Health Care in Metropolitan France
Issues in Health Economics (Questions d'économie de la santé) n° 164. 2011/04.
Coldefy M., Com-Ruelle L., Lucas-Gabrielli V. (Irdes)

Access to medical care has become a central issue in the current context of major hospital sector reforms and the anticipated decline in the number of physicians on the French territory. Measured in terms of physical distance and travel time, this study examines the spatial accessibility of nearest ambulatory and hospital care on January 1st 2007. An innovative methodology is proposed for the identification and geolocation of the main specialities provided by hospitals.
Travel times are generally satisfactory; 95 % of the French population has access to primary care in less than fifteen minutes. Similarly, the majority of private practice specialists and the most usual medical equipment are accessible by road in less than 20 minutes on average. 95% of the French population can equally access usual hospital care in less than 45 minutes, and 75% in less than 25 minutes.
However, inequalities in access to health care persist for both common and rare medical specialities. Rural regions, with a low population density, combine remoteness of both primary care and most of specialised ambulatory care. Since 1990, the average distance travelled to access care has decreased for some specialists, in particular urologists, and increased for others, notably paediatricians.

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Do the Transformations in Health Care Supply Correspond to General Medical Care Users’ Concerns?
Issues in Health Economics (Questions d'économie de la santé) n° 163. 2011/03.
Krucien N., Le Vaillant M., Pelletier-Fleury N. (Cermes-Prospere)

Primary care supply is currently undergoing significant changes, notably in general medicine. This is occasioned by several different factors including: demographic change within the profession and organisational reforms, the ageing of the population and the progressive increase in incidence and prevalence of chronic disease as well as changes in health care consumers’ expectations. Far from being specific to France, these changes fall within an international context that is paying more and more attention to the health care users’ perspective in the organisation of the health care system.
Based on a qualitative analysis method (Delphi ranking method), this study aims to examine current transformations in general medical care (GP, group practices, continuity of care, etc.) from the users’ perspective by identifying their major concerns.
Results show that the priority for general medical care consumers is the doctor-patient relationship and, more especially, information exchange. Users generally confer a high degree of importance to clinical quality (meticulousness of the medical examination, preventive action and health education…) and GPs’ ability to coordinate care in a way that asserts their assigned role of ‘gatekeeper’ within the health system. On the contrary, factors related to the physician’s characteristics (gender, age) or the medical structure within which the physician practices (multi-profession and multi-disciplinary or solo practice) have little importance.

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Take-up Rate of a Subsidising Scheme for Acquiring a Complementary Health Insurance in France: Key Findings from a Social Experiment in Lille
Issues in Health Economics (Questions d'économie de la santé) n° 162. 2011/02.
Guthmuller S. (Leda-Legos), Jusot F. (Leda-Legos, Irdes) , Wittwer J. (Leda-Legos), in collaboration with Desprès C. (Irdes)

The subsidising scheme for acquiring a complementary health insurance (ACS), introduced in 2005, aimed at targeting households with an income level situated just above the eligibility threshold for Universal Complementary Health Insurance (CMU-C). Even if the number of beneficiaries has slowly progressed, ACS take-up rates remain low. In order to understand the underlying motives behind poor take-up, a social experiment was carried out in Lille among a sample of statutory National Health Insurance (NHI) beneficiaries potentially eligible for ACS in terms of income.
The results of this experiment show that increasing the subsidy slightly improves ACS take-up and allows a better targeting of eligible households. They equally confirm the complexity of the ACS scheme and its poor performance in targeting its designated population: only 17% of NHI beneficiaries included in the experiment applied for ACS. Moreover, only 9% of beneficiaries invited to attend an information briefing on the ACS scheme did so, and for the others, the invitation proved to be more a source of discouragement than an incentive. Finally, only 55% of ACS applicants were effectively entitled to the voucher, notably because incomes were above the eligibility threshold. This high level of uncertainty regarding eligibility to the scheme is undoubtedly an additional obstacle in an already complex application process.

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Complementary Health Insurance in France: Wide-Scale Diffusion but Inequalities of Access Persist
Issues in Health Economics (Questions d'économie de la santé) n° 161. 2011/01.
Perronnin M., Pierre A., Rochereau T. (Irdes)

In the context of ever increasing health expenditures and the recent increment in the share of health expenditures no longer reimbursed by the Statutory Health Insurance scheme, widescale diffusion of complementary health insurance (CHI) has become a major determinant in maintaining low income and high care need populations’ access to health care. Over the last thirty years, the public authorities have instituted laws and implemented schemes aimed at extending access to complementary health coverage to the population as a whole.
Between 1980 and 2008, the percentage of individuals covered by CHI increased considerably: from 69% of the population in metropolitan France to 94%. According to the Health, Health Care and Insurance survey (ESPS), however, almost 4 million individuals remained without complementary health coverage in metropolitan France in 2008.
What are the different means of access to complementary health insurance? Who are the individuals that remain outside the complementary health insurance system? Is non-subscription a reasoned choice or is access to CHI impeded by persisting obstacles? What are the consequences of non-coverage regarding access to health care and health status?

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July 9th, 2012