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QUESTIONS D'ÉCONOMIE DE LA SANTÉ 2012
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 Effect of Interventions Targeting Tobacco Consumption: a Review of Literature Reviews
Issues in Health Economics (Questions d'économie de la santé) n° 182. 2012/12.
Grignon M. (Center for Health Economics and Policy Analysis, McMaster University ; Irdes), Reddock J. (McMaster University)
This synthesis of systematic literature reviews provides an update of current knowledge on the effectiveness of public policies or interventions targeting tobacco consumption. The effect of interventions warning secondary school pupils about the harmful effects and addictive nature of smoking, price increases due to cigarette tax increases and the various therapies designed to help smokers stop smoking will be examined more particularly.
Among the sixty four literature reviews identified, the majority deal with smoking cessation. Related interventions are more effective when carried out by health professionals who set a ‘quit date’ for smoking cessation and prescribe nicotine replacement products. Support for quitting smoking via interventions delivered by mobile phone or the Internet are also effective. Furthermore, all forms of support for cessation of tobacco use appear to be cost effective. Price increases set above average income increases reduce overall tobacco consumption but fail to completely dissuade smoking initiation. By contrast, community youth intervention initiatives appear to be more effective in reducing the percentage of regular smokers.











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An Overview of Employer-provided Complementary Health Insurance in France in 2009 and Employee Opinions of the Scheme
Issues in Health Economics (Questions d'économie de la santé) n° 181. 2012/11.
Perronnin M. (Irdes), Pierre A. (Irdes), Rochereau T. (Irdes)

The second edition of the Employer-provided Complementary Health Insurance Survey (PSCE 2009) was embedded in a different context than the previous edition conducted in 2003. It provides an overview of complementary health insurance (CHI) offered by companies following the implementation of the Fillon Law on January 1st 2009. With this Law, tax and social security deductions became conditional on the compulsory enrolment of employees on the CHI benefits scheme. PSCE 2009 was also enriched by a questionnaire collecting employees’ opinions on the insurance cover provided.
The percentage of companies offering group CHI contracts increased from 40% in 2003 to 44% in 2009. Even if a slight increase was recorded, the provision of employer-sponsored CHI remained unevenly distributed with a higher percentage of offers in large firms, notably in the industrial sector, and companies employing a high percentage of executives.
In 2009, 98% of employees reported benefitting from CHI in general, and 74% reported having access to employer-provided CHI of which 60% benefitted from it. Of these beneficiaries, 75% preferred to keep it rather than substitute it for a wage rise. Employees reporting not having access to employer-provided CHI were in the majority in the lower age and wage brackets, or on temporary or part-time contracts.











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The Evolution of Psychiatric Care Systems in Germany, England, France and Italy: Similarities and Differences
Issues in Health Economics (Questions d'économie de la santé) n° 180. 2012/10.
Coldefy M. (Irdes)

The treatment of mental illness, affecting one in four Europeans, became a health policy priority under the impetus of the World Health Organisation Mental Health Plan for Europe elaborated in 2005. This plan promoted a more effective balance between inpatient hospital care and outpatient care through the development of community mental healthcare services. Since the 1970’s, the majority of European countries have shifted away from institutionalised care in large mental hospitals to the integration of patients in their living environment through the provision of home and community care services.
After outlining the differences in the speed and scale of deinstitutionalisation of mental health care in Germany, England, France and Italy, we examine the current delivery and structure of mental health services in the same four countries.
Other than the difficulty of obtaining high quality data that are comparable across countries, the first elements of comparison reveal that the pace, scale and completeness of deinstitutionalisation has been uneven. They also point to the fact that France is lagging behind in the integration of psychiatric care in general hospitals and also in the development of mental health facilities and support services for persons treated outside the hospital context.









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In What Way Can Primary Care Contribute to Reducing Health Inequalities? A Review of Research Literature
Issues in Health Economics (Questions d'économie de la santé) n° 179. 2012/09.
Bourgueil Y., Jusot F., Leleu H. and the AIR project group

After defining primary healthcare and explaining its role as an organisational principal in an integrated health system in reducing social inequalities in health, we present a review of current research literature with a focus on effective initiatives in this domain. This review was carried out within the framework of the European project AIR (Addressing Inequalities Interventions in Regions). Three areas of intervention in the primary care sector were distinguished. The first concerns the development of disease prevention programmes, the second, measures aimed at improving specific populations’ financial access to healthcare, and the third, the introduction of best practice protocols aimed at improving the quality of care for the population as a whole within a framework of health system reorganisation.











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How to Explain Price Gaps between Me-too Drugs? A 2001-2009 Panel-data Analysis
Issues in Health Economics (Questions d'économie de la santé) n° 178. 2012/07-08.
Bergua L. (CHU de Rouen), Cartier T. (Université Paris Diderot, Sorbonne Paris Cité, Irdes), Célant N. (Irdes), Pichetti S. (Irdes), Sermet C. (Irdes), Sorasith C. (Irdes)

Although dating back to the 1960’s, the debate surrounding me-too drugs is still valid today given the continuing proliferation of these drugs on the market. Similar to the originator drug in a given therapeutic class in terms of chemical structure and mechanism of action, some consider these drugs to be therapeutically equivalent due to a ‘class effect’, whereas others justify their presence on the market in terms of innovative content, even minor. If me-too drugs are effectively close to the originator, then theoretically there should be no difference in price between the first-in-class and follow-on drugs given that one of the regulator’s primary objectives is to reward innovation. How do things actually stand?
The aim of this study is to explain price differences between the originator drug and successive follow-on drugs in a given therapeutic class over the period between 2001 and 2009. With an average price gap of 59% per drug group, our results reveal significant price differences between the originator and successive follow-on drugs. In conformity with French drug pricing regulations, one of the main factors determining price gap is therapeutic innovation. Yet, the size of the price gap resulting from even minimal innovation (+ 16% for one degree of innovation, + 43 % for two degrees or more) raises questions. Furthermore, monotonic pricing significantly widens the price gap proving inequitable for patients whose health status justifies stronger doses. In the light of foreign experience, the question of controlling me-too drugs to be included or excluded from the reimbursed drugs basket also deserves being raised.











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Sick Leave: What Explanation for Disparities between French Departments? First exploitation of the Hygie database
Issues in Health Economics (Questions d'économie de la santé) n° 177. 2012/06.
Ben Halima M. A., Debrand T., Regaert C. (Irdes)

In 2008, the amount paid out by statutory National Health Insurance for daily sick leave benefits in France totalled 11.3 billion Euros representing over 5% of total health expenditures. Since 2008, these expenditures have shown an upward trend. Furthermore, the proportion of employees on sick leave varies considerably from one department to the next: from 13% in the Hautes-Alpes to 29% in the Ardennes, for an average of 23%. This study attempts to shed light on the reasons for inter-departmental differences in sick leave rates using the Hygie database. Constructed by Irdes from the merger of Health Insurance (Cnamts) data and Pension Fund (Cnav) data for private sector employees in France in 2005, this database enables cross-referencing data never previously available conjointly on both employees (professional career, medical consumption, sick leave…) and the firms employing them (sector of activity, company size…). Following a description of employee characteristics and their different motives for taking sick leave, an econometric analysis is carried out to explain the key determinants of inter-departmental disparities in sick leave rates using two types of variable: composition variables made up of employees’ individual characteristics, those of the firms employing them and the insurance regime from which they benefit, and context variables providing departmental characteristics (unemployment rate, medical services supply) and the environment in which each firm operates within a same department (relative salary and working conditions).









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Sick Leave: What Explanation for Disparities between French Departments? First exploitation of the Hygie database
Issues in Health Economics (Questions d'économie de la santé) n° 177. 2012/06.
Ben Halima M. A., Debrand T., Regaert C. (Irdes)

In 2008, the amount paid out by statutory National Health Insurance for daily sick leave benefits in France totalled 11.3 billion Euros representing over 5% of total health expenditures. Since 2008, these expenditures have shown an upward trend. Furthermore, the proportion of employees on sick leave varies considerably from one department to the next: from 13% in the Hautes-Alpes to 29% in the Ardennes, for an average of 23%. This study attempts to shed light on the reasons for inter-departmental differences in sick leave rates using the Hygie database. Constructed by Irdes from the merger of Health Insurance (Cnamts) data and Pension Fund (Cnav) data for private sector employees in France in 2005, this database enables cross-referencing data never previously available conjointly on both employees (professional career, medical consumption, sick leave…) and the firms employing them (sector of activity, company size…). Following a description of employee characteristics and their different motives for taking sick leave, an econometric analysis is carried out to explain the key determinants of inter-departmental disparities in sick leave rates using two types of variable: composition variables made up of employees’ individual characteristics, those of the firms employing them and the insurance regime from which they benefit, and context variables providing departmental characteristics (unemployment rate, medical services supply) and the environment in which each firm operates within a same department (relative salary and working conditions).









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Protecting an Endangered Resource?
Lessons from a European Cross-Country Comparison of Support Policies for Informal Carers of Elderly Dependent Persons

Issues in Health Economics (Questions d'économie de la santé) n° 176. 2012/05.
Naiditch M. (Irdes)

Although important inter-country differences exist in organisations for the delivery of care and support to dependent elderly people, the contribution of informal carers (family or friends) predominates everywhere. LTC policies focusing on the disabled older population are thus facing a major challenge in how to ensure their continued contribution over the long term. This is particularly crucial because of the role informal carers play in reducing the costs of LTC. The implementation of policy measures addressing the needs of informal carers in Europe is therefore considered a major component of policies focused on meeting the needs of dependent older persons.
Within the framework of the European research programme INTERLINKS, a working group examined the possibility of identifying and describing a series of measures that would constitute the backbone of a specific policy for supporting informal carers. How does one evaluate the impact of such a policy on its beneficiaries? How does one judge its capacity to act synergistically with policies addressing the needs of elderly people in need of care? To answer these questions, a conceptual framework was created for the classification of measures intended at supporting informal carers. It was based on several criteria – the primary distinguishing criterion being defined as measures targeting only informal carers (specific measures) on the one hand, and measures targeting both carers and care recipients (non-specific measures) on the other.









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The Health Area, a Planning Tool for the Organisation of Care Supply and Health Policy? Evolutions from 2003 to 2011
Issues in Health Economics (Questions d'économie de la santé) n° 175. 2012/04.
Lucas-Gabrielli V. (Irdes), Coldefy M. (Irdes)

In 2003, during the preparation of the third generation Regional Strategic Health Plan (SROS 3), the Health Area was established as the regulatory framework for the organisation of healthcare, replacing the Health Map created in 1970. The health area is conceived as the key component in the organisational structure of healthcare framed by quantified care supply objectives, an area medical project, and Regional Health Conferences created to provide a consultative space promoting cooperation between different health sector players.
In this new context, regions are incited to rethink the geographical zoning of health areas. Initially centred on hospital facilities with the creation of the Regional Hospital Agency (ARH), the health area concept was then extended to include other public health and medico- social services within the framework of the 2009 Hospital, Patients, Health and Territories Act, and the creation of Regional Health Agencies (ARS). In what way have regions developed this care supply network? A panoramic view of the regionalisation of health services from 2003 to 2011.











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Local Potential Accessibility (LPA): A New Measure of Accessibility to Private General Practitioners
Issues in Health Economics (Questions d'économie de la santé) n° 174. 2012/03.
Barlet M. (Drees), Coldefy M. (Irdes), Collin C. (Drees), Lucas-Gabrielli V. (Irdes)

This study proposes an innovative and enriched indicator to measure spatial accessibility to healthcare, in this case applied to private general practitioners. The Local Potential Accessibility (LPA) indicator measures the supply of and demand for general practice (GP) services by taking into account practitioners’ volume of activity on the one hand, and service use rates differentiated by population age structure on the other. Although this is a local indicator calcu-lated at municipal level, it also takes into consideration supply and demand factors in neighbouring municipalities.
The Local Potential Accessibility (LPA) to private GPs indicator reveals a greater degree of variability than the traditionally used accessibility indicators (travel time, level of GP density in living areas…). In 2010, the LPA indicated an average 71 full-time equivalent (FTE) GPs per 100,000 inhabitants in France, but less than 31 FTE per 100,000 inhabitants for the 5% of the population with the lowest accessibility to GPs, and over 111 FTE for the 5% of the population with the highest accessibility.
The Local Potential Accessibility (LPA) to private GPs indicator is on average higher for populations living in urban municipalities. Within these municipalities, the inhabitants of small or average urban centres have better accessibility (81 FTE per 100,000 inhabitants) than those living in large urban centres (75 FTE per 100,000 inhabitants). Among rural municipalities, those ‘isolated’ have higher accessibility (63 FTE per 100,000 inhabitants) than outer suburb municipalities (52 FTE per 100,000 inhabitants).











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Cmu-c Beneficiaries Self-report more Illness than the Rest of the Population
Results of the ESPS 2006-2008 surveys

Issues in Health Economics (Questions d'économie de la santé) n° 173. 2012/02.
Allonier C. (Irdes), Boisguérin B. (Drees), Le Fur P. (Irdes)

The results of the 2006 and 2008 Health, Healthcare and Insurance surveys reveal that CMU-C beneficiaries, who tend to be younger and count a higher percentage of women, self-report a poorer health status than the rest of the population. At equivalent age and gender, the incidence rate of self-reported illnesses is higher among CMU-C beneficiaries than among rest of the population, which for certain disorders such as depression and diabetes can be twice as high. Exposure to health risk factors such as tobacco consumption and obesity is also higher among CMU-C beneficiaries than the rest of the population: 1.6 times higher for tobacco consumption and 1.7 for obesity, in accordance with the higher self-reported incidence rate of upper digestive tract disorders and cardiovascular diseases.
Among the motives for their last consultation with a general practitioner or specialist, backache, depression, respiratory, digestive and hepatic disorders are more frequently evoked by CMU-C beneficiaries, in accordance with the self-reported diseases. On the contrary, whereas they more frequently declare suffering from illnesses of the ear and teeth, they are less frequently evoked as motives for consulting a GP.









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Immigrants’ Health Status and Use of Healthcare Services: A Review of French Research
Issues in Health Economics (Questions d'économie de la santé) n° 172. 2012/01.
Berchet C., Jusot F. (Leda-Legos, Paris-Dauphine University ; Irdes)

This study presents a review of French research on immigrants’ health status and use of healthcare services over the last thirty years. Despite diverging results, notably due to the diversity of indictors used and the periods considered by the literature, this review reveals a number of disparities between the French and immigrant populations. Compared with the native French population, immigrants’ health status has deteriorated over the last thirty years and disparities seem to be more important among first generation immigrants and women but also tend to vary according to country of origin. Likewise, a lower rate of use to office-based medical practices and prevention services among immigrants is noted.
Although the migration selection effect explains the better initial health status of immigrants, their more disadvantaged economic situation and loss of social connections in the host country contribute to their health status deterioration and their lower use of healthcare services.
These conclusions call for the implementation of adapted health policies aimed at improving access to healthcare for foreign born population, notably through prevention, the development of community actions, and the simplification of access to certain rights such as Universal Health Insurance (CMU) or State Medical Assistance (AME).


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May 13th, 2013