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QUESTIONS D'ÉCONOMIE DE LA SANTÉ 2013
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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Involuntary Psychiatric Hospitalisation in 2010: First Exploitation of Rim-P and Overview of the Situation Prior to the Reform of July 5th 2011
Issues in Health Economics (Questions d'économie de la santé) n° 193. 2013/12.
Coldefy M., Nestrigue C. (Irdes)

This first overview of involuntary psychiatric hospitalisation, based on recently available data from the Medical Information Database for Psychiatry (Rim-P), has several aims: to obtain a snapshot of persons forcibly interned in psychiatric hospitals together with the diversity of care modalities and care paths in 2010. The final objective is to monitor the effects of the mental health reform instituted by the Law of July 5th 2011 on the rights and protection of individuals under psychiatric care. Modified in September 2013, this Law aims at reforming compulsory psychiatric care practices by authorising alternatives to full-time hospitalisation, previously the only care modality, and provides for the intervention of a custodial judge (JLD –"juge des libertés et de la detention") within this framework.
What does the notion of compulsory psychiatric care refer to? How many mentally disordered patients were hospitalised without consent in France in 2010? Under what care modalities, in what type of establishments, for how long and for which mental disorders were they hospitalised? These are the main questions to which this first insight will provide some answers.









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Young People and Alcohol: Changes in Behaviour, Risk and Protective Factors
Issues in Health Economics (Questions d'économie de la santé) n° 192. 2013/11.
Com Ruelle L., Le Guen N. (Irdes)

This study examines young peoples’ alcohol consumption behaviours using the results of the last Ireb survey (2007). The scope of this survey, previously limited to 13-20 year-olds, was extended to include 21-24 year-olds providing a better understanding of behavioural change during the critical transition from adolescence to adulthood which tends to occur at a later age. Complementary data from two European surveys, (HBSC and ESPAD) and two French surveys (ESCAPAD and the Inpes Health Barometer) were also exploited, providing data up to the year 2011.
Alcohol consumption patterns among young people aged 13 to 24 were measured in terms of frequencies, quantities consumed, episodes of drunkenness and the age at first alcohol use according to gender. Factors associated with different consumption patterns, particularly those presenting a risk of alcohol abuse and dependence, were then studied on the basis of young peoples’ individual and socioeconomic characteristics, social influences (family, peers), context (parties, outdoors…) and participation in sports. Finally, the results were examined in the light of behavioural changes observed since the beginning of the years 2000.
All the surveys confirmed a downward trend in alcohol consumption both in young people and adults, maintaining France within the European average. At the same time, they also revealed an increase in heavy episodic drinking (binge drinking) and intoxication, and an increased level of alcohol-use among girls thus narrowing the gender gap.








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Treatment modalities for Depression in Health Establishments
Issues in Health Economics (Questions d'économie de la santé) n° 191. 2013/10.
Coldefy M., Nestrigue C. (Irdes)

Psychiatric disorders and psychotropic medications cost 22.6 billion euros in 2011, representing 16% of total health expenditures for that year (CNAMTS, 2013). Depression is one of the most widespread psychiatric disorders in France affecting 3 million individuals (INPES, 2007). In cases of depression, individuals tend to consult their general practitioner first (21%), ahead of psychiatrists (13%) and psychologists (7%) in private practice. Even if the use of hospital care is relatively low in cases of depression (10 % of consultations -INPES, 2007), it is the main cause for seeking medical care in hospitals authorised to provide mental health services. Among the 1.5 million adults treated in hospital-based psychiatric units in France in 2011, almost one out of five was for depression.
If little was previously known concerning the treatment modalities available for these patients, the Medical Information Database for Psychiatry (Rim-P) instituted in 2007, used as the data source for this study, provides the missing information and a first national insight on the subject.








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Geographical distribution of multi-professional group practice structures ("maisons" and "pôles de santé") and its impact on private general practitioner density.
Second part of the evaluation of "maisons", "pôles" and "centres de santé" within the framework of experiments with new mechanisms of remuneration (ENMR)

Issues in Health Economics (Questions d'économie de la santé) n° 190. 2013/09.
Chevillard G. (Université Paris-Ouest Nanterre La Défense, Laboratoire Mosaïques, UMR Lavue 7218, CNRS ; Irdes), Mousquès J., Lucas-Gabrielli V., Bourgueil Y. (Irdes) en collaboration avec Rican S.

Are multi-professional group practice structures "maisons de santé" (MS) and "pôles de santé" (PS) established in areas where the provision of healthcare services has become fragile and care needs important? Has the development of these healthcare structures had an impact on general practitioner density? This second publication on the evaluation of multi-professional group practices participating in experiments with new mechanisms of remuneration (ENMR) deals with both questions. It concerns sites identified by the Observatory of Health Service Supply Re-structuring, analysed by means of two typologies constructed from social, economic and health situations within the French national territory; the first in predominantly rural areas and the second in predominantly urban areas. The resulting "living areas" and "pseudo cantons" thus defined, are then used to compare general practitioner (GP) density over two consecutive periods, 2004-2008 and 2008-2011, according to whether the area concerned hosts a multi-professional group practice (MS) or not.







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The Impact of Multi-professional Group Practices on Healthcare Supply
Evaluation Aims and Methods for "Maisons", "Pôles de Santé" and "Centres de Santé" within the Framework of Experiments with New Mechanisms of Remuneration

Issues in Health Economics (Questions d'économie de la santé) n° 189. 2013/07-08.
Afrite A., Bourgueil Y., Daniel F., Mousquès J. (Irdes) in collaboration with Couralet P.-E. and Chevillard G. (Université Paris-Ouest Nanterre La Défense, Laboratoire Mosaïques, UMR Lavue 7218, CNRS; Irdes)

Mono-disciplinary group practices, attractive for young general practitioners, are currently in the majority. Over the last ten years, the French public authorities have set up incentives to encourage multidisciplinary primary health care organisations and clusters of the type "maisons de santé", "pôles de santé" and "centres de santé". Within this framework, experiments in new mechanisms of remuneration (ENMR) aimed at these structures were implemented in 2010 to finance improvements in the organisation and coordination of care, the provision of new services for patients and the development of inter-professional cooperation.
Based on the observation of sites identified by the Observatory of Health Service Supply Re-structuring or sites participating in ENMR, this article presents evaluation aims and methods for multidisciplinary group practices, knowledge of which remains fragmentary. Two key questions are asked: do multidisciplinary group practices have an impact on maintaining health care supply in under-resourced areas? Are they more effective in terms of activity and productivity, consumption and quality of care?
Introducing the methodological framework, this edition of Issues in Health Economics is the first in a series of publications presenting the results of the study.









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How to Explain Why so Few Individuals Insure themselves against the Risk of Old-age Dependency?
A Review of the Literature

Issues in Health Economics (Questions d'économie de la santé) n° 188. 2013/06.
Fontaine R. (LEG, University of Burgundy; IRDES; Médéric Alzheimer Foundation), Zerrar N. (LEDa-Legos, Paris-Dauphine University)

In France, the financing of long-term care (LTC) for elderly dependent persons is organised around three main institutions: the family, the Government and the market. As it may prove difficult to make additional demands on social and family solidarity to meet increased long-term care needs, the question has been raised as to the future role that could be played by the LTC insurance market. Paradoxically, despite the excessive out-of-pocket payments incurred by the consumption of longterm care, that can amount to tens of thousands of euros, the majority of individuals are not insured against the risk of old-age dependency.
This review of the literature provides a synthesis of the various disincentives to voluntarily subscribing to LTC insurance. The first, on the supply side, are related to the unattractive offer providing only partial coverage at a relatively high price. The second concern the characteristics of the demand for long-term care insurance and the manner in which individuals perceive the dependency risk.
Relying on individual responsibility to anticipate and cover out-of-pocket payments generated by the consumption of long-term care would be unadvisable given the characteristics of dependency risk and the demand for insurance. A more precise empirical analysis of individuals’ perception of old-age dependency risk and insurance behaviours within the French context will provide a clearer view of the possibilities of introducing compulsory LTC insurance and under what terms and conditions.









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The Diffusion of New Anti-diabetic drugs: an International Comparison
Issues in Health Economics (Questions d'économie de la santé) n° 187. 2013/05.
Pichetti S. (Irdes), Sermet C. (Irdes), Van der Erf S. (Cnamts)

Regulation of the diffusion of pharmaceutical innovation represents a key issue in France where the structure of consumption distinguishes itself by the large place given to the most recent drugs that are also often the most expensive. This is the case for anti-diabetic drugs which for the National Health Insurance represent not only a public health issue but also a financial issue. The analysis of consumption data for this class of drugs indicates that France still tends to consume the most recent and most expensive molecules: in 2011, gliptins represented 8.2% of oral anti-diabetic agents consumed in France against 6.2% in Germany, 5.8% in the United Kingdom and only 4% in Australia.
This study, based on the analysis of the regulatory processes accompanying the market entry and diffusion of pharmaceutical innovation, reveals a dividing line between countries that systematically carry out economic evaluations, like Australia and the United Kingdom, and Germany where the practice is more occasional and France where it has only recently been adopted. Economic evaluations can have an impact on drugs reimbursement rules, such as the conditional reimbursement of gliptins in Australia. They also have an influence on prescribing recommendations for health professionals. In Australia and the United Kingdom, and more recently in France, these prescribing recommendations hierarchize diabetes treatments according to their efficiency.









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Hospital Activity, Productivity and Quality of Care before and after Activity-based Funding (T2A)
Issues in Health Economics (Questions d'économie de la santé) n° 186. 2013/04.
Bonastre J., Journeau F. (IGR, Institut Gustave Roussy), Nestrigue C., Or Z. (Irdes)

The activity-based funding (T2A) is used since 2004-2005, for financing acute hospital care in public and private hospitals with an objective to improve the efficiency of individual providers and the hospital sector as a whole. To date, however, the impact of T2A on hospital activity, productivity and quality of care has only been partially evaluated in France. This study provides new data and analyses for answering different questions: has the introduction of T2A contributed to increasing productivity of hospital sector? How has the production structure/casemix of different hospitals been modified? How has the quality of care been affected?
The results show that productivity in public sector hospitals increased steadily between 2002 and 2009 whatever the activity, but with a marked increase in surgical stays. In private-for-profit hospitals, we observe a significant increase in outpatient surgery and in parallel, a reduction in full-time hospitalisations in obstetrics and medicine.
Overall, we observe a positive trend in productivity of public sector since the introduction of T2A, while in private-for-profit sector there appear to be a change in the mix of care provided rather than a growth in total productivity. We also observe a significant increase in the rate of 30-day readmissions among patients receiving the main types of cardiovascular and cancer treatments. The analysis did not reveal a deliberate discrimination strategy against sicker and older patients, but a considerable increase in standardized rates for certain interventions or procedures that suggest the possibility of supplier-induced demand that is poorly or not at all justified.









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Is Follow-Up Dental Care for Diabetic Patients Adapted?
Exploitation of ESPS 2008

Issues in Health Economics (Questions d'économie de la santé) n° 185. 2013/03.
Rochereau T. (Irdes), Azogui-Lévy (Université Paris-Diderot and Inserm U1018 CESP)

Diabetes is characterised by chronic hypoglycaemia caused by insufficient insulin secretion which, if left uncontrolled, can lead to severe complications. Periodontal disease is one of the complications related to uncontrolled diabetes. This bacterial infection destroys the tissues that surround and support the teeth leading to their loss. Yet, preventing dental infection could have a beneficial effect on controlling insulin levels and improving diabetics’ quality of life.
Using data from the 2008 Health, Healthcare and Insurance survey (ESPS), representative of the general population, we describe the socioeconomic characteristics of individuals suffering from diabetes and question their access to and use of dental care.
In France, diabetes affects 4.5% of the population in general and 7.6% of individuals aged 35 and over studied here. Its prevalence increases significantly with age (by 1.6% for the 35-49 age group, and by 15.5% for individuals aged 70 and over) and affects more men than women. Furthermore, individuals suffering from diabetes are more disadvantaged than the rest of the population. Our results also show that among diabetics the use of dentists is no higher or lower than for non-diabetics even though they benefit from 100% coverage for diabetes-related conditions through the long-term illness scheme (LTI).









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Frailty and Preventing the Loss of Autonomy. A Health Economics Approach
Issues in Health Economics (Questions d'économie de la santé) n° 184. 2013/02.
Sirven N. (Irdes)

In a global context of population ageing, gaining better knowledge of the mechanisms leading to loss of autonomy has become a major objective, notably with the aim of implementing effective preventive health policies. The concept of ‘frailty’, originally introduced in gerontology and geriatrics as a precursor state to functional dependency, appears as a useful tool in this specific context. If several approaches co-exist, Fried’s model of frailty, based on five physiological criteria, (fatigue, loss of appetite, muscle weakness, slow walking pace, decreased physical activity), appears to be the most operational in measuring frailty and targeting populations at risk of dependency sufficiently upstream in the disablement process.
In terms of health economics, the loss of autonomy approach retained here is particularly interested in the economic and social causes and consequences of the onset of frailty in older adults, and examines the challenges not only in terms of health system efficiency but also in terms of social protection.









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The Impact of the Long-term Illness Scheme (LTI) on Inequalities in the Utilisation of Ambulatory Care Between 1998 and 2008
Issues in Health Economics (Questions d'économie de la santé) n° 183. 2013/01.
Dourgnon P. (Irdes ; Université Paris-Dauphine, Leda-Legos), Or Z. (Irdes), Sorasith C. (Irdes)

The aim of the long-term illness scheme (LTI) is to reduce the financial burden of medical care for national insurance beneficiaries suffering from a long-term and costly illness. First introduced in 1945 to cover four diseases (cancer, tuberculosis, poliomyelitis and mental illness), it currently covers 32 groups of diseases. In 2009, individuals covered by the LTI scheme represented 15% of National Health Insurance beneficiaries, or 8.6 million individuals. LTI health expenditures represented 60% of the total health expenditures reimbursed and recorded an annual increase of 4.9% between 2005 and 2010.
Can such a scheme overcome all the problems related to improving financial access to healthcare services? What is the combined effect of the LTI scheme and other schemes aimed at reducing out-of-pocket expenses (private complementary health insurance, Universal Complementary Health Insurance (CMU-C))? Using data from the IRDES Health, Healthcare and Insurance survey matched with data from the Permanent Sample of Health Insurance Beneficiaries (EPAS), this study examines the impact of the LTI scheme on inequalities in the utilisation of ambulatory care during the period 1998-2008.
Older than the rest of the population, individuals registered under the LTI scheme are also more disadvantaged and subject to higher out-of-pocket expenses. Inequalities in ambulatory care consumption within the population of LTI scheme beneficiaries (to the advantage of the wealthiest from 1998 to 2000), becomes non- significant from 2002 whereas it remains significant for the rest of the population. The LTI scheme improves beneficiaries’ access to ambulatory care, and thus contributes to reducing the level of inequality observed within the rest of the population. A form of complementarity also exists between the CMU-C and LTI schemes. Inequalities in the utilisation of specialist care, to the advantage of the wealthiest, nevertheless persists both for individuals registered under the LTI scheme and within the population as a whole.


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April 14th, 2015