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QUESTIONS D'ÉCONOMIE DE LA SANTÉ 2016
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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Disinvestment Strategies for Pharmaceuticals: An International Review
Issues in Health Economics (Questions d'économie de la santé) n° 220. 2016/08.
Parkinson B., Sermet C., Clement F., Crausaz S., Godman B., Garner S., Choudhury M., Pearson S.A., Viney R., Lopert R., Elshaug A.G.

The purpose of this international literature review is to evaluate the partial or full disinvestment policies of some publicly funded or subsidized drugs in five OECD countries (Australia, Canada, France, New Zealand and the United Kingdom). It is based on an international study published in the journal PharmacoEconomics in 2015. Disinvestment can take two forms, passive and active. The first is not linked to direct government intervention: a drug will be withdrawn from the market by the manufacturer for commercial reasons or because of identified safety problems. Active divestment is driven by a political will to improve the efficiency and quality of care by reducing the pressure on pharmaceutical budgets.
While countries rely more heavily on passive disinvestment, they tend to increasingly resort to active disinvestment. Governments are under increasing pressure to disinvest medicines with low therapeutic value in order to provide flexibility for innovative new medicines with recognized efficacy.









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Use of Outpatient Care and Distances Travelled by Patients: Significant Differences in Regional Access to Healthcare
Issues in Health Economics (Questions d'économie de la santé) n° 219. 2016/06.
Com-Ruelle L., Lucas-Gabrielli V., Pierre A. (Irdes), In collaboration with Coldefy M. (Irdes)

In France, the provision of medical care is on a par with the OECD (Organisation for Economic Cooperation and Development) countries' average, but it is unequally distributed across the territory. Doctors are mainly concentrated in urban areas, metropolises, and coastal regions. Inequalities in the provision of outpatient care are very pronounced when measured by the Local Potential Accessibility indicator (indicateur d'Accessibilité Potentielle Localisée, or APL), which assesses the adequacy between care provision and demand, at the municipal level.
Based on the 2010 Health, Health Care and Insurance Survey (Enquête Santé et Protection Sociale, or ESPS), conducted by the French Institute for Research and Information in Health Economics (Irdes), and matched with the administrative healthcare consumption data, this study highlights differences in outpatient care use, in terms of rates of utilisation, access to the closest doctor, and additional distances travelled by patients. The analysis takes into account patients' individual characteristics and three indicators related to territorial access to healthcare.
The results show that reduced outpatient care availability leads patients to make more frequent journeys, that is to say to use the closest form of healthcare less often. However, they are less prone to travel additional distances further than the closest doctors when they are located far from their places of residence, which limits their freedom of choice.









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Out-of-Pocket Spending for Ambulatory and Hospital Care after Reimbursement by the French Public Health Insurance: Unequally Distributed Financial Burden
Issues in Health Economics (Questions d'économie de la santé) n° 218. 2016/05.
Perronnin M. (Irdes)

The French Public compulsory health insurance scheme is characterized by “out-of-pocket payments » (OOP) on most of the care it covers, namely nearly a quarter of the expense on care and medical goods consumption (CSBM) in 2015 (Beffy et al., 2016). These public OOP are paid by private complementary health insurance or by households themselves. They are made of a superposition of financial contributions introduced over time: Public Copayments, daily allowances, lump sum contributions, extra fees... These financial contributions vary depending on the type of care consumed; they can reach high and hamper access to care by the poorest.
In this study, every financial contribution is studied according to its contribution to the inequalities in OOP based on income and distinguishing ambulatory and short-stay hospital care. The financial contributions for hospital co-payments and per-diem fees, appear the most inequitable. They are generally reimbursed in full by the complementary insurance, but 5% of people are not covered by such insurance and are therefore exposed to the full charge of OOP.









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High Out-Of-Pocket Payments: Beneficiaries' Profiles and Persistence Over Time
Issues in Health Economics (Questions d'économie de la santé) n° 217. 2016/04.
Franc C. (Inserm, Centre de recherche en épidémiologie et santé des populations, Université Paris-Saclay, Université Paris-Sud, UVSQ, CESP, Inserm U1018, Villejuif, Irdes), Pierre A. (Irdes)

In France, Out-Of-Pocket payments (OOP) to be paid by the insured after reimbursements by the National Health Insurance (NHI) account for a quarter of health spending on average. However, these costs can be very high for some people and constitute a barrier to access to care, especially when they are repeated over time. From the Health, Health Care and Insurance Survey (Enquête santé et protection sociale, ESPS) matched to health care consumption data, we defined profiles of the 10% of individuals who bore the highest burden in OOP in 2010 using a typology. Four profiles are identified based on various care items consumed and then described according to their socio-economic characteristics and health status. The first profile gathers patients primarily treated as outpatients for chronic diseases; the second profile gathers vulnerable individuals hospitalized in a public institution; the third profile mainly relates to employees who have spent on dental care; and the fourth profile gathers non-hospitalized elderly. The results show that individuals belonging to the first profile were the most likely to incur high OOP two years later (in 2012).









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Ageing, Frailty and Health Care Expenditures
Issues in Health Economics (Questions d'économie de la santé) n° 216. 2016/03.
Sirven N. (Liraes (EA 4470) Université Paris Descartes, Irdes), in collaboration with Rapp T. (Liraes (EA 4470) Université Paris Descartes)

In the context of an ageing population and rising health care expenditures, frailty emerges as an interesting notion regarding the consequences of ageing for both health professionals and regulatory policies. It is defined as a decrease in the resistance of the person dealing with stress, which increases her vulnerability and exposes her to the risk of adverse health outcomes, such as falls, and progression towards functional dependence. So far, some of the rise in health expenditure was often attributed to a mechanical effect of age, which failed to take into account the concept of frailty in multivariate analyses. The same age category could indeed conceal different individual situations. Could frailty contribute to reveal these differences? Using data from the Health, Health Care and Insurance Survey (Enquête santé et protection sociale, ESPS) matched to data from the Health Insurance, we test the hypothesis that frailty is one of the determinants of the elderly people's individual health costs. The analysis thus shows that, in 2012, the average amount of outpatient (ambulatory) health expenses of people aged 65 and over increases with the level of frailty.







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Older Adults' Satisfaction with Medical Care Coordination: A Qualitative Approach
Issues in Health Economics (Questions d'économie de la santé) n° 214. 2016/01.
Guillaume S. (Irdes) and Or Z. (Irdes)

This exploratory qualitative study aims to identify the dimensions of satisfaction with medical care and care coordination for older adults over age 70. Semi-structured interviews were conducted in spring 2015 with a sample of 18 people aged 72 to 90 years, living at home or in institution, as well as 4 informal carers looking after people suffering from cognitive problems.
All respondents (including informal carers), regardless of their type of accommodation, agree that the most important dimension in medical care is the quality of their relationship with health professionals. There seems to be a significant room for improvement in that relational quality and people's satisfaction which can be achieved often by means of simple gestures. Respondents evoke the importance of being well informed about their care process, having the opportunity to express themselves; and they stress the importance of communication and coordination between different healthcare professionals involved in their care.

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June 20th, 2017