WORKING PAPERS 2008

An advice?

How good is the quality of health care in France?
Or Z., Com-Ruelle L.
Irdes working paper n° 19, 2008/12

France has been classified by the WHO as having one of the best health systems in the world. However, there is surprisingly little systematic information on the quality and safety of health care provided in France. Despite many recent initiatives to improve quality and its measurement, the available data remain partial, inconsistent and not easily accessible. In order to obtain a global picture of health care quality problems and to develop quality-improvement strategies, it is important to collect national data on a consistent basis within a coherent framework. This paper provides an overview of the available data on quality of care in France following a common framework and international recommendations for measuring quality. By comparing the situation in France with the situation in other industrialised countries, the paper aims to identify the strong points as well as major deficiencies of the French system in terms of measuring and improving quality of care.

Published in: Journal d'Economie Médicale, vol 26, n° 6-7, 2008-10/11, 371-385. La qualité de soins en France : comment la mesurer pour l'améliorer ?
Or Z., Com-Ruelle L.

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A refutation of the practice style hypothesis: the case of antibiotics prescription by French general practitioners for acute rhinopharyngitis
Mousquès J. (Irdes) Renaud T. (Irdes) Scemama O. (HAS)
Irdes working paper n° 18, 2008/10

Many researches in France or abroad have highlighted the medical practice variation (MPV) phenomenon, or even the inappropriateness of certain medical decisions. There is no consensus on the origin of this MPV between preference-centred versus opportunities and constraints approaches. This study principal purpose is to refute hypothesis which assume that physicians adopt for their patient a uniform practice style for each similar clinical decision beyond the time. More specifically, multilevel models are estimated: First to measure variability of antibiotics prescription by French general practitioners for acute rhinopharyngitis, a clinical decision making context with weak uncertainty, and to tests its significance; Second to prioritize its determinants, especially those relating to GP or its practice setting environment, by controlling visit or patient confounders. The study was based on the 2001 activity data, added by an ad hoc questionnaire, of a sample of 778 GPs arising from a panel of 1006 computerized French GPs.
A great part of the total variation was due to intra-physician variability (70%). Hence, in the French general practice context, we find empirical support for the rejection of the ‘practice style', the 'enthusiasm' or the ‘surgical signature' hypothesis. Thus, it is patients' characteristics that largely explain the prescription, even if physicians' characteristics (area of practice, level of activity, network participation, participation in ongoing medical training) and environmental factors (recent visit from pharmaceutical sales representatives) also exert considerable influence. The latter suggest that MPV are partly caused by differences in the type of dissemination or diffusion of information. Such findings may help us to develop and identify facilitators for promoting a better use of antibiotics in France and, more generally, for influencing GPs practice when it is of interest.

Published in: Social Science & Medicine, vol 70, n° 8, 2010/04, 1176-1184.
Is the “Practice Style” Hypothesis Relevant for General Practitioners? An Analysis of Antibiotics Prescription for Acute Rhinopharyngitis.
Mousquès J., Renaud T., Scemama O.

An advice?

Impact of health care system on socieconomic inequalities in doctor use
Or Z. (Irdes) Jusot F. (LEGOS-LEDA, Irdes), Ylmaz E. (Irdes)
Irdes working paper n° 17, 2008/09

This study examines the impact of health system characteristics on social inequities in health care use in Europe, using data from national surveys in 13 European countries. Multilevel logistic regression models are estimated to separate the individual level determinants of generalist and specialist use from the health system level and country specific factors. The results suggest that beyond the division between public and private funding and cost-sharing arrangements in health system, the role given to the general practitioners and/or the organization of the primary care might be essential for reducing social inequities in health care utilisation.

Published in: Revue Economique, vol 60, n° 2, 2009/03, 521-543.
Inégalités de recours aux soins en Europe : Quel rôle attribuable aux systèmes de santé.
Or Z., Jusot F., Yilmaz E.

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Drug price setting and regulation in France
Grandfils N.
Irdes working paper n° 16, 2008/09

In France, drug prices have historically been regulated but approaches to setting and regulating prices have been evolving in recent years. In 2003, the prices of new outpatient drugs, which had hitherto been entirely regulated, were semi-liberalised, with drug companies setting prices on line with those in neighbouring countries; and in parallel with this in 2004, the prices of expensive drugs and/or drugs qualifying for reassignment must now also be set on line with European prices. In addition to this, price/volume regulation has recently been introduced. This document describes the price setting rules applicable to each drug category and discusses different measures for regulating drug price, particularly the conventional policies implemented under successive framework agreements. The regulatory path for medicines and the different actors involved are presented in an Appendix.

Published in: Revue Française des Affaires Sociales, n° 3-4, 2007/07-12, 53-72.
Setting and Regulating the Price of Drugs in France.
Grandfils N.

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Comparability of Health Care - Responsiveness in Europe - Using anchoring vignettes from SHARE
Sirven N. (Irdes), Santos-Eggimann B. (IUMSP), Spagnoli J. (IUMSP).
Irdes Working paper n° 15, 2008/09

The aim of this paper is to measure and to correct for the potential incomparability of responses to the SHARE survey on health care responsiveness. A parametric approach based on the use of anchoring vignettes is applied to cross-sectional data (2006-07) in ten European countries. More than 6,000 respondents aged 50 years old and over were asked to assess the quality of health care responsiveness in three domains: waiting time for medical treatment, quality of the conditions in visited health facilities, and communication and involvement in decisions about the treatment. Chopit models estimates suggest that reporting heterogenity is in uenced by both individual (socio-economic, health) and national characteristics. Although correction for dierential item functioning does not considerably modify countries ranking after controlling for the usual covariates, about two thirds of the respondents' self-assessments have been re-scaled in each domain. Our results suggest that reporting heterogenity tends to overestimate health care responsiveness for `time to wait for treatment', whereas it seems to underestimate people's self-assessment in the two other domains.

Published in: Social Indicators Research, vol 105, n°2, 2012, 255-271 Comparability of Health Care Responsiveness in Europe Using Anchoring Vignettes from SHARE.
Sirven N., Santos-Eggimann B., Spagnoli J.

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The Health of immigrants in France
Jusot F., Silva J., Dourgnon P., Sermet C.
Irdes Working paper n° 14. 2008/07.

Using the data from the French 2002-2003 decennial health survey, this article analyses the links between nationality, migration and health status in France. The findings show health inequalities related to immigration in favor of the native population living in France. Those inequalities appear to reflect a healthy migrant selection effect counterbalanced by a deleterious impact of migration, partly due to the poor socioeconomic conditions of immigrants in France. We also observe a long term effect of the economic and sanitary characteristics of country of birth that contribute to explain the heterogeneity of health status among immigrants.
Keywords: health, nationality, migration, social health inequalities

Which gave rise to: Issues in Health Economics n° 172. 2012/01.
Immigrants' Health Status and Use of Healthcare Services: A Review of French Research.
Berchet C., Jusot F.

Published in:: Bulletin Epidémiologique Hebdomadaire (InVS), n° 2-3-4, 2012/01/17 Etat de santé et recours aux soins des immigrés en France : une revue de la littérature.

Published in: Revue Economique, n° 2, vol 60, 2009/03, 385-411.
Inégalités de santé liées à l'immigration en France. Effet des conditions de vie ou sélection à la migration ?
Jusot F., Silva J., Dourgnon P., Sermet C.

A donné lieu à : Etat de santé et recours aux soins des populations immigrées en France. Rapport final : Volume 1 : Etat de santé des populations immigrées en France. Appel à projets de recherche Drees – Mire, 2009/03, 156 p.

Which gave rise to: Issues in Health Economics (Questions d'économie de la santé) n° 133. 2008/07.
Self Assessed Health of Immigrants in France - Analysis of the 2002-03 Decennial Health Survey.
Dourgnon P., Jusot F., Sermet C., Silva J.

Which gave rise to: Etat de santé des populations immigrées en France : une approche multiniveaux. 29es Journées des Économistes de la Santé Français. 2007/12.

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The sooner, the better? Analyzing preferences for early retirement in European countries
Debrand T. (Irdes), Blanchet D. (Insee)
Irdes working paper n° 13. 2008/07.

Individual preferences concerning retirement age are strongly differentiated both within and between countries. According to the SHARE survey, the proportion of workers aged from 50 to 65 who wished to retire as soon as possible in 2004 ranged from 31% in the Netherlands to 67% in Spain. Such a preference for early retirement can depend on both financial and non financial factors. Non financial factors include working conditions, health status and mortality expectations. Economic or “monetary” factors essentially correspond to the magnitude of pension entitlements and how they depend upon retirement age. Entitlements that depend positively on retirement age should reduce the motivation to retire as soon as possible.
This paper compares the role of these different factors by combining individual data from the SHARE survey with macroeconomic indicators of pension entitlements recently produced by the OECD. Health and work conditions come out as strong determinants of the preference for early retirement. Being generally satisfied with one's work leads to a drop of approximately 16 percentage points in the probability of wishing to retire as soon as possible. Declaring oneself in bad or very bad health has a positive effect on this probability of a comparable order of magnitude. However, these non financial factors do not significantly contribute to the explanation of cross-country differentials. Conversely, financial factors seem to have a lower impact at micro-level, but a higher one for the explanation of cross-country differentials.

Published in: Economie et Statistique, n° 403 – 404, 2007/12, 39-62.
Souhaiter prendre sa retraite le plus tôt possible : santé, satisfaction au travail et facteurs monétaires.
Blanchet D., Debrand T.

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Social heterogeneity in self-reported health status and measurement of inequalities in health
Tubeuf S., Jusot F., Devaux M., Sermet C.
Irdes working paper n° 12. 2008/06.

This study aims to analyse the impact of the measurement of health status on socioeconomic inequalities in health. A MIMIC model with structural equations is used to create a latent variable of health status from four health indicators: self-assessed health, report of chronic diseases, report of activity limitations and mental health. Then, we disentangle the impact of sociodemographic characteristics on latent health from their direct impact on each heath indicator and discuss their effects on the assessment of socioeconomic inequalities in health. This study emphasises differences in inequalities in health according to latent health. In addition, it suggests the existence of reporting heterogeneity biases. For a given latent health status, women and old people are more likely to report chronic diseases. Mental health problems are over-reported by women and isolated people and under-reported by the oldest people. Active and retired people as well as non manual workers in the top of the social hierarchy more often report activity limitations. Finally, highly educated and socially advantaged people more often report chronic diseases whereas less educated people underreport a poor self-assessed health. To conclude, the four health indicators suffer from reporting heterogeneity biases and the report of chronic diseases is the indicator which biases the most the measurement of socioeconomic inequalities in health.

Published in: Revue Française des Affaires Sociales, n° 1, 2008/01-03, 29-47.
Hétérogénéité sociale de déclaration de l'état de santé et mesure des inégalités de santé.
Devaux M., Jusot F., Sermet C., Tubeuf S.

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Health status, Neighbourhood effects and Public choice: Evidence from France
Debrand T., Pierre A., Allonier C., Lucas V.
Irdes working paper n° 11. 2008/06.

Observation of socioeconomic statistics between different neighbourhoods highlights significant differences for economic indicators, social indicators and health indicators. The issue faced here is determining the origins of health inequalities: individual effects and neighbourhood effects. Using National Health Survey and French census data from the period 2002-2003, we attempt to measure the individual and collective determinants of Self-Reported Health Status (SRH). By using a principal component analysis of aggregated census data, we obtain three synthetic factors called: “economic and social condition”, “mobility” and “generational” and show that these contextual factors are correlated with individual SRHs.
Since the 80s, different French governments have formulated public policies in order to take into account the specific problems of disadvantaged and deprived neighbourhoods. In view to concentrating national assistance, the French government has created “zones urbaines sensibles” (ZUS) [Critical Urban Areas, CUA]. Our research shows that in spite of implementing public policy in France to combat health inequalities, by only taking into account the CUA criterion (the fact of being in a CUA or not), many inequalities remain ignored and thus hidden.

Published in: Health Policy, vol 105, n°1, 2012/04, 92-101. Critical urban areas, deprived areas and neighbourhood effects on health in France.

Published in: Les disparités sociales et territoriales de santé dans les quartiers sensibles L'impact du contexte sur l'état de santé de la population : le cas des zones urbaines sensibles. Une analyse à partir de l'enquête décennale de santé (2003)
Debrand T. / Dir., Allonier C., Lucas-Gabrielli V., Pierre A.
Paris : Editions de la DIV, collection Les documents de l'Onzus 1, 2009/05, 108-146.

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Evolution of the concept of place in French health planning
Coldefy M., Lucas-Gabrielli V.
Irdes working paper n° 10. 2008/05.

Aim: Major parameters of French health care management and planning have been considerably modified with the policy reform entitled Hospital 2007. A particular emphasis has been put on the role of space. “Health territory” has become the relevant area for management of care aiming to propose a more global approach of the health system and of the assessment of care needs. All the 22 French regions have been invited to redraw the boundaries of health areas on the principles of accessibility, proximity and continuity of care. This paper aims to analyze how regions picked up this new planning space, which concepts and methods they used to divide regional spaces and which spatial outcomes have followed.
Methods: This research relies on a review of regional planning reports, laws and decrees implementing this new step in planning policy.
Results: This new planning space has been differently implemented by each region. While one third of them preferred to consolidate the previous geographical division into health sectors by maintaining it, grouping sectors together or by making minor modifications, most of the regions have sought to reinvent health areas by developing new methodologies. These different strategies have ended up in a slight increase of the number of areas with a stronger variability of their population size.
Conclusions: French regions have fairly well adopted the concepts of this new planning tool, even if some activities as psychiatry, social sector and ambulatory care have been insufficiently taken into account in the health areas construction. These different conceptions of health area make now question their management and development.

Published in: Pratiques et organisation des soins, n° 1, 2010/01-03, 73-80.
Les territoires de santé : des approches régionales variées de ce nouvel espace de planification.
Coldefy M., Lucas-Gabrielli V.

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Private supplementary health insurance: retirees' demand
Franc C. (Cermes, Inserm U750, CNRS UMR 8169, EHESS), Perronnin M. (Irdes), Pierre A. (Irdes)
Irdes working paper n° 9. 2008/04.

In France, private health insurance, that supplements public health insurance, is essential for access to health care. About 90% of the population is covered by a private contract and around half of them obtain their coverage through their employer. Considering the financial benefits associated with group contracts compared to individual contracts, we assume that the switching behaviors vary among different beneficiaries during the transition to retirement. Indeed, despite a 1989 law, the gap in premiums increases at retirement between group and individual contracts affords the opportunity to study the marginal price effect on switching behaviors. In this study, we consider the nature of the contract prior to retirement (compulsory or voluntary membership group contract and individual contract) as an indirect measure of the price effect. We focus on its role and check for a large number of individual characteristics that may influence the new retirees' health insurance demand.

Published in: The Geneva Papers, vol 33, n° 4, 2008/10, 610-626.
Private Supplementary Health Insurance: Retirees' Demand.
Franc C., Perronnin M., Pierre A.

Published in: Health and Ageing – The Geneva Association n° 19, 2008/10, 3-5.
Mobility on the Private Supplementary Health Insurance Demand: the Critical Period of the Transition to Retirement.
Franc C., Perronnin M., Pierre A.

which gave rise to: Issues in Health Economics (Questions d'économie de la santé) n° 126, 2007/10.
Complementary health cover changes at retirement time - Analysis of retirees' switching behaviour.
Franc C., Perronnin M., Pierre A.

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Working Conditions and Health of European Older Workers
Debrand T., Lengagne P.
Irdes working paper n° 8. 2008/02.

Working conditions have greatly evolved in recent decades in developed countries. This evolution has been accompanied with the appearance of new forms of work organisation that may be sources of stress and health risk for older workers. As populations are ageing, these issues are particularly worrying in terms of the health, labour force participation and Social Security expenditure. This paper focuses on the links between quality of employment and the health of older workers, using the SHARE 2004 survey. Our research is based on two classical models: the Demand-Control model of Karasek and Theorell (1991) and the Effort-Reward Imbalance model of Siegrist (1996), which highlight three main dimensions: Demand that reflects perceived physical pressure and stress due to a heavy work load; Control that refers to decision latitude at work and the possibilities to develop new skills; and Reward that corresponds to the feeling of receiving a correct salary relatively to efforts made, of having prospects for personal progress and receiving deserved recognition. These models also take into account the notion of support in difficult situations at work and the feeling of job security. Our estimations show that the health status of older workers is related to these factors. Fairly low demand levels and a good level of reward are associated with a good health status, for both men and women. Control only influences the health status of women. Lastly, the results reveal the importance on health of a lack of support at work and the feeling of job insecurity; regardless of gender; these two factors are particularly related to the risk of depression. Thus health status and working conditions are important determinants of the labour force participation of older workers.

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Promoting Social Participation for Healthy Ageing
Sirven N., Debrand T.
Irdes working paper n° 7. 2008/01.

Promoting social participation of the older population (e.g. membership in voluntary associations) is often seen as a promising strategy for ‘healthy ageing' in Europe. Although a growing body of academic literature challenges the idea that the link between social participation and health is well established, some statistical evidence suggest a robust positive relationship may exist for older people. One reason could be that aged people have more time to take part in social activities (due to retirement, fewer familial constraints, etc.); so that such involvement in voluntary associations contributes to maintain network size for social and emotional support; and preserves individuals' cognitive capacities. Using SHARE data for respondents aged fifty and over in 2004, this study proposes to test these hypotheses by evaluating the contribution of social participation to self-reported health (SRH) in eleven European countries. The probability to report good or very good health is calculated for the whole sample (after controlling for age, education, income and household composition) using regression coefficients estimated for individuals who do and for those who do not take part in social activities (with correction for selection bias in these two cases). Counterfactual national levels of SRH are derived from integral computation of cumulative distribution functions of the predicted probability thus obtained. The analysis reveals that social participation contributes by three percentage points to the increase in the share of individuals reporting good or very good health on average. Higher rates of social participation could improve health status and reduce health inequalities within the whole sample and within every country. Our results thus suggest that ‘healthy ageing' policies based on social participation promotion may be beneficial for the aged population in Europe.

Published in: Social Science & Medicine, vol 67, n° 12, 2008/12, 2017-2026.
Social Participation and Healthy Ageing: An International Comparison Using SHARE Data.
Sirven N., Debrand T.