WP n° 28

What are the Motivations of Pathways to Retirement in Europe: Individual, Familial, Professional Situation or Social Protection Systems?
Debrand T., Sirven N.
Irdes working paper n° 28. 2009/10.

The aim of this research is to identify the determinants of pathways to retirement in Europe and, by measuring the influence or combined influence of individual, contextual and institutional domains on labor force participation, to better understand inter-country variations in the employment rates of older citizens. The dataset consists of both the first two longitudinal waves of SHARE (2004-2006) and some macroeconomic series from the OECD describing three complementary social protection systems (pensions, disability, employment). The analysis is simultaneously carried out in terms of “stocks” (labor force participation in 2004) and “flows” (pathways from employment in 2004 to retirement in 2006). Indicators are developed to measure the contribution of each domain (individual, contextual, institutional), and their various combinations to the employment rate of older citizens, and their role in explaining inter-country differences. As expected, results demonstrate that labor force participation and the decision to retire are determined by the various individual and contextual domains with social protection systems, each playing a significant role. Institutional determinants explain most of the intercountry differences. There appears to be a complementary effect between the different categories of social protection, and the global effect of the three systems combined is greater than the sum of the idiosyncratic effect of each system. Future public policies aiming at increasing the workforce participation of older citizens should therefore take into account that retirement decisions are determined by complex, interactive and individual determinants, and that within the European Union, the main convergence factors are to be found in the differences in social protection systems.

Published in: Retraite et Société (Cnav), n° 57, 2009/06, 35-53.
Les facteurs explicatifs du départ à la retraite en Europe.
Debrand T., Sirven N. In Emploi et retraite en Europe - Enquête SHARE. Coordonné par Attias-Donfut C. (Cnav), Sirven N. (Irdes)

Which gave rise to: Issues in Health Economics (Questions d'économie de la santé) n° 148. 2009/11.
Pathways to Retirement in Europe: Individual Determinants and the Role of Social Protection.
Debrand T., Sirven N.

Which gave rise to: Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems.
Or Z., Cases C., Lisac M., Vrangbaek K., Winblad U., Bevan G. Document de travail Irdes n° 27. 2009/09

Published in: Health Economics Policy and Law, vol 5, n° 3, 2010/07, 269-293 Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems.
Or Z., Cases C., Lisac M., Vrangbaek K., Winblad U., Bevan G.

WP n° 27

An advice?

Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems
Or Z. (Irdes), Cases C. (Irdes), Lisac M. (Bertelsmann Stiftung), Vrangbæk K. (University of Copenhagen), Winblad U. (Uppsala University), Bevan G. (London School of Economics).
Irdes working paper n° 27. 2009/09.

Industrialised countries face similar challenges for improving the performance of their health system. Nevertheless the nature and intensity of the reforms required are largely determined by each country's basic social security model. This paper looks at the main differences in performance of five countries and reviews their recent reform experience, focusing on three questions: Are there systematic differences in performance of Beveridge and Bismarck-type systems? What are the key parameters of health care system which underlie these differences? Have recent reforms been effective? Our results do not suggest that one system-type performs consistently better than the other. In part, this may be explained by the heterogeneity in organisational design and governance both within and across these systems. Insufficient attention to those structural differences may explain the limited success of a number of recent reforms.

Published in: Health Economics Policy and Law, vol 5, n° 3, 2010/07, 269-293.
Are Health Problems Systemic? Politics of Access and Choice under Beveridge and Bismarck Systems.
Or Z., Cases C., Lisac M., Vrangbaek K., Winblad U., Bevan G.

WP n° 26

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What Moves you to Retire? Personnal, Family or Professional Situation, or Social Protection Systems?
Debrand T. (Irdes), Sirven N. (Irdes).
Irdes working paper n° 26. 2009/06

This paper dedicates special attention to the role of overall social protection systems – besides the usual individual and contextual determinants of labour supply – in explaining the differences in employment rates of older citizens in Europe. The dataset consists of both the first two longitudinal waves of SHARE (2004-2006), and some macroeconomic series from the OECD describing three complementary social protection systems (pensions, disability, unemployment). The analysis is carried out in terms of “stock” (being occupied in 2004) and “flows” (moving from employment in 2004 to retirement in 2006). Some indices are developed to measure the contribution of each domain (individual, contextual, institutional) and their various combinations to the rate of employment (both in “stock” and “flows”). As expected, the various individual and contextual situations determine the decision to retire, and each system of social protection plays a significant role. In the detail, the institutional variables explain most of inter-countries differences. However, the global effect of the three systems altogether is higher than the sum of the idiosyncratic effect of each system on employment. One may thus think of a substitution effect between the different categories of social protection. Ongoing reforms of the labour market should have to do with the various set of inter-related institutions for social protection, rather than focusing on a single one.

WP n° 25

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One price for all? Sources of cost variations between public and private hospitals
Or Z., Renaud T., Com-Ruelle L.
Irdes working paper n° 25. 2009/05.

Within the framework of its activity-based payment system, introduced in 2005, the French government is now seeking to achieve price convergence between public and private hospitals. This paper questions the economic justification of this convergence by examining the literature on hospital costs variation and analyzing French hospital activity data.
The literature on hospital economics identifies many factors which can generate cost differences between hospitals a part from efficiency. These include hospital size and its range of activity, differences in patient characteristics and quality of the care. The results from the literature suggest that DRG prices should be adjusted to take into account these factors, which are not always under the control of public hospitals but which have a direct impact on their costs.
In addition, the analysis of French hospital activity indicates a strong partitioning of the type of care provided between the public and private sectors, corresponding to different hospital profiles. Not taking these different profiles into account when setting DRG prices could endanger the capacity of the hospital system to provide necessary care as well as equity of access.

WP n° 24

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Income and the Demand for Complementary Health Insurance in France
Grignon M. (McMaster University; Associate researcher, Irdes), Kambia-Chopin B. (Irdes).
Irdes working paper n° 24, 2009/04

This paper examines the demand for complementary health insurance (CHI) in the non-group market in France and the reasons why the near poor seem price insensitive. First we develop a theoretical model based on a simple tradeoff between two goods: CHI and a composite good reflecting all other consumptions. Then we estimate a model of CHI consumption and empirically test the impact of potential determinants of demand for coverage: risk aversion, asymmetrical information, non-expected utility, the demand for quality and health, and supply-side factors such as price discrimination. We interpret our empirical findings in terms of crossed price and income elasticity of the demand for CHI. Last, we use these estimates of elasticity to simulate the effect of various levels of price subsidies on the demand for CHI among those with incomes around the poverty level in France. We find that the main motivation for purchasing CHI in France is protection against the financial risk associated with copayments in the public health insurance scheme. We also observe a strong income effect suggesting that affordability might be an important determinant. Our simulations indicate that no policy of price subsidy can significantly increase the take-up of CHI among the near poor; any increase in the level of subsidy generates a windfall benefit for richer households.

Which gave rise to: Issues in Health Economics (Questions d'économie de la santé) n° 153. 2010/04.
What Would be the Optimal Subsidy to Encourage Subscription to Supplementary Health Insurance?
Grignon M.,Kambia-Chopin B.

WP n° 23

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Activity based payment in hospitals: Principles and issues drawn from the economic literature and country experiences
Or Z., Renaud T.
Irdes working paper n° 23. 2009/03.

In 2005, France joined the ranks of most other developed countries when it introduced an activity based payment system to finance all acute care hospitals. Despite some basic principles in common, the design of these systems can vary significantly across countries. In order to understand better the issues raised by the new system in France, this paper examines the economic rationale for such a system, the key implementation decisions to be made and the challenges involved.
The principle of paying hospitals according to their activity in relation to homogeneous groups of patients has some obvious advantages to improve efficiency and the transparency in health care financing. However, the literature and the experience of the other countries presented in this paper show that this mechanism of payment presents a certain number of risks and requires regular and careful adjustments to obtain the benefits expected of such a system. To ensure both the clinical and economic coherence of the classification used to define hospital activity, and to establish the corresponding level of tariffs, constitute two major challenges. The principle of paying a fixed price which is directly indexed on the average costs observed and which remains common to all types of hospitals has been increasingly subject to criticism. Furthermore, activity based payment, by its nature, can induce some perverse effects which requires complementary regulatory mechanisms to guarantee the quality of the care and equitable access. From the point of view of controlling health expenditure, it is equally important to follow closely the evolution of health care activity in different hospital settings, as well as in ambulatory care, since activity based payment may encourage hospitals to increase their activity by inducing greater demand for profitable services while shifting part of their costs towards medium/long-term care settings or to home-based or informal care.

Which gave rise to: Issues in Health Economics (Questions d'économie de la santé) n° 149, 2009/12.
Is there a Relationship between Volume of Activity and Quality of Care in French Hospitals?
Or Z., Renaud T.

WP n° 22

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The preferred doctor scheme: A political reading of a French experiment of Gate-keeping
Naïditch M. (Denis Diderot University, Irdes), Dourgnon P. (Irdes)
Irdes working paper n° 22, 2009/03

Study objective: Since January 2005 France is exploring a new scheme termed “preferred doctor” (médecin traitant) which can be considered as an innovative version of Gate Keeping in order to reduce the excess of postulated excess in health consumption, more especially access to specialist care. This paper describes the political process which lead to it's implementation, tries to relate some of the scheme specific features with it's results after one year implementation and tries to catch a glimpse for the next steps of the reform.
Material and methods: In order to measure the scheme impact on the “patient treatment pathway” and on physician income, we used a sample of 7198 individual from the 2006 “French health, Health Care and Insurance Survey “(ESPS),”including health, socioeconomic and insurance status and through a set of questions relating to patient's understanding of the scheme and different data bases of the national sickness fund as well as different studies done by regulatory agencies.
Results and discussion: First results after one year implementation show that most patients chose a preferred doctor, who in a vast majority happened to be their family doctor. A vast majority of patients also considered the scheme as mandatory. Impact on access to specialist care, as measured through self assessed unmet need for specialist care, appears not negligible, especially for the less well off and those not covered by a complementary insurance. In term of financial impact, the new constraints on access to ambulatory care seem to have been offset by rises in the fee schedules for the specialities which lost direct access.
We discuss why these short term weak outcomes are linked with a wicked system of the health system governance and to the political and professional context in which the scheme unfolded strongly and determined its structure and implementation pathway. On a more long range perspective, we analyse how the new scheme may nevertheless lead up to reinforced managed care reforms.

Published in: Health Policy, vol 94, n° 2, 2010/02, 129-134.
The Preferred Doctor Scheme : A Political Reading of a French Experiment of Gate-keeping.
Dourgnon P., Naiditch M.

WP n° 21

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Evolution 1998-2002 of the antidepressant consumption in France, Germany and the United Kingdom
Grandfils N., Sermet C.
Irdes working paper n° 21, 2009/02

The aim of this paper is to compare the evolution of antidepressant consumption in France, Germany and the United Kingdom between 1998 and 2002. Commercial databases (IMS Health) have been used in conjunction with administrative data (PACT for the UK, GKV for Germany and Afssaps for France) to estimate antidepressant consumption in Daily Defined Doses. The main results are: (1) Antidepressant consumption has increased significantly over the last decade in France (x2), Germany (x2.4) and the UK (x3.8); (2) SSRIs are the most heavily consumed drugs in France (67%) and the UK (60%); (3) Germany is distinguished by an overall level of antidepressant consumption twice as low as the other two countries and a relatively low use of SSRI antidepressants (31%), in favour of TCAs. In conclusion, the combined use of administrative and commercial data is possible for an evaluation of the volume of consumption. This study sheds both medical and economic light on the differences in both the level and structure of consumption in these three countries.

WP n° 20

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Dynamic Estimation of Health Expenditure: A new approach for simulating individual expenditure
Albouy V. (Insee), Davezies L. (Insee), Debrand T. (Irdes)
Irdes working paper n° 20, 2009/01

This study compares estimates of outpatient expenditure computed with different models. Our aim is to predict annual health expenditures. We use a French panel dataset over a six year period (2000-2006) for 7112 individuals. Our article is based on the estimations of five different models. The first model is a simple two part model estimated in cross section. The other models (models 2 to 5) are estimated with selection models (or generalized tobit models). Model 2 is a basic sample selection model in cross section. Model 3 is similar to model 2, but takes into account the panel dimension. It includes constant unobserved heterogeneity to deal with state dependency. Model 4 is a dynamic sample selection model (with lagged adjustement), while in model 5, we take into account the possible heteroskedasticity of residuals in the dynamic model.
We find that all the models have the same properties in the cross section dimension (distribution, probability of health care use by gender and age, health expenditure by gender and age) but model 5 gives better results reflecting the temporal correlation with health expenditure. Indeed, the retransformation of predicted log transformed expenditures in homoscedastic models (models 1 to 4) generates very poor temporal correlation for " heavy consumers ", although the data show the contrary. Incorporation of heteroskedasticity gives better results in terms of temporal correlation.

Published in: Economic Modelling, vol 27, n° 4, 2010/07, 791-803.
Health Expenditure Models : A Comparison Using Panel Data.
Albouy V., Davezies L., Debrand T.

Which gave rise to: Document de travail Insee, n° G2010 / 02, 2010/02, 31 p.
Health Expenditure Models: a Comparison of Five Specifications Using Panel Data.
Albouy V., Davezies L., Debrand T.

WORKING PAPERS 2009