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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Polypharmacy: definitions, measurement and stakes involved
Review of the literature and measurement tests

Issues in Health Economics (Questions d'économie de la santé) n° 204. 2014/12.
Monégat M. (Irdes), Sermet C. (Irdes) In collaboration with Perronnin M. (Irdes) and Rococo E. (Institut Gustave Roussy-IGR)

Polypharmacy, defined by the World Health Organisation as "the administration of many drugs at the same time or the administration of an excessive number of drugs" is frequent among the elderly as they often suffer from chronic diseases with concomitant pathologies. If polypharmacy is legitimate in some cases, it can also be inappropriate and in all cases carries the risk of adverse effects or drug interactions. In an ageing society such as ours, polypharmacy is a major public health issue in terms of quality and efficiency of care and health expenditures. It is thus essential to examine the definitions and measurement of polypharmacy.
Based on a review of the literature, different definitions of polypharmacy were identified (simultaneous, cumulative and continuous polypharmacy) and the measurement of polypharmacy was examined according to different thresholds. The five most frequently used tools to measure polypharmacy, according to the literature, were then tested using the IMS Health database, Disease Analyzer on 69,324patients and 687 physicians. The aim was to compare the ability of indicators to identify polypharmacy and to evaluate the technical feasibility of their calculations.

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The International Migration of Doctors: Impacts and Political Implications
Issues in Health Economics (Questions d'économie de la santé) n° 203. 2014/11.
Moullan Y. (University of Oxford, International Migration Institute, Irdes) In collaboration with Bourgueil Y. (Irdes)

If the international migration of doctors has been part of the "brain drain" debate, few studies have focused on the question in depth due to statistical data limitations. An innovative data source based on foreign-trained doctors over the period 1991 to 2004, made it possible to draw up an overview of the migration flow of doctors, to study its impact and draw economic policy implications.
The Asian countries record the highest emigration rates for doctors (India, the Philippines), followed by Canada and the United Kingdom with France in 25th position. In 2004, Subsaharan Africa recorded the lowest density of doctors in the world but a relatively high emigration rate at 19%. In 2004, 60% of foreign-trained doctors were located in the United States, the country receiving the highest number of doctors in the world, and 20% in the United Kingdom. Australia, Canada and Germany each receive 3%, Belgium 2% and France 1.34%.
What effect do these migrations have on the origin countries both from an economic point of view and in terms of health indicators? What lines of action or public policies can be envisaged in the face of emigration? What form of international cooperation can be envisaged in terms of health professionals' international mobility? What are the impacts on the receiving countries' in terms of health profession regulation policies?

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Long-stay psychiatric hospitalisation: analysis and determinants of territorial variability
Issues in Health Economics (Questions d'économie de la santé) n° 202. 2014/10.
Coldefy M., Nestrigue C. (Irdes)

Long-stay psychiatric hospitalisation (lasting a year or over, over a continuous period or not, and associated with a period of hospitalisation the preceding year) concerned almost 12,700 patients in 2011. Although it only represents 0.8% of hospitalisations in the active patient file, it nevertheless represents a quarter of the total number of hospital days and a quarter of hospital beds. When there are no therapeutic indications to warrant hospitalisation and in the context of reduced hospital capacity and average hospital stays, and the development of ambulatory psychiatric care, prolonged hospitalisation raises a number of questions.
Using the Medical Information Database for Psychiatry (Rim-P, Recueil d'informations médicalisées en psychiatrie) and numerous medical-administrative databases, this study aims to answer several questions: what are the characteristics of long-stay psychiatric inpatients? How to explain territorial variations in the use of long-stay hospitalisation? What role is played by the organisation of care supply, medical-social care supply and the socioeconomic context in these disparities?

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Forms of primary care teams
A typology of multidisciplinary group practices, health care networks and health care centers participating in the Experiments of New Mechanisms of Remuneration (ENMR)

Issues in Health Economics (Questions d'économie de la santé) n° 201. 2014/09.
Afrite A., Mousquès J. (Irdes)

What are the characteristics of primary care teams in France (multidisciplinary group practices (MGP), health care networks (HCN) and health care centers (HCC)) involved in the Experiments of New Mechanisms of Remuneration (ENMR) in terms of size, human resources, equipment and information systems? What are their organisational and functional characteristics in terms of care supply, coordination and multi-professional cooperation?
This fourth publication evaluating the primary care teams participating in the ENMR proposes an analysis of their structural, organisational and functional characteristics based on a survey conducted among 147 sites for the period 2008-2012. The sites were grouped together on the basis of factorial analyses and classifications resulting in five clusters: two HCC clusters, grouping salaried practitioners, and three MGP and HCN clusters grouping self-employed practitioners.

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Experiencing the Impact of a Specific Funding Scheme for Primary Care Teams on Professional Dynamics and Inter-Professional Teamwork in France: A Qualitative Assessment
Issues in Health Economics (Questions d'économie de la santé) n° 200. 2014/07-08.
Fournier C. (Cermes3 - CNRS UMR 8211 - Inserm U988 - EHESS - Paris Descartes), Frattini M.-O. (Prospere), Naiditch M. (Irdes, Prospere)

This qualitative research examines professional dynamics in primary care teams and more specifically, the effect of a prospective and supplementary budget (called NMR) allocated to the practice, specifically to foster new forms of inter-professional teamwork. Our analysis of this pilot program called "Experiments with New Mechanisms of Remuneration" (ENMR) is based on a sample of four primary care teams purposively selected among 114 participating primary care teams but only those with self-employed professionals.
This paper gives a summary of the main results of an in-depth analysis (Fournier et al., 2014) and is the third Issues in Health Economics in a series. The first paper presents the aims and methods of the forthcoming quantitative evaluation developed by IRDES over the last four years 2009-2013 (Afrite et al., 2013). Based on this assessment, the second paper analyses the geographical distribution of the participating primary care teams and their impact on the density of general practitioners (Chevillard et al., 2013 a and b).
This exploratory research has three aims: to study the conditions under which inter-professional teamwork emerges and the numerous forms it exhibits within the selected sample; to generate hypotheses on the main factors that favour or hinder the development of inter-professional team work and more particularly the role played by the new funding scheme (NMR); finally, to contribute to the public debate about what factors ought to be taken into consideration so that this experiment can be scaled up and implemented successfully.

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Index of the first 200 issues of Questions d'économie de la santé
January 1998 – July-August 2014

Issues in Health Economics (Questions d'économie de la santé) hors série. 2014/09.

Marking the publication of the 200th issue of Questions d'économie de la santé (Issues in Health Economics), a look back at the entire series launched in 1998 reveals – besides the diversity of research topics covered and the ones recurring the most frequently – the evolution of research at IRDES over more than 15 years. Recurrence of topics is partly the result of the data production carried out regularly by IRDES, notably through the Health, Health Care and Insurance survey (ESPS). Among the main topics covered: health care access and use, complementary health cover, health expenditures, health status, health geography, health inequalities, health system organization, medical practices (cooperation, grouping of health professionals…), health professionals, etc. These last years, other topics emerged – such as dependency and ageing, drugs, relations between health and work, unmet care needs, primary care, mental health – as a response to society's contemporary concerns.
This special edition offers French and English abstracts of the last twelve issues of Questions d'économie de la santé as well as two indexes encompassing the entire series: one organized by chronology and the other by research topics.

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Measuring Age-related Frailty in the General Population: a Comparison of the ESPS and SHARE Surveys
Issues in Health Economics (Questions d'économie de la santé) n° 199. 2014/06.
Sirven N. (Irdes), In collaboration with Rochereau T. (Irdes)

Research potential provided by the recent development of studies on age-related frailty is considerable, particularly in terms of gaining a better understanding of the mechanisms leading to old age dependency. Several studies have used data collected by the Survey on Health, Ageing and Retirement in Europe (SHARE) to identify individual determinants leading to the loss of autonomy. A specific questionnaire dealing with frailty was added to the IRDES Health, Health Care and Insurance survey (ESPS) in 2012. However, due to differences in the methodologies used, the measure of frailty in SHARE and ESPS is not identical.
Consequently, it therefore seemed appropriate to compare the frailty indicators obtained in the two surveys: in other words, can the measure of frailty accommodate a certain degree of freedom regarding data collection methods, or should they be identical in each survey?
The comparison revealed slight discrepancies in the prevalence rates of frailty, not only between the two surveys through the use of different questions (ESPS and SHARE), but also through the use of dissimilar measures within the same survey (SHARE). Despite these differences, it also revealed relative homogeneity between the determinants of frailty. Both surveys thus provide potential data resources for research on frailty. In this respect, observed social inequalities in later life frailty in both SHARE and ESPS provide an avenue for future research that should not be neglected. Finally, this first study also confirms that ESPS can effectively contribute to research on age-related frailty.

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The 2012 Health, Health Care and Insurance Survey (ESPS)
First Results

Issues in Health Economics (Questions d'économie de la santé) n° 198. 2014/05.
Célant N., Dourgnon P., Guillaume S., Pierre A., Rochereau T., Sermet C. (Irdes)

The Health, Health Care and Insurance Survey (ESPS) have been conducted by IRDES every two years since 1988. In 2012, over 8,000 households comprising a total of 23,000 individuals were interviewed on general health topics such as health status, access to complementary health insurance, the use of health care services or unmet care needs and more specific questionnaire modules dealing with issues such as frailty, insurance against old-age dependency, working conditions, vaccination coverage, accidents of everyday life and blood donation.
The survey's specificities, its short two-year periodicity, its longitudinal dimension and its enrichment with National Health Insurance data have contributed to creating an invaluable public policy monitoring tool as well as a research tool for the social sciences. In 2014, ESPS will be used as the basis of the European Health Interview Survey (EHIS). The results of the 2012 survey presented in this summary are taken from the ESPS report (Célant et al., 2014) which includes the totality of quantified data accessible on-line in the form of Excel tables.

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Disabled Persons' Access to Dental, Ophthalmological and Gynaecological Care in France
Exploitation of the Health and Disability Households survey (Enquête Handicap-Santé Ménages)

Issues in Health Economics (Questions d'économie de la santé) n° 197. 2014/04.
Lengagne P., Penneau A., Pichetti S., Sermet C. (Irdes)

To date, few French studies have analysed the question of health care use among people with disabilities. The Health and Disabilities Households (HSM, Handicap-Santé Ménages) and Institutions (HIS, Handicap-Santé Institutions) surveys conducted by the DREES and INSEE in 2008-2009 partially filled the information gaps on disability. Using HSM survey data, this study examines access to three types of routine medical care (dental, ophthalmological and gynaecological care) within a population aged from 20 to 59 years old. The analysis is based on two disability indicators: the presence of functional limitations (motor, cognitive, visual or hearing limitations) and administrative recognition of disability measured by access to allowances, benefits, employment or specific rights.
This first study reveals that disabled persons have less access to dental and gynaecological care whatever the disability indicator used. On the contrary, it does not reveal difficulties in accessing ophthalmological care. Differential access to health care as a result of disability may be explained by this population's more disadvantaged social situations. It can also be related to physical difficulties in accessing care structures or transport. Finally, considerable inequalities in access to routine medical care were observed among persons benefitting from the Disability Allowance for Adults (AAH, Allocation aux adultes handicapés). This population has a lower income level than those benefitting from invalidity pensions and invalidity insurance benefits and, contrary to the latter, are not entitled to 100% medical expenditure reimbursements.
Other disability studies will follow to analyse the use of other health care services, particularly preventive care and access to care for disabled persons in institutions.

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Reconciling General Medical Records and Health Insurance Reimbursement Data: Feasibility Study and First Results
Issues in Health Economics (Questions d'économie de la santé) n° 196. 2014/03.
Bourgueil Y. (Irdes, Prospere), Perlbarg J. (Irdes, Prospere), in collaboration with Allonier C. (Irdes), Boisnault P. (Prospere), Daniel F. (Irdes), Le Fur P. (Irdes, Prospere), Szidon P. (Prospere)

The aim of this study was to test the feasibility of chaining clinical data with National Health Insurance reimbursement data and to validate the interest in doing so. This data linking trial is part of a long term project aimed at creating an information system enabling the advancement of research on health care services. Based on a representative sample of general practitioners (GPs) and patients, an information system of this kind would provide a means of measuring morbidity management in the primary care sector and a tool to analyse GP practices and patient care pathways so as to improve the efficacy and efficiency of the health care system.
The first step consisted in auditing the technical feasibility of the data linking process. The second phase made it possible to evaluate the interest in enriching Health Insurance data with clinical data in the aim of identifying populations suffering from chronic diseases, namely diabetic and hypertensive patients.

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Explaining the Non-take-up of a French Health Insurance Vouchers Program (Aide à l'acquisition d'une complémentaire santé, ACS)
Results of a Survey Conducted in 2009 among Potential Beneficiaries in Lille

Issues in Health Economics (Questions d'économie de la santé) n° 195. 2014/02.
Guthmuller S. (Université de Bordeaux, Isped), Jusot F. (Université Paris-Dauphine, Leda-Legos et Irdes), Renaud T. (Tecsta), Wittwer J. (Université de Bordeaux, Isped, Leda-Legos)

The Health Insurance Vouchers Scheme (Aide à l'acquisition d'une complémentaire santé (ACS)) was introduced in 2005 as a financial incentive to help poor individuals obtain complementary health coverage and as a means of improving access to health care. This financial support is entitled for households with income just above the eligibility threshold for the free Complementary Universal Health Coverage (Couverture maladie universelle complémentaire (CMU-C)). Despite an increase in the number of beneficiaries since its introduction, the non-take-up of ACS entitlements remains high; only 22% of eligible persons had claimed the allowance in 2011 (CMU Fund, 2012). In this context, it is essential to understand the reasons for non-take-up in order to improve the scheme's efficiency and allow low income households access to complementary health insurance. To this effect, and as a follow-up to a social experiment, a survey was conducted in Lille in 2009 among individuals potentially eligible for ACS so as to gain a better understanding of their characteristics and determine motivations or barriers to using the scheme.
The results of this survey showed that the sample population identified in Lille as being entitled to ACS were confronted with both socio-economic difficulties and important health care needs. The ACS take-up rate was low with only 18% of respondents having taken steps to obtain it. The reasons most frequently evoked for non-take-up were: ineligibility, lack of information, the complexity of procedures, and the cost of complementary health insurance for persons without coverage even after deducting the value of the "health voucher".

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Towards an Information System on Health Care Costs, Public and Complementary Health Insurance Reimbursements, and Out-of-pocket Payments
Issues in Health Economics (Questions d'économie de la santé) n° 194. 2014/01.
Dourgnon P., Evrard I., Guillaume S. (Irdes)

The Monaco project (Methods, Tools and Standards for Statutory and Complementary Health Insurance Data Linkage, Méthodes, outils et normes pour la mise en commun des données des assurances complémentaire et obligatoire) is a first step toward the creation of an information system aimed at improving knowledge on beneficiaries' remaining out-of-pocket payments (OOP) after reimbursement by the National Health Insurance (NHI) and complementary health insurance (CHI) schemes. It involves testing the technical possibility of linking individual records from the NHI and CHI providers administrative files based on the Health, Health Care and Insurance Survey (ESPS) framework. Monaco combines the main branches of the National Health Insurance scheme and ten organisations providing complementary health insurance under the auspices of the Institute for Health Information (IDS).
After a description of the data linkage methodology, we present first technical conclusions and a review of the research perspectives this new tool would enable.