ISSUES IN HEALTH ECONOMICS 2017

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Variations in Surgical Practices in Breast Cancer Treatment in France.
Issues in Health Economics (Questions d'économie de la santé) n° 226. 2017/03.
Or Z. (IRDES), Mobillion V. (Upec, IRDES), Touré M. (IRDES), Mazouni C. (Gustave Roussy), Bonastre J. (Gustave Roussy, INSERM-CESP)

In 2015, breast cancer was the most common form of cancer suffered by women in France in terms of incidence (54,000 new cases) and mortality (12,000 deaths) [Inca, 2015]. The surgical treatment of breast cancers has improved due to developments in diagnoses and therapies, as well as the reconfiguration of cancer care provision.
Conservative surgery (tumorectomy) became the principal treatment in more than 70% of the cases in the vast majority of hospitals in 2012. Between 2005 and 2012, the sentinel lymph node biopsy technique was offered in most of the healthcare facilities, and the number of patients who underwent this treatment tripled over the period. However, immediate breast reconstruction (IBR) after a total or radical mastectomy was still relatively rare, despite an increase in the number of instances where this technique was used.
The implementation of these practices varied between hospitals and départements. These variations may partly be linked to patients' health status and their preferences. But they also attest to differences in the organisation of services and the availability of technical platforms, as well as differences in medical practices between hospitals. All things being equal, the probability of benefitting from the sentinel lymph node technique or immediate breast reconstruction is greater in the Cancer Centres (Centres de Lutte Contre le Cancer, or CLCC), the Regional Teaching Hospitals (Centres Hospitaliers Régionaux, or CHR), and in hospitals with a high patient volume.

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Public and Private Health Insurances: How do they Contribute to Social Solidarity?
Issues in Health Economics (Questions d'économie de la santé) n° 225. 2017/03.
Jusot F. (Paris-Dauphine University, PSL Research University, Leda-Legos and IRDES), Legal R. (DREES), Louvel A. (DREES), Pollak C. (DREES and Paris Dauphine University Leda-Legos), Shmuel A. (Hebrew University-Hadassah School of Public Health)

A health insurance system ensures solidarity through organized transfers (income redistribution) between high and low income classes. The solidarity depends on the structure of healthcare consumption and health insurance contributions by income groups. The solidarity that underpins the French health insurance system is primarily based on the progressive funding of compulsory health insurance: higher income individuals contribute more than lower income individuals. But despite strong social inequalities in health, which imply more extensive healthcare needs among low-income individuals, the benefits are relatively homogeneous between different income groups. They therefore only marginally increase the solidarity of the health insurance system due to barriers in access to certain types of healthcare.
Unlike compulsory public health insurance, complementary private health insurance and out-of-pocket health expenses imply very few transfers between income groups. The mixity of the French health insurance system is therefore also a limiting factor in its solidarity between income groups.

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An Evaluation of the Health Ageing and Retirement Project (PARI): Phase 1
Is it possible to Use Administrative Data to Identify Risks for Vulnerable Elders?
Issues in Health Economics (Questions d'économie de la santé) n° 224. 2017/03.
Sirven N. (LIRAES (EA 4470), Université Paris Descartes, and IRDES)

The Health Ageing and Retirement Project (Programme d'Action pour une Retraite Indépendante), known as the Pari project, implemented by the French Social Security Fund for Self-Employed Workers (Régime Social des Indépendants, or RSI), is aimed at RSI contributors aged between 60 and 79. Using the RSI's medico-administrative documents, the plan aims to produce a diagnostic analysis of individual situations in order to detect economic, social, and health-related frailty and anticipate loss of autonomy, by providing coordinated solutions that are adapted to specific cases.
The Pari project's efficacy is primarily based on its ability to detect individual needs. This preliminary study aims to assess the effectiveness of the Pari plan's capacity to detect individual needs. Its objective is to assess to what extent ‘target individuals' - whose loss of autonomy could be anticipated thanks to a suitable service offering - are correctly identified using the Pari project's diagnostic tool. The preliminary results of the evaluation demonstrate that the project's detection system detected persons who had needs - particularly social ones - that were hitherto undetected. This evaluation study will need to be complemented by controlled experimentation aimed at analysing and ascertaining the effectiveness of the supportive initiatives implemented by the Pari plan.

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The State of Public Health in France and Risk Factors
Preliminary Results of the 2014 European Health Interview Survey - The Health, Health Care and Insurance Survey (EHIS-ESPS 2014)
Issues in Health Economics (Questions d'économie de la santé) n° 223. 2017/03.
Pisarik J. (DREES), Rochereau T. (IRDES), In collaboration with Célant N. (IRDES)

According to the preliminary results of the 2014 European Health Interview Survey: The Health, Health Care and Insurance Survey (EHIS-ESPS 2014), conducted in private households (non-institutional population), almost one third of the population (aged 15 or over) in mainland France rated their health as fair, poor, or very poor. Almost 40% of respondents stated they had a chronic medical condition and a quarter had a health condition that limited their ability to perform common daily activities. These health indicators varied greatly according to the socio-professional categories, to the detriment of disadvantaged sections of the population, particularly households of unskilled workers. Almost one in ten women and one in twenty men had depressive symptoms, which were more acute in persons aged 75 or over, and mainly concerned employed households. With 7% of the population suffering from depression, France is on a par with the European average.
Among the risk factors, 46% of the population in mainland France was excess overweight, (31% overweight, and 15% obese), which is less than most of the other European countries that took part in the survey. However, 28% of the respondents smoked (22% smoked daily), representing a smoking rate that is higher than the European average. These two risk factors vary greatly according to the socio-professional categories, to the detriment, in particular, of working-class households. Two other Issues in Health Economics/Studies and Results (Questions d'économie de la santé/ Études et Résultats) will be published in 2017, presenting the preliminary results relating to health insurance and access to healthcare. All the survey's results will, in any case, be released in an IRDES (Institute for Research and Information in Health Economics) report, which will be published in 2017.

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Compulsory Psychiatric Treatment: An Assessment of the Situation Four Years after the Implementation of the Act of 5 July 2011
Issues in Health Economics (Questions d'économie de la santé) n° 222. 2017/02.
Coldefy M. (Irdes), Fernandes S. (ORU-Paca, Université Aix-Marseille), In collaboration with Lapalus D. (ARS Paca)

French law relating to compulsory psychiatric treatment was amended by the Act of 5 July 2011. It reaffirmed the rights of people receiving compulsory treatment and introduced two key measures: the intervention of the judge of freedom and detention ("juge des libertés et de la détention" or JLD), who monitors the need for compulsory treatment, and the possibility of compulsory ambulatory care as part of treatment programmes. In addition, a new form of admission "in the case of imminent danger" (Acute Involuntary Admission or AIA) was introduced to facilitate access to care for isolated and socially excluded people.
Based on medico-administrative data, this study analyses the evolution in the use of compulsory psychiatric treatment since the introduction of the Act in 2011. 92,000 people received compulsory treatment in 2015, that is 12,000 more people than in 2012. This rise is explained by several factors: the extension of the duration of out-of-hospital compulsory care, as part of treatment programmes, and the rise in the treatment rates for people in imminent danger. Used to facilitate hospital admission in emergency situations and relieve third parties of this difficult process, this mechanism is used in a disparate manner, depending on the geographical area in France.

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Accessing Cancer Care: Developments in Cancer Care from 2005 to 2012
Issues in Health Economics (Questions d'économie de la santé) n° 221. 2017/01.
Bonastre J. (INSERM, Institut Gustave Roussy), Mobillion V. (Upec, IRDES), Or Z. (IRDES), Touré M. (IRDES)

With about 355,000 new cases per year, cancer care is a challenge both in medical and economic terms. Over the last ten years, cancer care went through extensive restructuring, on the one hand under the influence of activity-based funding (Tarification à l'Activité, T2A) as a mode of financing hospitals and, on the other hand, following the implementation of minimal activity thresholds, although it is not yet known what the impacts are in terms of cancer care redistribution, geographical access, and quality of care across the French territory.
The developments in hospital cancer care between 2005 and 2012 are described here, focusing on surgical and chemotherapy facilities. The effects of the reconfiguration of cancer care are examined from the perspective of the evolution of distances of access and admission rates at the département level.
Over the studied period, some one hundred facilities that used to perform cancer surgery but with a low level of activity volume have been closed down, while the number of cases per facility increased, notably in the state-owned sector. Despite this, the average distance travelled by patients receiving cancer surgery or chemotherapy did not change much, but variations in admission rates for both of these treatments persist across departments.
One of the next Issues in Health Economics, devoted to breast cancer surgery, will provide an analysis of the territorial differences in medical practices, which question equality of access and care quality across départements.