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Despite the implementation of incentive policies to promote seasonal flu vaccination for more than 20 years in France, the coverage of high-risk individuals remains largely insufficient. While there is extensive literature on the determinants of vaccination in a given year, it rarely considers the specificity of flu vaccination, which must be repeated every autumn to remain effective. We aim to fill this gap by focusing on the flu vaccination behavior of high-risk individuals (65 years and older, chronic diseases) over a 15-year period. Based on data from 87,820 women in the French E3N cohort, we used sequence analysis methods (localized Optimal Matching) to identify typical seasonal flu vaccination profiles based on individual trajectories from 2004 to 2018. Then, using a multinomial model, we studied the individual determinants associated with the different patterns of vaccination use identified. Sequence analysis resulted in a partition of 8 clusters, which can be summarized into 4 typical behaviors: almost half of the women get vaccinated against flu each year (43%); conversely, another important share never get vaccinated against flu (32%); some do not get vaccinated for several years and then get vaccinated every year (20%); and finally, a minor share discontinued vaccination (5%). Thus, once women start getting vaccinated they generally continue every year. Nonetheless, this is a double-edged sword, as an important share of women considered at risk refrain from being vaccinated for more than a decade. Determinants associated with regular vaccination are being more at risk (age, weight, and chronic diseases), being in contact with physicians, being more educated, being in couple, having children, not smoking, and undergoing breast cancer screening.

[eng] Over the past decade, the journal Economie et Statistique has devoted two special issues to health economics. After the special issues published in 2013 and 2016, this Thematic Section brings together a selection of articles from the 41st Journees des economistes de la sante francais (JESF, Annual congress of French health economists) held at the University of Poitiers in December 2019.

International audience; France has first experimented, in 2009, and then generalized a practice level add-on payment to promote Multi-Professional Primary Care Groups (MPCGs). Team-based practices are intended to improve both the efficiency of outpatient care supply and the attractiveness of medically underserved areas for healthcare professionals. To evaluate its financial attractiveness and thus the sustainability of MPCGs, we analyzed the evolution of incomes (self-employed income and wages) of General Practitioners (GPs) enrolled in a MPCG, compared with other GPs. We also studied the impacts of working in a MPCG on GPs’ activity through both the quantity of medical services provided and the number of patients encountered. Our analyses were based on a quasi-experimental design, with a panel dataset over the period 2008–2014. We accounted for the selection into MPCG by using together coarsened exact matching and difference-in-differences (DID) design with panel-data regression models to account for unobserved heterogeneity. We show that GPs enrolled in MPCGs during the period exhibited an increase in income 2.5% higher than that of other GPs; there was a greater increase in the number of patients seen by the GPs’ (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 showed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014. Hence, our results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

Introduction : Les medecins generalistes (MG) jouent un role cle dans l’offre de services de prevention et de depistage cible, en particulier dans le cas des cancers du sein, du col de l’uterus et du colon. Cependant, leur implication reste limitee et tres variable selon les medecins et le type de cancer. En utilisant la methodologie des choix discrets, notre objectif est d’analyser les preferences des MG quant aux leviers susceptibles d’ameliorer leur implication dans le depistage de ces trois cancers.Methodes : Un echantillon representatif de la population des MG francais a ete constitue entre mars et avril 2014 ; les 402 participants ont eu a reveler leurs preferences sur la base de 12 scenarios de choix construits autour de cinq dispositifs destines a promouvoir leur activite de depistage.Resultats : Les MG sont sensibles a la fois aux incitations financieres et non financieres, tels que le financement d’une formation ou la transmission bisannuelle d’un listing des patient(e)s ayant ete depiste(e)s. Les preferences varient selon le type de cancer a depister, les MG etant relativement plus sensibles aux incitations financieres pour le cancer colorectal et aux incitations non financieres pour les cancers du sein et du col de l’uterus.Conclusion : Les resultats de l’etude permettront de mieux definir les mesures a prioriser et/ou a associer aux schemas existants (depistages organises, P4P) afin de favoriser de facon plus efficiente l’offre de depistage des cancers en medecine generale.

In many countries, policies and reforms have explicitly encouraged the integration of primary care organizations and interprofessional cooperation in order to improve the productive and allocative efficiency of care provision and to address the unequal geographical distribution of doctors. In France, the Social Security Department of the Ministry of Health and a nonprofit organization called Asalee (Action de sante liberale en equipe; Team Health Project in Private Practice) set up an experiment to promote vertical integration and teamwork between general practitioners (GPs) and nurses, based in particular on the staffing and training of nurses, as well as the authorization of task substitution between general practitioners and nurses, and new forms of remuneration. This article evaluates the expansion of this experiment over the period 2010–2016 by studying the joint effect on GPs’ activity of the cooperation between general practitioners and nurses, the specific organization of Asalee, and the underlying economic incentives. GPs’ activity was based on the following indicators: number of working days, number of different patients seen at least once (active file) and, among them, those who listed the GP as their treating physician, and the number of appointments carried out (either in the consultation room or at the patient’s home). We control, as much as possible, for endogeneity and selection biases by using a case-control design, consisting of exact matching methods and difference-in-differences estimations on panel data. We highlight a positive but relatively modest effect of the Asalee pilot on GPs’ number of working days (+1.2%) and a more pronounced effect on the number of patients seen (+7.55%) or listing the GP as their attending physician (+6.87%). Yet, we find no effect on the number of consultations or home visits. JEL codes: C31, C33, I11, J22, L23

General practitioners (GPs) play a key role in the delivery of preventive and screening services for breast, cervical, and colorectal cancers. Yet, their current provision of screening services remains low and varies considerably across screening contexts and GPs. This study investigates the determinants of GPs' involvement in cancer screening activities using discrete choice experiment (DCE) methodology.A representative sample of 402 GPs was recruited in France between March and April 2014. The participants completed 12 choice tasks designed to elicit their preferences for 5 cancer screening attributes aimed at increasing their supply of cancer screening services.GPs are sensitive to both financial and non-financial incentives, such as a compensated training and systematic transmission of information about screened patients, aimed to facilitate communication between doctors and patients. There is also evidence that the preferences differ across screening contexts: GPs appear to be relatively more sensitive to financial incentives for being involved in colorectal cancer screening, whereas they have higher preference for non-financial incentives in breast and cervical cancers.Our study provides new findings for policymakers interested in prioritizing levers to increase the supply of cancer screening services in general practice.

International audience; The integration of primary care organizations and interprofessional cooperation is encouraged in many countries to both improve the productive and allocative efficiency of care provision and address the unequal geographical distribution of general practitioners (GPs). In France, a pilot experiment promoted the vertical integration of and teamwork between GPs and nurses. This pilot experiment relied on the staffing and training of nurses; skill mixing, including the authorization to shift tasks from GPs to nurses; and new remuneration schemes. This article evaluates the overall impact of this pilot experiment over the period 2010–2017 on GP activities based on the following indicators: number of working days, patients seen at least once, patients registered, and visits delivered. We control for endogeneity and reduce selection bias by using a case-control design combining coarsened exact matching and difference-in-differences estimates on panel data. We find a small positive impact on the number of GP working days (+1.2%) following enrollment and a more pronounced effect on the number of patients seen (+7.55%) or registered (+6.87%). However, we find no effect on the number of office and home visits. In this context, cooperation and teamwork between GPs and nurses seem to improve access to care for patients.

Despite several incentive policies for cancer screenings over the last two decades, the overall and regular use of cancer screenings remains insufficient in France. While the individual determinants of cancer screening uptake have been fairly well studied, the literature has rarely focused on the regularity of screening uptake, which is key to early cancer detection. We aimed to address this issue by studying cancer screening behaviors over 15 years, emphasizing the regularity and diversity of use. Using data from 40,021 women in the French E3N cohort, we studied the individual trajectories of screenings for breast, colorectal and cervical cancer between 2000 and 2014. We employed optimal matching methods to identify typical behaviors of use for each cancer screening. Then, we determined the associations between the identified behavior screening patterns for the different cancer screenings and, finally, assessed the associated individual determinants with logistical and multinomial models. We found that screening behaviors were fairly stable over time, with few typical screening patterns for each cancer. Overall, once a woman starts screening, she continues, and once she stops, she no longer returns. Cancer screening behaviors appear consistent; in particular, insufficient use of mammography appears to be associated with long-term nonuse of other cancer screenings. Factors associated with low or nonuse of screening are overall common between cancer screenings and are similar to those identified in the literature of screening use at a single point in time. Ultimately, these barriers prevent some women from entering a screening process in the long run, ultimately reinforcing social inequalities in health. Targeting women with insufficient mammography uptake may reach women outside of cancer screening settings more generally and, thus, both increase the overall uptake of cancer screening and reduce social inequalities in cancer screening.

In most developed countries, the average income of female physicians remains much lower than that of their male counterparts. This paper analyses how much of the gender earnings gap among French self-employed physicians can be attributed to women’s family responsibilities, choice of medical specialty, and opportunity to charge extra billings. The question is of growing concern for regulators because it may influence patients’ future access to care. We used an exhaustive administrative database that merges information on the medical activity, earnings, and family structure of self-employed doctors in 2005, 2008, and 2011. Using the 2011 database, results suggest that when demographic and professional characteristics are controlled, female physicians still exhibit an annual earnings gap that varies according to family structure: having young children worsens the situation of female physicians, particularly GPs. Using our panel datasets from 2005, we show that there is a ‘carer effect’ of having children for female doctors that exacerbates the gender income gap, particularly for GPs. We do not highlight any real strategic behaviour of female specialists authorised to charge extra fees to increase their extra billings after a birth to maintain their previous income.

Pay-for-performance (P4P) has been increasingly used across different healthcare settings to incentivize the provision of targeted services. In this study, we investigated the effect of a nationwide P4P scheme for general practitioners implemented in 2012 in France, on cervical cancer screening practices. Using data from a nationally representative permanent sample of health insurance beneficiaries, we analyzed smear test use of eligible women for the years 2006-2014. Our longitudinal sample was an unbalanced panel comprising 180,167 women eligible from 1 to 9 years each. We took into account that during our study period some women were exposed to another incentive for screening participation: the implementation in 2010 of organized screening (OS) in a limited number of areas. To evaluate the effect of P4P, we defined three different measures of smear utilization. For each measure, we specified binary panel-data models to estimate annual probabilities and to compare each estimate to the 2011 baseline level. To explore the combined effect of P4P and OS in areas exposed to both incentives, we computed interaction terms between year dummies and area of residence. We found that P4P had a modest positive effect on recommended screening participation. This effect is likely to be transient as annual smear use, both for the whole sample and among women overdue for screening, increased only in 2013 and decreased again in 2014. The combined effect of P4P and OS on screening participation was not cumulative during the first years of coexistence.

General practitioners (GPs) play a key role in the delivery of preventive and screening services for breast, cervical, and colorectal cancers. In practice, GPs' involvement varies considerably across types of cancer and among GPs, raising important questions about the determinants of GPs' implication in screening activities: what is the relative impact of financial and non-financial incentives? Are GPs' preferences for financial and non-financial incentives cancer-specific? Is there preference heterogeneity and how much does it differ according to the screening context? This study investigates the determinants of GPs' involvement in cancer screening activities using the discrete choice experiment (DCE) methodology. A representative sample of 402 GPs' was recruited in France between March and April 2014. Marginal rates of substitution were used to compare GPs' preferences for being involved in screening activities across three types of cancers: breast, cervical, and colorectal. Variability of preferences was investigated using Hierarchical Bayes mixed logit models. The results indicate that GPs are sensitive to both financial and non-financial incentives, such as a compensated training and systematic transmission of information about screened patients, aimed to facilitate communication between doctors and patients. There is also evidence that the level and variability of preferences differ across screening contexts, although the variations are not statistically significant on average. GPs appear to be relatively more sensitive to financial incentives for being involved in colorectal cancer screening, whereas they have higher and more heterogeneous preferences for non-financial incentives in breast and cervical cancers. Our study provides new findings for policymakers interested in prioritizing levers to increase the supply of cancer screening services in general practice.

A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP. Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old. Based on an administrative database of 50,752 women aged 50–74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use). Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41–2.35 %)], but the effect was not significantly different following the implementation of the contract. The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.

We analyze the existence and persistence of moral hazard over time to test the assumption of pent-up demand. We consider the effects of supplemental health insurance provided by a private insurer when added to compulsory public insurance that is already supplemented by private insurance. Using original panel data from a French mutuelle, we study the influence of insurance on all of the dimensions of healthcare expenditures: (1) the probability of using health care, (2) the number of uses conditional on use, and (3) the per unit cost of care. To conduct this study, we control, to the extent possible, for endogeneity because of adverse selection using the characteristics of our panel data. Our study allows us to confirm a positive and significant effect of the extra complementary health insurance on healthcare consumption, primarily in terms of the probability of using care. More interestingly, our results show that these effects are principally transitory mainly for the probability of using dental care and optical care and depend on income. Finally, we show that individuals did not postpone health care before enrollment. Copyright © 2015 John Wiley & Sons, Ltd.

The ANI reform mandates all private sector employers to offer sponsored Complementary Health Insurance (CHI) to all of their employees beginning on January 1st, 2016. This research simulates the likely effects of this mandate on the welfare of the population considering the Expected utility theory framework. The results show that the ANI reform may induce an increase in social welfare only if wages and CHI’s premiums remain the same. Assuming that premiums of individual CHI contracts increase because of the new risks segmentation, the reform may hardly impact the social welfare. The gain in welfare that benefit private sector employees is therefore offset by the loss of welfare that suffer the individuals insured by an individual CHI contract or who chose to be uninsured before the reform. Considering in addition that employers will include their subsidy amount into wages, the reform may greatly reduce the social welfare.; Depuis le 1er janvier 2016, les employeurs du secteur privé ont obligation de proposer et de financer partiellement une complémentaire santé à tous leurs salariés. Dans ce travail, nous simulons les gains et les pertes de bien-être à attendre de cette réforme sur l’ensemble de la population en mobilisant la théorie de l’utilité espérée. Les résultats montrent que la réforme augmente le bien-être collectif si et seulement si les salaires et les primes des contrats restent inchangés. En considérant que les primes des contrats individuels augmentent du fait de l’accord national interprofessionnel (ANI), l’impact de la réforme est quasi nul sur le bien-être collectif. Le gain en bien-être des salariés qui bénéficient de la réforme est alors contrebalancé par la perte de bien-être subie par les personnes couvertes en individuel ou que la réforme oblige à s’assurer. En considérant en sus que les employeurs intègrent le montant de leur subvention aux salaires, l’ANI réduit fortement le bien-être collectif.

En France, le financement des soins se caractérise par la juxtaposition des remboursements de l’Assurance maladie obligatoire (AMO) et des assurances complémentaires (AMC). Les dépenses de santé restant à la charge des assurés après intervention de ces deux niveaux de couverture constituent des indicateurs incontournables de l’accès aux soins mais ont été peu étudiées à ce jour, faute de sources nationales adéquates. Cet article vise à pallier ce manque en mobilisant les données administratives d’une mutuelle particulière gérant simultanément l’AMO et l’AMC, permettant ainsi une analyse des restes à charge avant et après intervention de la complémentaire (RACO et RACC). Les données concernent l’année 2002 correspondant à une période d’observation où la population d’intérêt bénéficiait d’un contrat unique de complémentaire santé, c’est-à-dire avant la mise en place d’une surcomplémentaire. L’étude porte donc sur un champ limité et une période relativement ancienne, mais elle permet néanmoins d’illustrer le type d’interaction pouvant exister entre l’AMO et l’AMC. Dans un premier temps, nous étudions le niveau, la distribution et la concentration des RACO et des RACC sur l’ensemble des dépenses ambulatoires puis par poste de soins. Dans un second temps, nous analysons la concentration des RAC après intervention de l’AMO et de l’AMC en tenant compte de deux indicateurs des besoins de soins : le fait d’être exonéré ou non du ticket modérateur et le niveau des dépenses avant remboursements. Dans notre échantillon, 5 % (resp. 1 %) de la population supportaient en 2002 des RACC de plus de 511 euros sur les dépenses ambulatoires (resp. 1 272 euros). Le RACC des individus exonérés du ticket modérateur était en moyenne 70 % plus élevé que celui de ceux qui n’en étaient pas exonérés. Nous montrons que, même si l’AMO et l’AMC assurent successivement une certaine mutualisation, elles ne réduisent pas de la même façon la concentration des restes à charge qui peut exister sur les individus les plus malades. Ainsi, pour les postes de soins le plus souvent associés à la maladie et pour lesquels il existe une certaine liberté tarifaire (consultations, actes médicaux techniques et autres prescriptions), l’effet mutualisant de l’AMC apparaissait en 2002 relativement faible en comparaison de celui de l’AMO., Franc Carine, Pierre Aurélie. Conséquences de l'assurance publique et complémentaire sur la distribution et la concentration des restes à charge : une étude de cas. In: Economie et statistique, n°475-476, 2015. La santé et les soins. pp. 31-49.

Peu de temps apres un numero special deja consacre a ce theme en 2012, la presente edition d’Economie et Statistique revient sur la question de la sante. Elle rassemble une selection d’articles issus des 35 Journees des economistes de la sante francais (JESF) qui se sont tenues a l’universite Paris‑Est Creteil en decembre 2013. Ces journees donnent regulierement lieu a publication d’un numero special consacre a la sante dans une revue a comite de lecture. Apres la Revue Economique et, a deux reprises, la revue Economie Publique, c’est au tour d’Economie et Statistique d’accueillir ces actes. Re‑aborder ce sujet, a des dates aussi rapprochees, s’explique evidemment par son importance, a la fois sociale et budgetaire, et nous allons y revenir dans un premier temps. Mais le precedent pour la revue ne se limite pas a ce numero special de 2012 : la thematique « sante » y a toujours eu une presence reguliere et importante. Apres un etat des lieux des donnees disponibles pour eclairer ce theme, on detaillera de quelle facon chacun des articles de ce numero est alle puiser dans cette masse de donnees, qu’elles relevent ou non du strict domaine de la statistique publique, et quels messages ont pu en etre tires.

In France, about 90 per cent of the population is covered by private health insurance that supplements public health insurance. More than half of policyholders obtain their coverage through their employer. Considering the financial benefits associated with group contracts compared to individual contracts, we assume that switching behaviours vary among different beneficiaries during the transition to retirement. The gap in premiums at retirement between group and individual contracts gives the opportunity to study the marginal price effect on switching behaviours. 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 show the significance of this price effect as policyholders formerly enrolled in group contracts switch much more frequently than those formerly covered by an individual contract. We also discuss other determinants of the decision to switch private supplementary health insurance. The Geneva Papers (2008) 33, 610–626. doi:10.1057/gpp.2008.31

A partir d’une base de donnees exhaustive, restreinte aux medecins generalistes installes en liberal entre 2005 et 2011, cet article etudie les determinants du choix de leur lieu d’installation au sein d’une region, en distinguant quatre zones : banlieue, ville centre, ville isolee, rurale. Si les variables individuelles influencent relativement peu le choix d’une zone, les caracteristiques de l’offre et de la demande locale de soins, les dispositifs d’exonerations fiscales eventuellement offerts et les equipements disponibles dans chaque zone, expliquent significativement leur choix. Ces resultats sont mobilises pour simuler l’impact de trois mesures visant a augmenter le nombre de generalistes s’installant en zone rurale.

The privatization of social services is being increasingly discussed. The market of social services is often characterized by market failures, like informational asymmetries, externalities, distributional problems, which all justify public intervention. But the quality of services provided by public authorities or by private insurers in the context of health insurance is different and could be observable. The public reimbursement of health care is often conditional on rules, like the choice of the physician or the hospital, that induce a disutility of using social insurance instead of private insurance. An alternative solution to a complete privatization is to allow some individuals to opt out. We can imagine that the government allows and even in some cases favors part of the population leaving the public health insurance system. We analyze the situations where the opting out is welfare improving. We then study the optimal policy depending on the characteristics of the economy considering a Rawlsian criterion. The Geneva Papers on Risk and Insurance Theory (2004) 29, 115–136. doi:10.1023/B:GEPA.0000046565.39206.7c

National audience; Peu de temps après un numéro spécial déjà consacré à ce thème en 2012, la présente édition d’Économie et Statistique revient sur la question de la santé. Elle rassemble une sélection d’articles issus des 35 Journées des économistes de la santé français (JESF) qui se sont tenues à l’université Paris‑Est Créteil en décembre 2013. Ces journées donnent régulièrement lieu à publication d’un numéro spécial consacré à la santé dans une revue à comité de lecture. Après la Revue Économique et, à deux reprises, la revue Économie Publique, c’est au tour d’Économie et Statistique d’accueillir ces actes. Ré‑aborder ce sujet, à des dates aussi rapprochées, s’explique évidemment par son importance, à la fois sociale et budgétaire, et nous allons y revenir dans un premier temps. Mais le précédent pour la revue ne se limite pas à ce numéro spécial de 2012 : la thématique « santé » y a toujours eu une présence régulière et importante. Après un état des lieux des données disponibles pour éclairer ce thème, on détaillera de quelle façon chacun des articles de ce numéro est allé puiser dans cette masse de données, qu’elles relèvent ou non du strict domaine de la statistique publique, et quels messages ont pu en être tirés.

In any fee-for-service system, doctors may be encouraged to increase the number of services (private activity) they provide to receive a higher income. Studying private activity determinants helps to predict doctors’ provision of care. In the context of strong feminization and heterogeneity in general practitioners’ (GP) behavior, we first aim to measure the effects of the determinants of private activity. Second, we study the evolution of these effects along the private activity distribution. Third, we examine the differences between male and female GPs. From an exhaustive database of French GPs working in private practice in 2008, we performed an ordinary least squares (OLS) regression and quantile regressions (QR) on the GPs’ private activity. Among other determinants, we examined the trade-offs within the GPs’ household considering his/her marital status, spousal income, and children. While the OLS results showed that female GPs had less private activity than male GPs (−13 %), the QR results emphasized a private activity gender gap that increased significantly in the upper tail of the distribution. We also find gender differences in the private activity determinants, including family structure, practice characteristics, and case-mix variables. For instance, having a youngest child under 12 years old had a positive effect on the level of private activity for male GPs and a negative effect for female GPs. The results allow us to understand to what extent the supply of care differs between male and female GPs. In the context of strong feminization, this is essential to consider for organizing and forecasting the GPs’ supply of care.

International audience; Background: In France, equality in access to screening has been one of the main thrusts of public policies implemented between 2009 and 2013 (the national cancer plan). Our aim in this study was to analyse the obstacles to and levers for breast, cervical, and colorectal cancer screening uptake and their trends over time. Methods: Based on representative data from the French Health Care and Health Insurance Survey (three independent, cross-sectional surveys: 2006, 2008, and 2010), multivariate logistic regressions were used to model the association between the nonuse of screening for the three cancers and various independent variables. Then, interactions with survey year dummies allowed the changes in the determinants of these cancer screenings over time to be estimated. Results: Whereas the incentives for screening were strengthened during the period considered, cervical and breast cancer screenings decreased, and colorectal cancer screenings increased sharply (from 18.2% (95% CI = [17.0-19.4]) in 2006 to 38.9% (95% CI = [37.4-40.5] in 2010. Under-users of the three cancer screenings were primarily unskilled workers (OR cervix = 1.64 [1.38-1.95]), individuals without complementary health insurance (OR breast = 2.05 [1.68-2.51]), or individuals with free complementary health insurance who more rarely use outpatient care. Moreover, individuals reporting either risky behaviours, namely heavy smokers (OR colorectal = 1.70) and high-risk drinkers (OR cervix = 1.42) or very safe behaviours, namely neither smoking nor drinking, underused screenings. Despite the implementation of national programmes for breast and colorectal cancer screenings, the disparities and inequalities in screening uptake did not decrease over the study period. Conclusions: These results demonstrate the need for additional primary prevention efforts targeting the identified under-users by focusing on, for instance, individuals with a very healthy lifestyle. Health authorities could also intensify their efforts to promote increased access to screening for the most disadvantaged individuals.

Objective. Pay-for-performance programmes have been widely implemented in primary care, but few studies have investigated their potential adverse effects on the intrinsic motivation of general practitioners (GPs) even though intrinsic motivation may be a key determinant of quality in health care. Our aim was to compare methods for developing a composite score of GPs’ intrinsic motivation and to select one that is most consistent with self-reported data. Study design. A postal survey. Setting. French GPs practicing in private practice. Main Measures. Using a set of variables selected to characterize the dimensions of intrinsic motivation, three alternative composite scores were calculated based on a multiple correspondence analysis (MCA), a confirmatory factor analysis (CFA) and a twoparameter logistic model (2-PLM). Weighted kappa coefficients were used to evaluate variation in GPs’ ranks according to each method. Results. The three methods produced similar results on both the estimation of the indicators’ weights and the order of GP rank lists. All weighted kappa coefficients were >0.80. The CFA and 2-PLM produced the most similar results. Conclusions. There was little difference regarding the three methods’ results, validating our measure of GPs’ intrinsic motivation. The 2-PLM appeared theoretically and empirically more robust for establishing the intrinsic motivation score. Code JEL. C38, C43, I18.

Background In many OECD countries, the gender differences in physicians’ pay favour male doctors. Due to the feminisation of the doctor profession, it is essential to measure this income gap in the French context of Fee-for-service payment (FFS) and then to precisely identify its determinants. The objective of this study is to measure and analyse the 2008 income gap between males and females general practitioners (GPs). This paper focuses on the role of gender medical practices differentials among GPs working in private practice in the southwest region of France. Methods Using data from 339 private-practice GPs, we measured an average gender income gap of approximately 26% in favour of men. Using the decomposition method, we examined the factors that could explain gender disparities in income. Results The analysis showed that 73% of the income gap can be explained by the average differences in doctors’ characteristics; for example, 61% of the gender income gap is explained by the gender differences in workload, i.e., number of consultations and visits, which is on average significantly lower for female GPs than for male GPs. Furthermore, the decomposition method allowed us to highlight the differences in the marginal returns of doctors’ characteristics and variables contributing to income, such as GP workload; we found that female GPs have a higher marginal return in terms of earnings when performing an additional medical service. Conclusions The findings of this study help to understand the determinants of the income gap between male and female GPs. Even though workload is clearly an essential determinant of income, FFS does not reduce the gender income gap, and there is an imperfect relationship between the provision of medical services and income. In the context of feminisation, it appears that female GPs receive a lower income but attain higher marginal returns when performing an additional consultation.

Background Like many other OECD nations, France has implemented a pay-for-performance (P4P) model in primary care. However, the benefits have been debated, particularly regarding the possibly undesirable effects of extrinsic motivation (EM) on intrinsic motivation (IM). Objective To examine the relationship between French GPs’ IM and EM based on an intrinsic motivation composite score (IMCS) developed for this purpose. If a negative relationship is found, P4P schemes could have side effects on GPs’ IM that is a key determinant of quality of care. Method From data on 423 GPs practicing in a region of France, IM indicators are selected using a multiple correspondence analysis and aggregated from a multilevel model. Results Several doctors’ characteristics have significant impacts on IMCS variability, especially group practice and salaried practice. Qualitative EM variables are negatively correlated with the IMCS: GPs who report not being satisfied with their income or feeling “often” constrained by patients’ requests in terms of consultations length and office appointments obtain a lower mean IMCS than other GPs. Conclusion Our results provide a cautionary message to regulators who should take into account the potential side effects of increasing EM through policies such as P4P.

Adverse selection, which is well described in the theoretical literature on insurance, remains relatively difficult to study empirically. The traditional approach, which focuses on the binary decision of “covered” or “not”, potentially misses the main effects because heterogeneity may be very high among the insured. In the French context, which is characterized by universal but incomplete public health insurance (PHI), we study the determinants of the decision to subscribe to supplemental health insurance (SHI) in addition to complementary health insurance (CHI). This work permits to analyze health insurance demand at the margin. Using a panelized dataset, we study the effects of both individual state of health, which is measured by age and previous individual health spending, and timing on the decision to subscribe. One striking result is the changing role of health risk over time, illustrating that adverse selection occurs immediately after the introduction of SHI. After the initial period, the effects of health risks (such as doctors’ previous health expenditures) diminish over time and financial risks (such as dental and optical expenses and income) remain significant. These results may highlight the inconsistent effects of health risks on the demand for insurance and the challenges of studying adverse selection.

International audience; A representative sample of 611 French pediatricians was interviewed on their knowledge, attitudes, beliefs towards and practices regarding childhood obesity through a 39-item Likert format questionnaire. A vast majority of the respondents regarded obesity as an illness (86.4%), 70.2% were aware that without any treatment an obese child has a high risk to remain obese in adulthood, 84% reported that managing obesity is part of their responsibility in the routine practice and 89.3% affirmed to systematically inform parents of obese children on health risks associated with obesity. At the same time, 82.4% were convinced that managing obesity is bound to fail and only 46.5% that it is professionally gratifying. However, doctors who followed a vocational training dedicated to obesity felt themselves more efficient in managing childhood obesity (p

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.

La rémunération des médecins est au coeur de nombreuses tentatives de réformes. Nous montrons dans cet article pourquoi il est si difficile pour un gouvernement (lorsqu’il est l’assureur) d’instaurer un système de paiement optimal. Un patient représentatif peut contracter deux types de maladies (grave ou bénigne). Si la qualité du diagnostic est endogène, le gouvernement ne peut plus instaurer un système qui favorise simultanément la qualité, en incitant le médecin à fournir un effort, et réduise les dépenses, en évitant les prescriptions excessives (demande induite). The design of reimbursement schemes of health care providers is a main issue in most reforms. We show in this paper why it is so difficult for a government (which is also the insurer) to implement an optimal mechanism. The representative consumer can incur two types of illness (serious or benign). If the quality of the diagnosis is depending on an effort of the physician, it is no longer possible for the government to implement a system which, at the same time, favours the quality and prevents the increasing in health expenses (induced demand).

La reforme de l’assurance maladie du 13 aout 2004 place finalement les organismes complementaires d’assurance maladie au cœur du dispositif, en leur faisant porter une lourde responsabilite. L’enjeu des structures creees est de permettre une coordination perenne non seulement entre le regime obligatoire et les organismes complementaires (OC) mais aussi et surtout entre les OC eux-memes. Dans le cas ou cette coordination serait un echec, la reforme, affichee comme innovante, se resumerait a des outils traditionnels de transfert des depenses vers les financeurs prives. Le defi de la cooperation est donc lourd de consequences.

Cet article analyse les incitations produites par les differents schemas de remuneration des medecins sur la realisation d’actes de prevention secondaire. La fourniture d’actes preventifs est le resultat d’un arbitrage du medecin dans l’allocation de son temps disponible et eventuellement contraint, entre les activites preventives et curatives. Conformement aux intuitions, le systeme du paiement a la capitation pour les actes curatifs est celui qui fournit le plus d’incitations a la prevention. En effet, un medecin ainsi remunere integre dans son calcul les effets a long terme de la prevention secondaire sur son activite medicale. Le modele que nous proposons permet egalement d’evaluer l’impact de mesures visant a reduire la perte d’information, comme la mise en place d’un dossier medical partage.

In January 2013, within the framework of a National Inter-professional Agreement (NIA), the French government required all employers (irrespective of the size of their business) to offer private complementary health insurance to their employees from January 2016. The generalization of group complementary health insurance to all employees will directly affect insurers, employers and employees, as well as individuals not directly concerned (students, retirees, unemployed and civil servants). In this paper, we present the issues raised by this regulation, the expected consequences and the current debate around this reform. In particular, we argue that this reform may have adverse effects on equity of access to complementary health insurance in France, since the risk structure of the market for individual health insurance will change, potentially increasing inequalities between wage-earners and others. Moreover, tax exemptions given to group contracts are problematic because public funds used to support these contracts can be higher at individual level for high-salary individuals than those allocated to improve access for the poorest. In response to the criticism and with the aim of ensuring equity in the system, the government decided to reconsider some of the fiscal advantages given to group contracts, to enhance programs and aids dedicated to the poorest and to redefine an overall context of incentives.

This thesis deals with the place of private health insurance in the overall health insurance scheme in France, focusing on social inequalities and on solidarity between healthy individuals and sick patients. It particular, it addresses the role of private health insurance on access to health care, mutualization of health expenditure, and welfare. The results of this thesis reveal the key role of private health insurance to access to care postponed over time for financial reasons. However, our results also show that generalizing complementary health insurance in the current health insurance scheme does not allow pursuing equity goals nor increasing welfare. They finally reveal that the mutualization induced by private health insurance appears relatively weak, compared to the one induced by public health insurance. They therefore encourage a change in the role of private health insurance in funding medical care., Cette thèse s’intéresse, en France, à la place de l’assurance maladie privée (ou complémentaire) dans l’organisation globale du système d’assurance, sous l’angle des inégalités sociales et de la solidarité entre les individus bien-portants et les malades. Elle étudie en particulier le rôle joué par l’assurance complémentaire sur l’accès aux soins, la mutualisation des dépenses de santé et le bien-être de la population. Les travaux menés dans cette thèse révèlent l’importance de l’assurance complémentaire pour accéder à des soins reportés dans le temps pour raisons financières. Ils montrent en revanche que, généraliser l’assurance complémentaire, dans le modèle actuel de co-financement des soins, ne permet ni de répondre à des objectifs d’équité ni-même d’améliorer le bien-être de la population. Ils révèlent en sus que l’assurance complémentaire induit une moindre mutualisation des dépenses de santé pour les plus malades et invitent à repenser son rôle dans le financement des soins.

In the context of changes of general practice (uneven distribution of young general practitioners (GPs) across the country, strong feminisation), this thesis focuses on the determinants of the outpatient care supply of general practitioners. Using different micro-econometric analyses, firstly we want to understand the impact of feminization on the incomes of general practitioners and specifically on their private practice behaviours in terms of volume of care provided but also composition of the activity (consultations, home visits). Secondly, we study the determinants of the practice location choice within the region and we identify the levers that could improve the distribution of GPs in the area. Our results confirm that female GPs provide fewer services than male GPs and they also have a different composition of private practice activity. However, we show that male and female GPs adopt a similar practice location choice. Factors characterizing the place of installation as the characteristics associated with the supply of care, the demand for care, or equipment influence the practice location choice., Dans un contexte de grandes transformations de la médecine générale, cette thèse s’intéresse aux déterminants de l’offre de soins des médecins généralistes. Nous avons développé différentes stratégies micro-économétriques pour dans premier temps comprendre l’effet de la féminisation sur les revenus des médecins généralistes et plus particulièrement sur leurs comportements d’activité en termes de volume de soins fournis mais également de composition de l’activité. Dans un deuxième temps, nous cherchons à étudier les déterminants du choix du lieu d’installation des jeunes médecins généralistes, au sein d’une région et à identifier les leviers qui pourraient améliorer leur répartition sur le territoire. Nos résultats confirment que les femmes ont d’une part une offre de soins quantitativement plus faible que celle des hommes et que le contenu de leur offre est également différent. Toutefois, ils adoptent des comportements d’installation similaires. Les facteurs qui influencent le choix du lieu d’installation sont plutôt des caractéristiques du lieu, comme les caractéristiques associées à l’offre de soins, à la demande de soins, ou aux équipements. L’objectif de ce projet de recherche est, à travers une approche micro-économétrique, de mieux appréhender les préférences des médecins. Nous souhaitons comprendre ces préférences à travers les arbitrages travail/loisir du médecin et donc l’intensité de l’offre de travail (arbitrage entre nombre d’actes et durée de consultation), mais aussi selon les choix d’installation du médecin tant par le choix du lieu que par les modalités de cette installation, à savoir une activité libérale et ou salariée tout en sachant que ces décisions dépendent fortement des revenus espérés et donc de contextes différenciés de demande de soins.

This thesis addresses several issues raised by the introduction in France of economic incentives such as pay-For-Performance applied to general practice. These incentive schemes are designed to improve the quality of care, but they are discussed both in terms of effectiveness and potential side effects. Initially, we assess the impact of the CAPI scheme on various indicators of quality of care: the consultation length and cancers screening. Then, using the discrete choice experiment methodology, we reveal general practitioners (GPs) preferences for devices aimed at improving the early detection of cancers. Finally, we analyse empirically the relationship between French GPs' intrinsic and extrinsic motivations. We show that the CAPI has not had a significant impact on the selected quality indicators. In addition, GPs would be sensitive to potentially less costly nonmonetary devices. Eventually, we highlight a negative relationship between GPs' intrinsic and extrinsic motivations. Our results call for greater caution in the definition of economic incentives in general practice., Cette thèse s’intéresse à plusieurs questions posées par l’introduction et la généralisation, en France, d’incitatifs économiques de type P4P appliqués à la médecine générale. Ces schémas incitatifs (CAPI, ROSP) ont pour objectif d’améliorer la qualité des soins, mais ils sont débattus en termes d’efficience et d’effets indésirables potentiels. Dans un premier temps, nous évaluons l’impact du CAPI sur différents indicateurs de la qualité des soins : la durée de la consultation et le dépistage des cancers. Puis, nous étudions les modalités d’une meilleure implication du médecin généraliste (MG) dans le dépistage des cancers, en appliquant la méthodologie des choix discrets. Enfin, nous analysons la relation entre motivations intrinsèques et extrinsèques des MGs français. Nous montrons que le CAPI n’a pas eu d’impact significatif sur les indicateurs de qualité considérés et que les MGs seraient sensibles à d’autres dispositifs non monétaires potentiellement moins coûteux. Enfin, nous mettons en évidence une relation de substituabilité entre motivations intrinsèques et extrinsèques. Ces résultats invitent à davantage de prudence dans la définition des incitatifs économiques en médecine générale.