Pathology-based pricing, hospital heterogeneity, and technical innovations: an econometric approach to hospital stays for acute myocardial infarction.

Summary In this thesis, we study the potential effects on French public hospital expenditures of the introduction of a pathology-based pricing system based on the principle of competition by comparison, using patients with acute myocardial infarction (AMI) as a framework. We show that a purely prospective pricing system based on current GHMs leads to a budgetary gain of around 40% for medical GHMs. However, this payment penalizes hospitals with specific missions (teaching, etc.) assigned by the supervisory authority and hospitals performing innovative procedures. In the latter case, pathology-based pricing may encourage hospitals to select patients. To take account of the heterogeneity between hospitals, we recommend the use of a mixed pricing system that combines a flat rate and reimbursement of the observed cost. An econometric approach makes it possible to define the share allocated to each type of regulation in the payment. We then define a type of payment that minimizes moral hazard while taking into account all unobserved heterogeneity as long as it is constant over time. In this case, budgetary savings of around 16% are achieved. Furthermore, an econometric study allows us to observe that patients are directed towards technical hospitals according to their need for innovative therapeutic procedures. Moreover, the exogeneity of the variables relating to the transfer of patients to another hospital and the length of stay means that these variables are not manipulated in order to control costs. Finally, innovative procedures lengthen the length of stay for patients with AMI with or without complications. However, for patients who have benefited from the evolution of medical techniques (angioplasty instead of bypass surgery), the diffusion of innovation has led to a shorter length of stay and a reduction in the associated additional costs.