DORMONT Brigitte

Most developed nations provide generous coverage of care services, using either a tax financed healthcare system or social health insurance. Such systems pursue efficiency and equity in care provision. Efficiency means that expenditures are minimized for a given level of care services. Equity means that individuals with equal needs have equal access to the benefit package. In order to limit expenditures, social health insurance systems explicitly limit their benefit package. Moreover, most such systems have introduced cost sharing so that beneficiaries bear some cost when using care services. These limits on coverage create room for private insurance that complements or supplements social health insurance. Everywhere, social health insurance coexists along with voluntarily purchased supplementary private insurance. While the latter generally covers a small portion of health expenditures, it can interfere with the functioning of social health insurance. Supplementary health insurance can be detrimental to efficiency through several mechanisms. It limits competition in managed competition settings. It favors excessive care consumption through coverage of cost sharing and of services that are complementary to those included in social insurance benefits. It can also hinder achievement of the equity goals inherent to social insurance. Supplementary insurance creates inequality in access to services included in the social benefits package. Individuals with high incomes are more likely to buy supplementary insurance, and the additional care consumption resulting from better coverage creates additional costs that are borne by social health insurance. In addition, there are other anti-redistributive mechanisms from high to low risks. Social health insurance should be designed, not as an isolated institution, but with an awareness of the existence—and the possible expansion—of supplementary health insurance.

This article analyzes the impact of health system regulation on physicians' health care supply behavior and how their work fits into the objectives of the French system. Is it possible to reconcile universal and supportive health insurance with a high degree of freedom for private physicians? Results obtained on French data provide a body of evidence scientifically validated by academic publications. They show the importance of the individual preferences of private practitioners in their volume of care and their location, as well as a marked interaction between volumes of care and prices. They exclude that there may be a problem of attractiveness of the private medical profession for financial reasons. They show that the regulation of supply by the number of students admitted to medical studies has had major consequences on income inequalities between generations of doctors. In the current framework where fee-for-service payment is dominant, the management of supply is a narrow path, or rather a challenge, between the plethora of doctors, which leads to losses of efficiency because of induced demand behaviour, and the shortage, which hinders access to care for citizens.

Following the example of the United States, most European countries reformed their hospital regulations in the early 2000s, with the introduction of a new payment system aimed at encouraging efficiency in care delivery. Because they put strong pressure on hospitals to lower their costs, wide implementation of these reforms raised concerns for some about quality of care. One solution has been to encourage quality competition among hospitals. The purpose of this volume is to bring together relevant theoretical and empirical results regarding the impact of hospital competition on the quality of care. Contributions come from academic economists recognized as the best specialists of the topic worldwide. They address the following questions: Does more intense competition among hospitals operating under fixed price systems always result in improved quality of care? Do hospital objectives and/or ownership matter? Is the impact identical for different diseases? Is it appropriate to introduce competition among hospitals with different mandates?.

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Following the example of the United States, most European countries reformed their hospital regulations in the early 2000s, with the introduction of a new payment system aimed at encouraging efficiency in care delivery. Because they put strong pressure on hospitals to lower their costs, wide implementation of these reforms raised concerns for some about quality of care. One solution has been to encourage quality competition among hospitals.The purpose of this volume is to bring together relevant theoretical and empirical results regarding the impact of hospital competition on the quality of care. Contributions come from academic economists recognized as the best specialists of the topic worldwide.

There is ongoing debate about the effect of ownership on hospital performance as regards efficiency and care quality. This paper proposes an analysis of the differences in productivity and efficiency between French public and private hospitals. In France, public and private hospitals do not only differ in their objectives. They are also subject to different rules as regards investments and human resources management. In addition, they were financed according to different payment schemes until 2004: a global budget system was used for public hospitals, while private hospitals were paid on a fee-for-service basis. Since 2004, a prospective payment system (PPS) with fixed payment per stay in a given DRG is gradually introduced for both private and public hospitals. Payments generally differ for the same DRG, depending on whether the stay occurred in a private or public hospital. A convergence of payments between the nonprofit and for profit sectors was planned by 2018 by the previous government, but this project has been abandoned by the newly elected government. Pursuing such a convergence comes down to suppose that there are differences in efficiency between private and public hospitals, which would be reduced by the introduction of competition between these two sectors. The purpose of this paper is to compare the productivity of public and private hospitals in France. We try to assess the respective impacts, on productivity differences, of differences in efficiency, patient characteristics and production composition. We have chosen to estimate a production function. For that purpose, we have defined a variable measuring the volume of care services provided by each hospital, synthetizing the hospital multiproduct activity into one homogenous output. Our data comes from two administrative sources which record exhaustive information about French hospitals. Matching these two database provides us an original source of information, at the hospital-year level, about both the production composition (number of stays in each DRG), and production factors (number of beds, facilities, number of doctors, nurses, of administrative and support staff, etc.). We observe 1,604 hospitals over the period 1998-2003, of which 642 hospitals are public, 126 are private not-for-profit and 836 are private-for-profit. This database is relative to acute care and covers more than 95 % of French hospitals. We use a stochastic production frontier approach combined with hospitals fixed effects. We find that the lower productivity of public hospitals is not explained by inefficiency (distance to the frontier), but oversized establishments, patient characteristics and production characteristics (small proportion of surgical stays). Once patient and production characteristics are taken into account, large and medium sized public hospitals appear to be more efficient than private hospitals. As a result, payment convergence would provide incentives for public hospitals to change the composition of their supply for care.

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We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.

In France, in 2014, healthcare expenses amounted to 190 billion euros. This amount, which grows year after year, is financed for 76.6% by a social insurance, compulsory and proportional to income, taking care of all residents - the Health Insurance . 13.5% is financed by supplementary insurance and 8.5% directly by households in the form of out-of-pocket expenses. The relationship between public and private insurance is characteristic of mixed systems, in which insurance can complement each other, but can also lead to inefficient interactions. In the first part, we study theoretically a system where public insurance can be complemented by supplementary and/or additional insurance. While there was confusion between these two types of insurance in the literature (Petretto, 1999), we find sometimes opposite effects between complementary and supplementary insurance. Since the marginal utility of the poorest is higher than that of the richest, we find that by simply using the sum of individual utilities as the social welfare utility function, the optimal public insurance rate is positively related to the redistributive character of the insurance.In this first section, we note that the split between what is in the domain of supplementary and supplementary insurance is a function of the definition of the public goods basket. The second chapter studies the optimal composition of this public basket. At the heart of the choice of criteria to be used to select socially reimbursed goods is the possibility of comparing preferences, which has been debated at length in welfare theory and formalized by Arrow's incompatibility theorem. The income-equivalence principle of Fleurbaey et al (2013) proposes to overcome this limitation. This ordinal criterion, defined as income in full health equivalent to income in poor health, allows for interpersonal comparisons. Adapting a theoretical model studying the definition of a social optimal basket (Hoel, 2007) and using the income-equivalent principle, we find that the presence of private insurance changes the ranking of goods that need to be socially covered and reduces the optimal social budget. While the second part of the paper revealed which treatments should not be reimbursed as a priority by the health insurance system in the context of a limited budget, the last chapter studies a market characterized by a very low participation of the social insurance system. The optical market is characterized by information asymmetries and product differentiation. Beyond financing health care expenditures, we wonder whether private insurance is able to reduce these market failures and control health care expenditures. In the context of the literature on managed-care and competition for the right to serve, the last part studies the impact of networks set up by private insurers in the optical market to reduce expenditure. Using a proprietary database assembled by the author on a network of contracted opticians set up by the National Education Mutual Insurance Company (MGEN), the effect of the network on the number of sales and the prices charged is tested empirically. The effect of network and market competition on prices for single vision and bifocal lenses is estimated in 450 groups of French municipalities. Empirically, we find that in-network competition significantly reduces in-network prices, while in-market competition affects out-of-network prices.

This paper examines whether general practitionersí(GPsí) earnings are high enough to keep this profession attractive. We set up two samples, with longitudinaldata relative to GPs and executives. Those two professions have similar abilities but GPs have chosen a longer education. To measure if they get returns that compensate for their higher investment, we study their career proÖles and construct a measure of wealth for each individual that takes into account all earnings accumulated from the age of 24 (including zero income years when they start their career after 24). The stochastic dominance analysis shows that wealth distributions do not differ significantly between male GPs and executives but that GP wealth distribution dominates executive wealth distribution at the first order for women.Hence, while there is no monetary advantage or disadvantage to be a GP for men, it is more profitable for women to be a self-employed GP than a salaried executive.

This thesis is devoted to mixed health insurance systems where compulsory public coverage can be improved by a complementary health insurance. The questions addressed concern the inflationary effect of the complementary health insurance on the price of care and the impact of age-based pricing on solidarity between sick and healthy people and between income groups. The empirical analyses are based on French data. This original database includes the health care consumption of 99,878 MGEN members over the 2010-2012 period. Chapter 1 estimates the causal effect of better coverage on the consumption of excess fees and demonstrates the inflationary effect of complementary health insurance on the price of care. Chapter 2 considers the heterogeneity of the impact of better coverage on overcharges and its correlation with insurance demand. In fact, the inflationary effect of complementary insurance is accentuated by selection effects. Chapter 3 shows that age-based pricing maximizes transfers between the sick and the healthy at the expense of solidarity between high and low incomes.

We evaluate the causal impact of an improvement in insurance coverage on patients’ decisions to consult physicians whocharge more than the regulated fee. We use a French panel data set of 43,111 individuals observed from 2010 to 2012. Atthe beginning of the period, none of them were covered for balance billing. by the end, 3819 had switched to supplementaryinsurance contracts that cover balance billing. Using instrumental variables to deal with possible non-exogeneity of thedecision to switch, we find evidence that better coverage increases demand for specialists who charge high fees, therebycontributing to the rise in medical prices. People whose coverage improves increased their average amount of balancebilling per consultation by 32%. However, the impact of the coverage shock depends on the supply of physicians. Forpeople residing in areas where few specialists charge the regulated fee, better coverage increases not only prices but alsothe number of consultations, a finding that suggests that balance billing might limit access to care. Conversely, in areaswhere patients have a genuine choice between specialists who balance bill and those who do not, we find no evidence of aresponse to better coverage. Copyright © 2016 John Wiley & Sons, Ltd.

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672 billion, or 31.8% of GDP. Within the OECD, our country stands out for the size of the public share of this expenditure and the institutional fragmentation of the social protection system. This fragmented governance raises three fundamental economic problems. First, it makes it more difficult to make collective trade-offs on the size of public spending on social protection and on its sharing between different risks. Second, the lack of coordination within the same social risk, between basic and supplementary schemes, makes it impossible to satisfy needs at the lowest cost to society. Third, this organization does not allow a clear distinction to be made between two types of social protection with different logics of solidarity and financing: schemes that pay contributory benefits, the objective of which is to ensure replacement income for working incomes, and social protection systems that offer benefits to all citizens according to their needs, without any relation to their contributions.

We evaluate the introduction of various forms of antihypertensive treatment in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is practically feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the technical sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post-approach, and the need to consider distributional effects in a broader institutional setting.

No summary available.

The aim of this paper is to determine if the profession of GP is financially attractive in France.Using longitudinal data, we created two samples of 1,389 self-employed GPs and 4,825 salariedexecutives observed from 1980 to 2004. These two professions require high qualification levels,but studying to become a GP takes longer. To measure if GPs get returns that compensate fortheir investment in education, we analyze GPs’ and executives’ career profiles and construct ameasure of individual wealth that takes into account all earnings from the age of 24, includingyears with no or low income for GPs before they set up their practice.Econometric analysis shows that after an initial period of patient recruitment, physicians experiencea flatter career profile than executives. We also find that GP incomes for recent cohorts arefavored by the low numerus clausus applied when they were in medical school.Stochastic dominance analysis shows that, for men, wealth distributions do not differ significantlybetween GPs and executives, but, for women, GP wealth distribution dominates executive wealthdistribution at the first order. Hence, the relative return on medical studies is higher for women.While for men there is no monetary advantage or disadvantage in being a GP, for women, it ismore profitable to be a GP than an executive. This can explain the large proportion of femaleGPs and the strong increase in the share of women among medical students.

In this paper, we estimate the causal impact of a positive shock on supplementary health insurance coverage on the use of specialists who balance bill. For that purpose, we evaluate the impact on patients' behavior of a shock consisting of better coverage of balance billing, while controlling for supply side drivers, i.e. proportions of physicians who balance bill and physicians who do not. We use a panel dataset of 58,336 individuals observed between January 2010 and December 2012, which provides information, at the individual level, on health care claims and reimbursements provided by basic and supplementary insurance. Our data makes it possible to observe enrollees that are heterogeneous in their propensity to use physicians who balance bill. We observe them when they are all covered by the same supplementary insurer, with no coverage for balance billing, and after 5,134 of them switched to other supplementary insurers which offer better coverage. Our estimations show that better coverage contributes to a rise in medical prices by increasing the demand for specialists who balance bill. On the whole sample, we find that better coverage leads individuals to raise their proportion of consultations of specialists who balance bill by 9 %, which results in a 34 % increase in the amount of balance billing per consultation. However, the effect of supplementary health insurance clearly depends on the local supply side organization. The inflationary impact arises when specialists who balance bill are numerous and specialists who do not are relatively scarce. When people have a real choice between physicians, a coverage shock has no impact on the use of specialists who balance bill. When the number of specialists who charge the regulated fee is sufficiently high, there is no evidence of limits in access to health care, nor of an inflationary effect of supplementary coverage.

Tunisia is experiencing a significant increase in health care spending and in the life expectancy of Tunisians. But these results go hand in hand with inequalities in access to care, motivating a health insurance reform implemented in 2007. The main changes aim at improving coverage for chronic diseases and generalizing insurance for private health care. This applied microeconometrics thesis examines the impact of the reform on access to care and out-of-pocket expenses. The evaluations are based on surveys of several thousand individuals in 2005 and 2010. The motivations for the reform are presented, before analyzing the choice of insurance and its influence on the use of public or private care providers in 2010, after the reform. An evaluation of the reform was analyzed using the difference-in-differences approach. Overall, the results show that this reform seems to have achieved several of its objectives: improved access to care for members of the National Social Security Fund (CNSS), better access to private care, and a reduction in out-of-pocket expenses and catastrophic expenses for people with chronic diseases.

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France is distinguished by the mixed nature of its health insurance system. Two types of operators contribute to the coverage of the same care: social security and complementary organizations. This type of organization leads to high management costs and encourages higher prices for care. The current regulation of complementary health insurance also encourages risk selection, which produces inequalities in access to insurance and care.

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In France, the prices of EHPADs are high in relation to a quality that seems insufficient. The objective of this thesis is to study whether this dilemma can be solved, by analyzing in particular the role of competition, both real and comparative, that could be introduced in this sector. Using a micro-econometric approach, we organize our analysis around three research questions: (i) what can be expected from the proposed reforms of pricing and the increase in the capacity of institutions? (ii) how could the development of the private for-profit sector allow for a reduction in prices and an improvement in quality? (iii) are there environmental constraints responsible for the low quality of EHPAD? We observe, on the one hand, that the reform projects would make it possible to reduce the inefficiency and therefore possibly the prices of EHPADs, but at the expense of their quality. On the other hand, we note that the growth of for-profit EHPADs is accompanied by an increase in fees and a deterioration in the quality of care, which could be moderated by a more competitive market structure. Finally, the EHPADs are confronted with local difficulties in retaining care staff, which affect their quality and which do not seem to be resolved by adjusting salaries. These results can be used as benchmarks for the implementation of an appropriate public policy.

The aim of this paper is to provide an assessment of individual uncertainty regarding length of life. We have collected original data through a survey performed in 2009 on a representative sample of 3,331 French people aged 18 or more. The survey design recorded several survival probabilities per individual, which makes it possible to compute (i) subjective life expectancy, defined as the first moment of the individual’s subjective distribution of personal longevity. (ii) the standard error of this distribution, which provides insight on the individual’s uncertainty regarding his or her own longevity. There is considerable between-individual variability in subjective life expectancies, in (small) part explained by age, illnesses, risky behavior, parents’ death and socioeconomic variables. The second main finding is that individual subjective uncertainty about length of life is quite large, equal on average to more than 10 years for men and women. It is logically decreasing with age, but apart from age, very few variables are correlated with it. These results have important consequences for public health and retirement policy issues.

France is distinguished by the mixed nature of its health insurance system. Two types of operators contribute to the coverage of the same care: social security and complementary organizations. This type of organization leads to high management costs and encourages higher prices for care. The current regulation of complementary health insurance also encourages risk selection, which produces inequalities in access to insurance and care.

No summary available.

In this paper, we estimate the causal impact of a positive shock on supplementary health insurance coverage on the use of specialists who balance bill. For that purpose, we evaluate the impact on patients' behavior of a shock consisting of better coverage of balance billing, while controlling for supply side drivers, i.e. proportions of physicians who balance bill and physicians who do not. We use a panel dataset of 58,336 individuals observed between January 2010 and December 2012, which provides information, at the individual level, on health care claims and reimbursements provided by basic and supplementary insurance. Our data makes it possible to observe enrollees that are heterogeneous in their propensity to use physicians who balance bill. We observe them when they are all covered by the same supplementary insurer, with no coverage for balance billing, and after 5,134 of them switched to other supplementary insurers which offer better coverage. Our estimations show that better coverage contributes to a rise in medical prices by increasing the demand for specialists who balance bill. On the whole sample, we find that better coverage leads individuals to raise their proportion of consultations of specialists who balance bill by 9 %, which results in a 34 % increase in the amount of balance billing per consultation. However, the effect of supplementary health insurance clearly depends on the local supply side organization. The inflationary impact arises when specialists who balance bill are numerous and specialists who do not are relatively scarce. When people have a real choice between physicians, a coverage shock has no impact on the use of specialists who balance bill. When the number of specialists who charge the regulated fee is sufficiently high, there is no evidence of limits in access to health care, nor of an inflationary effect of supplementary coverage.

Health equivalent income concept [.].

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With a higher level of health expenditure than in many developed countries, France's health performance is quite good, but with particularly marked social inequalities in health. The purpose of this Note is to propose directions for improving the efficiency of the health system as a whole. Three avenues for reform are proposed.

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This thesis examines several issues related to the quality of hospital care through the disciplinary prisms of economics and public health.The first chapter introduces the notion of quality of care in public health and economics. An examination of the traditional treatment of this notion in the two disciplines highlights the convergence of the definitions of quality of care proposed and the complementarity of the approaches to regulation promoted by the two disciplines.Competition at fixed prices, such as that induced by activity-based pricing, should lead to an improvement in the quality of care if demand is sensitive to quality. In the second chapter, we use data on the public dissemination of hospital rankings to estimate the elasticity of demand for care with respect to quality, for the public and private sectors, based on a panel of French hospitals and for several clinical situations. We show an impact of the rankings on the activity of private hospitals, for one of the clinical situations considered. On the other hand, the demand on the public sector does not seem to be influenced by the publication of the rankings. These results question the hypothesis of competition in quality in the public sector in France. The third chapter focuses on the cost of strategies for the control of nosocomial infections, from a hospital perspective. We evaluated the costs associated with interventions promoting general hygiene measures or targeted screening for multidrug-resistant bacteria in two European multi-center clinical trials in intensive care and surgery. Our results highlight the greater variability in costs for comprehensive promotion strategies and, for interventions shown to be effective in these studies, a cost of implementation consistent with the assumption that these interventions are cost-effective.

Many countries have introduced competitive mechanisms in health insurance, while at the same time introducing regulation to avoid risk selection and guarantee solidarity between the sick and the healthy. The "regulated competition" model is thus applied to basic health insurance in Switzerland, the Netherlands, Germany and Israel. It inspires the reform of health insurance in the United States. This article analyzes the functioning of such a system by considering the case of Switzerland, where we focus on the potential interference between the supplementary insurance market and the basic insurance market. The current organization of health insurance in France differs from that of the Swiss system. But the question of regulating the supplementary insurance market could be raised in the long run. Twelve years after the introduction of regulated competition, the results observed in Switzerland are disappointing. Although the premium differentials between insurance companies are very high, the proportion of policyholders who change insurance companies remains low. It is as if policyholders do not take advantage of competition. Our analysis shows that the low mobility of policyholders results from the coexistence of two health insurance markets subject to different rules: the basic insurance market, where risk selection is prohibited, and the supplementary insurance market, where it is allowed. Estimates show that the propensity to switch is much lower among supplementary insurance holders who perceive their health as not excellent. Since it is preferable for practical reasons to have one's basic and supplementary insurance with the same insurer, there is a de facto link between the two markets. The right to select applicants for supplementary insurance undermines competition for basic insurance.

With a higher level of health expenditure than in many developed countries, France's health performance is quite good, but with particularly marked social inequalities in health. The purpose of this Note is to propose directions for improving the efficiency of the health system as a whole. Three avenues for reform are proposed.

With a higher level of health expenditure than in many developed countries, France's health performance is quite good, but with particularly marked social inequalities in health. The purpose of this Note is to propose directions for improving the efficiency of the health system as a whole. Three avenues for redesign are proposed. First, contrary to the current logic of limiting Social Security expenditure by reducing reimbursement rates, a "solidarity basket of care" should be defined, which should be accessible to all without financial barriers. This basket would include all health products and curative or preventive procedures, performed in outpatient medicine or in hospitals, which would be covered for clearly identified indications. Its scope would be defined and updated in a systematic and transparent manner on the basis of a ranking of available treatments according to their respective benefits in relation to their costs. Treatments outside this basket would not be covered, even partially, by the community. Second, in order to allocate expenditure according to need and to improve the efficiency of care pathways, the regional health agencies (ARS) should be given a global financial envelope, based on the estimated needs of the populations for which they are responsible. The ARSs would be able to allocate this envelope as best they could between ambulatory medicine, hospitals and the medical-social sector. They would also have control over the agreements and remuneration methods of health professionals. Placing the ARS at the center of the management system would make it possible to better adapt the supply of care to the needs of each region and to optimize resources across all modes of intervention. Third, it is urgent to promote the development of health information systems. A decisive investment is needed to convince the players in the health system, and in particular the insured, to develop the personal medical file. It is indeed crucial that all health professionals produce and share health data, in a secure manner for the patient, in order to coordinate care and limit unnecessary examinations. Public information must also be produced and disseminated on the quality of care provided by hospitals, nursing homes and homes for the dependent elderly (EHPAD) in order to encourage competition in quality and promote equal access to quality care. Finally, comparable indicators on the performance of regions in terms of public health, social inequalities in health and access to care must be produced and widely disseminated. This Note was presented to the Deputy Director of the Prime Minister's Office on Tuesday, July 2, 2013.

This article aims to understand the differences in productivity observed in France between public hospitals, private non-profit hospitals (PSPH) and private clinics. We examine whether there is an influence of the composition of patients and stays on the productivity of hospitals. If this is the case, introducing competition between hospitals on the basis of Activity-Based Pricing not only promotes efficiency, but also creates strong pressure within institutions to reorient the supply of care. The database used is a panel of hospitals close to exhaustiveness for acute care: 1,604 hospitals are observed over the period 1998-2003. The analysis covers the six years preceding the introduction of T2A in France in order to observe the situation that existed before the introduction of new incentives. We show that the diagnosis of the productive efficiency of public hospitals depends on the definition of the production frontier: with a classical function, the efficiency scores of public hospitals are lower than those of PSPH hospitals, which are themselves lower than those of private clinics. However, the order of relative performance is reversed when the characteristics of the patient population and the composition of hospital stays are taken into account: with the exception of small establishments, public and PSPH hospitals then appear to be more efficient than private clinics. These results must be interpreted in the light of the differences in the specifications governing the activities of public and private hospitals. A final breakdown shows that the lower productivity of public hospitals is mainly explained by their size, the composition of their patient base and the composition of their stays, characterized by a low proportion of surgical stays. It is not explained by a lower efficiency of public hospitals.

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We compare two approaches to measuring inequity in the health distribution. The first is the concentration index. The second is the calculation of the inequality in an overall measure of individual well-being, capturing both the income and health dimensions. We introduce the concept of equivalent income as a measure of well-being that respects preferences with respect to the trade-off between income and health, but is not subjectively welfarist since it does not rely on the direct measurement of happiness. Using data from a representative survey in France, we show that equivalent incomes can be measured using a contingent valuation method. We present counterfactual simulations to illustrate the different perspectives of the approaches with respect to distributive justice.

The first chapter studies the impact of the regulation of medical demography on the careers of general practitioners. We show that the conditions of installation of doctors, which are linked to the numerus clausus, affect their fees in a substantial and lasting way. The analysis in terms of stochastic dominance also shows that the differences linked to individual heterogeneities do not compensate for the considerable differences identified on average for the cohorts. A second chapter focuses on a remarkable phenomenon in the population of general practitioners : the existence of a large minority of doctors with very low incomes. We show that these low incomes result from the greater preference of these physicians for leisure. This very low activity is not a sign of a deterioration in the status of the doctor. It reflects an advantage of the liberal medical profession - doctors can choose to work little. A third chapter evaluates the positioning of general practitioners by comparing their income with that of senior executives. Comparing the career value of physicians and executives provides a measure of the relative advantage of being a physician. The analysis shows that there is a very clear financial advantage to being a general practitioner and that this advantage has increased over time. The existence of an annuity for doctors is the result of the competitive examination for admission to medical school. This rent has evolved positively with the restrictions on the numerus clausus.

The purpose of this thesis is to analyze health care consumption behaviors and their impact on the evolution and distribution of health care expenditures in the population. We conduct an analysis on individual data and use original microsimulation methods in order to highlight the effects of heterogeneity of behavior at the individual level. The first chapter presents the econometric methods used to estimate explanatory equations of health care consumption on individual data. A second chapter develops an original method to analyze the factors of the increase in health care expenditure, and shows that this increase is mainly due to changes in health care behavior, and very little to demographic aging. A third chapter proposes an innovative method of decomposing inequalities in health care consumption by factor. We show that half of the observed inequity is due to heterogeneity in behavior, which is not identifiable in standard decompositions.

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.

In this thesis, we examine the effect of the time profile of unemployment compensation on the rate of return to employment of the unemployed by comparing two successive regulations. The old regulation (1986-1992) is characterized by a single drop in the level of compensation while the new one (1993-1996) is characterized by successive drops. Estimates of duration models show that under the pre-1992 regulation, the rate of job re-entry increases sharply as the end of the full benefit period approaches. This result holds mainly for unemployed persons with the highest previous wages. The transition to the new regulations has had the effect of smoothing the temporal profile of job re-entry rates. Our study also shows that, even after controlling for the effects of cyclical changes in the labor market, there is still a gap between the probabilities of returning to work under the old and new regulations. This residual difference can be explained by the difference in the time profiles of compensation. This means that the introduction of a more degressive time profile of benefits probably slowed down the return to employment.

The purpose of this thesis is to study the professional and family trajectories of young people, by examining their interactions. Do unemployment and precarious employment situations threaten access to the maturity that constitutes residential autonomy? Conversely, does a prolonged stay in the parental home improve the process of professional integration or, on the contrary, discourage the effort to look for a job? The trajectories in question are processes that do not necessarily have the same significance depending on whether they take time or not. We examine the impact of work and family trajectories on each other by studying the length of time it takes to find a first job and the length of time spent living with parents. For the empirical work, we use the Céreq "Mesures jeunes" panel, which allows us to observe the professional and family situation of 2,423 young people with little or no formal education, with a technical background, from the time they left the school system in June 1989 until December 1993. The interactions are studied in the framework of bivariate duration models. The specification of a bivariate exponential distribution makes it possible to test these interactions between access to employment and departure from the parental home by means of a dependency term. Our analysis confirms the existence of a link between the duration of access to employment and access to residential autonomy. It is therefore possible to analyze the current extension of young people's cohabitation with their parents as the result of their difficulties on the labor market. Conversely, the prolonged cohabitation of young people delays their access to a permanent job. However, another important result of our research contributes to seriously relativizing the role of interactions: the effects of differences in gender, level of education and specialization are clearly more important than the mutual influence of trajectories.

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In France, the unemployment rate is now more than 12% of the active population. This high rate is characterized by strong persistence. It is also accompanied by an increased precariousness of employment. The objective of this research is to explain these phenomena by examining the labor demand behavior of firms. The work presented here is situated at the microeconomic level of the firm: the aim is to evaluate the sources of labor demand rigidities. This thesis articulates theory and empirical applications: numerous estimates are made using the techniques of applied econometrics on firm data. In addition to wage costs, two factors of labor demand rigidities are examined: labor adjustment costs and uncertainty. We show that the existence of uncertainty about the firm's income, associated with adjustment costs, leads to labor demand rigidities and encourages the firm to use a flexible workforce to better adjust to cyclical shocks. 3 results are obtained: an increase in uncertainty reinforces the expectation behaviors regarding hiring on a permanent basis and firing. The inertia observed on cdi jobs is compensated by an <> on cdd jobs. Finally, an increase in the share of fixed-term contracts in the firm improves overall employment flexibility, while protecting fixed-term workers from layoffs. Finally, we are interested in the impact of resignation flows. In France, these flows are important (more important than layoffs) and procyclical. We show that the demand for fixed-term contracts is more sensitive to its exogenous determinants when the resignation rate increases.