BARDEY David

We investigate the effect of competition in the nursing homes sector with a two-sided market approach. More precisely, we investigate the distributional implications across the three key actors involved (residents, nurses and nursing homes) that arise from the two-sidedness of the market. Within a Hotelling set up, nursing homes compete for residents and for nurses, who provide quality to residents, by setting residents price and nurses wage. Nurses are assumed altruistic and therefore motivated to provide quality. The market is two-sided because: i) a higher number of residents affects nurses workload, which affects their willingness to provide labour supply. and ii) a higher number of nurses affects residents quality through a better matching process and by relaxing nurses time constraints. Our key findings are that i) the two-sidedness of the market leads to higher wages for nurses, which makes the nurses better off. ii) this is then passed to residents in the form of higher prices, which makes residents worse off. iii) nursing homes profits are instead unaffected. In contrast, when nurses wages are regulated, the two-sidedness of the market implies a transfer between residents and nursing homes. When residents price are regulated, it implies a transfer between nurses and nursing homes. These results are robust to institutional settings which employ pay-for-performance schemes (that reward either nursing homes or nurses): the two-sidedness of the market is strengthened and residents are still worse off.

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A monopoly seller advising buyers about which of two goods fits their needs may be tempted to recommend the higher margin good. For the seller to collect information about a buyer’s needs and provide truthful advice, the profits from selling both goods must be similar enough, i.e., within an implementability cone. The optimal regulation controls pricing distortions and information‐collection incentives separately via price regulation and fixed rewards respectively. This no longer holds when the seller has private information about costs as both problems interact. We study whether competition and the threat by buyers to switch sellers can substitute for regulation.

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We study physicians’ incentives to use personalized medicine techniques, replicating the physician’s trade-offs under the option of personalized medicine information. In a laboratory experiment where prospective physicians play a dual-agent real-effort game, we vary both the information structure (free access versus paid access to personalized medicine information) and the payment scheme (pay-for-performance (P4P), capitation (CAP) and fee-for-service (FFS)) by applying a within-subject design. Our results are threefold. i) Compared to FFS and CAP, the P4P payment scheme strongly impacts the decision to adopt personalized medicine. ii) Although expected to dominate the other schemes, P4P is not always efficient in transforming free access to personalized medicine into higher quality patient care. iii) When it has to be paid for, personalized medicine is positively associated with quality, suggesting that subjects tend to make better use of information that comes at a cost. We conclude that this last result can be considered a “commitment device”. However, quantification of our results suggests that the positive impact of the commitment device observed is not strong enough to justify generalizing paid access to personalized medicine.

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Most studies of the dukes of Burgundy have largely neglected the Capetians. The objective is to consider the government of the last four dukes of this dynasty - from Robert II (1272-1306) to Philippe de Rouvres (1349-1361) - based on the evolution of documentary practices. By drawing up a panorama of the sources preserved in Dijon, in particular in the Archives Départementales de la Côte-d'Or, the aim will be to grasp the changes and influences on government practices in the field of administration, accounting and archives.

The reign of Robert II of Burgundy (1272-1306) marks a rupture within the Capetian duchy'.s government. The evolutions that feature his governance are deeply linked to the relations that unite him to the kings contemporary to his reign such as Philip III the Bold and Philip IV the Fair. Showing signs of a flawless faithfulness, Robert II places himself close to these kings in order to reaffirm his authority and to fulfill his own ambitions. This rapprochement is due to two major events - the first one being the matrimonial policy initiated by the Dukes of Burgundy since Hugh IV and the second one the numerous favours from Robert II to the kings both in the military field and regarding royal government. This closeness plays a part in the progression of the government'.s doings, because he frequently leaves his lands to be on the king'.s duty, Robert II has to hand down his power and to be able to have his authority respected despite his numerous absences. Besides, these ties take part in the evolution of his power and seem to modify the administrative policies in the duchy - proven by the advancement in bookkeeping and in the careers of people close to the duke.

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We consider a market in which sellers can exert an information-gathering effort to advise buyers about which of two goods best fits their needs. Sellers may steer buyers towards the higher margin good. We show that for sellers to collect and reveal information, profits on both goods must be sufficiently close to each other, i.e., lie within an implementability cone, which competition or regulation may ensure. Instruments to do so vary with the context. Controlling market power while improving the quality of advice is more difficult when sellers have private information on the profitability of the goods.

This paper examines the evolution of drug use in Colombia over the past years. Our analysis, based on surveys from the Dirección Nacional de Estupefacientes, shows that drug consumption grew substantially between 1996 and 2013. The growth occurred for both genders, all ages, socioeconomic strata and types of occupation. The results also suggest that men of high socioeconomic strata who regularly consume alcohol and cigarettes and who are between 18 and 24 years of age are more likely to use drugs. Finally, the paper presents some indirect evidence that contradicts the alleged effects of the judgment of the Constitutional Court (Sentencia C-221 of May 1994) that decriminalized the personal dose on the consumption of drugs in Colombia.

We determine the optimal health policy mix when the average utility of patients increases with the supply of drugs available in a therapeutic class. Health risk coverage relies on two instruments, copayment and reference pricing, both of which affect the risk associated with health expenses and diversity of treatment. For a fixed supply of drugs, the reference pricing policy aims at minimizing expenses, in which case the equilibrium price of drugs is independent of the copayment rate. However, with an endogenous supply of drugs, diversity of treatment may susbtitute for insurance so that the reference pricing may depart from maximal cost-containment in order to promote entry. We next analyze the determinants of the optimal policy. While an increase in risk aversion, or in the side effect loss, increases diversity and decreases the copayment rate, an increase in entry cost decreases both diversity and the copayment rate.

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This paper analyzes the three-party contracting problem among the payer, the patient and the physician when the patient and the physician may collude to exploit mutually beneficial opportunities. Under the hypothesis that side transfer is ruled out, we analyze the mechanism design problem when the physician and the patient submit the claim to the payer through a reporting game. To induce truth telling by the two agents, the weak collusion-proof insurance payment mechanism is such that it is sufficient that one of them tells the truth. Moreover, we identify trade-offs of a different nature faced by the payer according to whether incentives are placed on the patient or the physician. We also derive the optimal insurance scheme for the patient and the optimal payment for the physician. Moreover, we show that if the payer is able to ask the two parties to report the diagnosis sequentially, the advantage of the veto power of the second agent allows the payer to achieve the first-best outcome.

This article examines a model of competition between two types of health insurer: Health Maintenance Organizations (HMOs) and nonintegrated insurers. HMOs vertically integrate health care providers and pay them at a competitive price, while nonintegrated health insurers work as indemnity plans and pay the health care providers freely chosen by policyholders at a wholesale price. Such difference is referred to as an input price effect which, at first glance, favors HMOs. Moreover, we assume that policyholders place a positive value on the provider diversity supplied by their health insurance plan and that this value increases with the probability of disease. Due to the restricted choice of health care providers in HMOs a risk segmentation occurs: policyholders who choose nonintegrated health insurers are characterized by higher risk, which also tends to favor HMOs. Our equilibrium analysis reveals that the equilibrium allocation only depends on the number of HMOs in the case of exclusivity contracts between HMOs and providers. Surprisingly, our model shows that the interplay between risk segmentation and input price effects may generate ambiguous results. More precisely, we reveal that vertical integration in health insurance markets may decrease health insurers' premiums.

Objectives: To assess the issue of hospital variations in Colombia and to contribute to the methodology on health care variations by using a model that clusters the variance between hospitals while accounting for individual-level reimbursement rates and objective health-status variables. Methods: We used data on all births (N ¼ 11,954) taking place in a contributory-regimen insurer network in Colombia during 2007. A multilevel logistic regression model was used to account for the share of unexplained variance between hospitals. In addition, an alternative variance decomposition specification was further carried out to measure the proportion of such unexplained variance due to the region effect. Results: Hospitals account for 20% of the variation in performing cesarean sections, whereas region explains only onethird of such variance. Variables accounting for preferences on the demand side as well as reimbursement rates are found to predict the probability of performing cesarean sections. Conclusions: Hospital variations explain large variances within a single-payer’s network. Because this insurer company is highly regarded in terms of performance and finance, these results might provide a lower bound for the scale of hospital variation in the Colombian health care market. Such lower bound provides guidance on the relevance of this issue for Colombia. Some factors such as demand-side preferences and physician reimbursement rates increase variations in health care even within a single-payer network. This is a source of inefficiencies, threatening the quality of health care and financial sustainability. The proposed methodology should be considered in further research on health care variations.

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Given the focus of this special issue of Medicine/Science on personalized medicine, it seems unnecessary for two economists to attempt to summarize or comment from a medical perspective on the advances and innovations that have characterized genetics research over the past two decades. Instead, we will focus on the implications of advances in genetic research on health insurance markets, their functioning and the levels of coverage they offer to individuals under the current regulations. More precisely, we will address the central theme of the value of information in a first section, while in a second section, we will study how the different effects that make up this value of information decline according to the regulations in force in the health insurance markets.

We study competition in two-sided markets with a common network externality rather those than with the standard inter-group effects. This type of externality occurs when both groups benefit, possibly with different intensities, from an increase in the size of one group and from a decrease in the size of the other. We explain why common externality is relevant for the health and education sectors. We focus on symmetric equilibrium and show that when the externality itself satisfies a homogeneity condition then platforms’ profits and price structures have some specific properties. Our results reveal how the rents coming from network externalities are shifted by platforms from one side to the other, according to the homogeneity degree. Prices are affected but in such a way that platforms only transfer rents from consumers to providers. In the specific but realistic case where the common network externality is homogeneous of degree zero, platforms’ profits do not depend on the intensity of the (common) network externality. This result differs from those of the two-sided models, which deal with standard positive inter-group network externality.

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We develop a model where a genetic test reveals whether an individual has a low or high probability of developing a disease. A costly prevention effort allows high-risk agents to decrease this probability. Agents are not obliged to take the test, but must disclose its results to insurers, and taking the test is associated to a discrimination risk. We study the individual decisions to take the test and to undertake the prevention effort as a function of the effort cost and of its efficiency. If effort is observable by insurers, agents undertake the test only if the effort cost is neither too large nor too low. If the effort cost is not observable by insurers, moral hazard increases the value of the test if the effort cost is low. We offer several policy recommendations, from the optimal breadth of the tests to policies to do away with the discrimination risk.

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Many countries have chosen to use market-based mechanisms to manage health risk. Although the diversity of regulations associated with them is important, the use of market mechanisms is currently an undeniable fact. The objective of this thesis is to analyze the arguments that justify the introduction of such mechanisms while the debate on public intervention in the health insurance sector remains open. In this respect, the first part of the thesis focuses on moral hazard behavior, the first chapter being devoted to ex ante moral hazard behavior while the second one deals with ex post moral hazard. In the second part, we propose hybrid forms of health risk management, located at the intersection of the two allocation modes mentioned. In chapter 3, we take up Diamond's position of organizing competition in the health insurance sector according to an auction procedure. We show that the presence of increasing returns to scale in the health insurance sector is not a sufficient condition for the different groups of insureds to be allocated to only one insurer. In chapter 4, we study the possibility of introducing fictitious competition between the local branches of a national public monopoly. We propose an estimate of the efficiency of health expenditure at the departmental level using the DEA econometric method. We show that health expenditure in some departments is abnormally high given the results obtained in terms of morbidity.