DOURGNON Paul

BACKGROUND: For financial reasons, dental prosthetics is one of the major unmet dental healthcare needs [Financial-SUN (F-SUN)]. Private fees for dental prosthetics result in significant out-of-pocket payments for users. This study analyzes the impact of geo-variations in protheses fees on dental F-SUN. METHODS: Using a nationwide French declarative survey and French National Health Insurance administrative data, we empirically tested the impact of prosthetic fees on dental F-SUN, taking into account several other enabling factors. Our empirical strategy was built on the homogeneous quality of the dental prosthesis selected and used to compute our price index. RESULTS: Unmet dental care needs due to financial issues concern not only the poorest but also people with middle incomes. The major finding is the positive association between dental fees and difficulty in gaining access to dental care when other enabling factors are taken into account (median fee in the highest quintile: OR = 1.35. P value = 0.024. 95% CI 1.04-1.76). People with dental F-SUN are those who have to make a greater financial effort due to a low/middle income or a lack of complementary health insurance. For identical financial reasons, the tendency to give up on healthcare increases as health deteriorates. CONCLUSIONS: The results underscore the need for fee regulation regarding dental prosthetics. This is in line with the current French government dental care reform.

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Time to diagnosis, defined as the time span from first symptoms to final diagnosis, has received little if no attention, although it is perceived as highly variable across conditions, patients and countries and as a key determinant of health prognoses and outcomes. In this paper, we offer one of the first measures of time to diagnosis for four chronic conditions (bipolar trouble, Crohn disease, multiple sclerosis and psoriasis), and analyze the role played by patients education and social networks in explaining time to diagnosis. Adopting a patient's perspective, we use self-reported data from an online open access questionnaire administered to a large French social network of patients with chronic conditions. Duration models are used to explain variations in time to diagnosis. Our findings suggest that social participation and social support indeed reduce the probability of experiencing longer time spans to diagnosis. But contrary to expectations, higher levels of education have the reverse effect. We further analyze these results by identifying differences in patients' health care-seeking behavior: more educated patients tend to consult specialists first, which leads to longer time spans to diagnosis as they are less prone than GPs to referring patients to hospitals for additional tests, when needed. While our social networks findings support WHOs recommendations to enhance individual social capital, results on education provide support for reforms aimed at implementing GP referral systems.

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In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists’ services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000–2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.

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Despite the stated objectives of respecting the principle of horizontal equity, social inequalities in the use of health care are observed in countries with socialized health care systems.This thesis proposes, through four studies, to contribute to the analysis of public policies in the health care system, from the point of view of equity in the use of health care services. The introduction describes the social inequalities in the use of health care in France and the main mechanisms that may be at the origin of these inequalities within the French health care system. The first chapter studies the links between financial barriers to access to health care and health status. It shows that foregoing care for financial reasons is associated with a worse future health status.The second chapter proposes an analysis of the doctor-patient interaction and its role in the formation of inequalities in the use of care. We study the categorizations made by doctors about their patients according to their social situations. We then show the relationship between these categorizations and the practices observed. The first one proposes an analysis of the reform and its context, in particular the role of the different actors. The second proposes a study of the consequences of the reform on financial access to specialist care.

Despite the stated objectives of respecting the principle of horizontal equity, social inequalities in the use of health care are observed in countries with socialized health care systems.This thesis proposes, through four studies, to contribute to the analysis of public policies in the health care system, from the point of view of equity in the use of health care services. The introduction describes the social inequalities in the use of health care in France and the main mechanisms that may be at the origin of these inequalities within the French health care system. The first chapter studies the links between financial barriers to access to health care and health status. It shows that foregoing care for financial reasons is associated with a worse future health status.The second chapter proposes an analysis of the doctor-patient interaction and its role in the formation of inequalities in the use of care. We study the categorizations made by doctors about their patients according to their social situations. We then show the relationship between these categorizations and the practices observed. The first study analyses the reform and its context, in particular the role of the different actors.