MILCENT Carine

In the French DRG-based payment system, both private and public hospitals are financed by a public single-payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single-payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.

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Background and Aim: Does spatial organization of healthcare access still matter in China? I assess how e-health has transformed the notion of healthcare access and what spatial dimension of healthcare means in China today and in the near future. I also consider a dynamic perspective to propose keys to anticipate upcoming changes. Hong Kong has a very efficient healthcare system with a dense network of high-level hospitals and a high level of healthcare access. In major Chinese urban centers, a deliberate policy to improve healthcare availability has resulted in a spectacular increase in the number of healthcare structures over the last two decades. This includes urban healthcare centers and outpatient clinics. Nevertheless, the most of the population faces explicit and implicit financial penalties to get full healthcare access. To solve the problem, a digital health revolution is emerging. Methods: I use a qualitative case study approach. I conducted a series of semi-structured, face-to-face interviews to evaluate experiences, expectations, and opinions of patients regarding healthcare access and its associated financial burden as well as their use of digital health. Results: I assessed how e-health has transformed the notion of healthcare access and what spatial dimension of healthcare means today and in the near future in China. I also considered a dynamic perspective to propose keys to anticipate upcoming changes. Healthcare centers tend to shift from a place to get cured to a link within an e-healthcare pathway. For instance, this is a place to get e-prescribed medication. Advantages of this shift include a reduction in the cost of healthcare and remote access to highly qualified medical staff, bypassing the lack of trust in the quality of care offered in local hospitals. Conclusion: A forward-looking approach suggests that e-healthcare is becoming the entry point to healthcare for a large part of the population. Relevance to Patients: This study informs the policy makers of upcoming changes, and contributes to understanding and anticipating modifications needed in the healthcare system.

We explore the effects of adapted physical exercise programs in nursing homes, in which some residents suffer from dementia and/or physical limitations and others do not. We use data from 452 participants followed over 12 months in 32 retirement homes in four European countries. Using a difference-in-difference with individual random effects model, we show that the program had a significant impact on the number of falls and the self-declared health and health-related quality of life of residents (EQ-5D). The wide scope of this study, in terms of sites, countries, and measured outcomes, brings generality to previously existing evidence. A simple computation, in the case of France, suggests that such programs are highly cost-efficient.

We explore the competition impact on patient management in healthcare (length of stay and technical procedure's probability to be performed) by difference-indifference , exploiting time variations in the intensity of local competition caused by the French pro-competition reform (2004-2008). Models are estimated with hospital fixed effects to take into account hospital unobserved heterogeneity. We use an exhaustive dataset of in-hospital patients over 35 admitted for a heart attack. We consider the period before the reform from 2001 to 2003 and a period after the reform from 2009 to 2011. Before the reform, there were two types of reimbursement systems. Hospitals from private sector, were paid by fee-for-service. Hospitals from public sector were paid by global budget. They had no current activity's link, and a weak competition incentive. After the DRG-based payment reform, all hospitals compete with each other to attract patients. We find the reform a sizeable positive competition effect on high-technical procedure for the private sector as well as a negative competition effect on the length of stay for public hospitals. However, the overall local competition effect of the reform explained a very marginal part of the explanatory power of the model. Actually, this period is characterised by two contradictory components: a competition effect of the reform and in-patients who are more concentrated. Results suggest that if competition impacted management patient's change, it is through a global competition included in a global trend much more than a local competitive aspect of the reform.

This paper uses an original telepsychology European survey conducted by the EFPA (European Federation of Psychologists Associations) Project Group in e-Health between March 18th and May 5th, 2020, to consider online practices of psychologists. We set up evidence from France compared with other European countries. First, we observe that France is the European country where psychologists’ perception of the concept of online consultations is the worse. It goes through the lowest rate of specific training concerning online consultations. Also France is the European country where psychologists have the worse experience (after Belgium) with online consultations, prior to the COVID-19 outbreak. Second, we address the issue of determinants of the teleconsultation feelings. We take advantage of this survey panel of 13 European countries that allows us to consider within-country telepractice behaviour. Our results show that a specific training is a key factor for a positive feeling with the concept of online consultation practices. In addition, telepresence (feeling of being connected with one another) and positive overall experience capture the effect of the specific training. French psychologists differ from the other European countries telepsychologists by an absence of specific training effect on the feeling with online consultation that may be explained by the lack of specific training. However, as for European psychologists, French psychologists’ perception of telepractice depends on their level of telepresence and on their overall experience in telepractice.

We explore the effects of adapted physical exercise programs in nursing homes, in which some residents suffer from dementia and/or physical limitations and other do not. We use data from 452 participants followed over 12 months in 32 retirement homes in four European countries. Using a difference-in-difference with individual random effects model, we show that the program has exerted a significant impact on the number of falls and the self-declared health and health-related quality of life of residents (EQ-5D). The wide scope of this study, in terms of sites, countries, and measured outcomes, brings generality to previously existing evidence. A simple computation, in the case of France, suggests that such programs are highly cost-efficient.

BACKGROUND: Prior to the COVID-19 pandemic, teleconsultation were seldom used in France. The sanitary crisis has brought with it a great need for the use of teleconsultation and other interventions using digital technology. OBJECTIVE: Indentify how has French teleconsultation for obstetrics and gynecology care services been used prior and during this sanitary crisis. METHODS: We first described the global picture of the teleconsultation context prior to the sanitary crisis and then during the first quarantine and lockdown measures. We set up three aspects, namely: 1-use of teleconsultation as regards to providers’ ability. 2- use of teleconsultation as regards to technology features. 3- use of teleconsultation for which type of healthcare. Second, we studied the determinant factors of teleconsultation use and those of provider’s satisfaction with teleconsultation practice. RESULTS: We show the central role of training, the importance of some main digital technology benefits including improving public health, responding to patient's request and facilitating healthcare access, as well as the importance of some main digital technology drawbacks including lack of convenience and lack of veracity (truthfulness). CONCLUSIONS: Our results guide the regulator on the suppliers’ motivation and needs for teleconsultation adoption. They highlight the conditions for an efficient use of teleconsultation.

We explore the competition impact on patient management in healthcare (length of stay and technical procedure's probability to be performed) by difference-indifference , exploiting time variations in the intensity of local competition caused by the French pro-competition reform (2004-2008). Models are estimated with hospital fixed effects to take into account hospital unobserved heterogeneity. We use an exhaustive dataset of in-hospital patients over 35 admitted for a heart attack. We consider the period before the reform from 2001 to 2003 and a period after the reform from 2009 to 2011. Before the reform, there were two types of reimbursement systems. Hospitals from private sector, were paid by fee-for-service. Hospitals from public sector were paid by global budget. They had no current activity's link, and a weak competition incentive. After the DRG-based payment reform, all hospitals compete with each other to attract patients. We find the reform a sizeable positive competition effect on high-technical procedure for the private sector as well as a negative competition effect on the length of stay for public hospitals. However, the overall local competition effect of the reform explained a very marginal part of the explanatory power of the model. Actually, this period is characterised by two contradictory components: a competition effect of the reform and in-patients who are more concentrated. Results suggest that if competition impacted management patient's change, it is through a global competition included in a global trend much more than a local competitive aspect of the reform.

A prospective disease group-based payment is a reimbursement rule used in a wide array of countries. It turns to be the hospital's payment rule to imply. The secret of this payment is a fee payment as well as a hospital's activity based payment. There is a consensus to consider this rule of payment as the least likely to be manipulated by the actors. However, the defined fee per group depends on recorded information that is then processed using complex algorithms. What if the data itself can be manipulated? The result would be a fee per group based on manipulated factors that would lead to an inefficient budget allocation between hospitals. Using a unique French longitudinal database with 145 million stays, I unambiguously demonstrate that the implementation of a finer classification led to an upcoding-learning effect. The end result has been a budget transfer from public non-research hospitals to for-profit hospitals. The 2009 policy lead to upcoding disconnected from any changes in the trend of production of care.

Background:Is there any difference in performance based on ownership of rehabilitation structures? In France, they can be private for-profit, non-profit or public. The type of ownership impacts the activity of the rehabilitationunit (as a public service mission), the management of healthcare institution staff and the institution healthcare’s organization. As a consequence, it may affect the performance. However, what do we mean by performance? This indicator is, in fact, multidimensional. We propose 5 outcomes as performance indicators based on a literature survey. Methods: We consider six samples set up on the frequency of Major Diagnostic Category (MDC) stays. As a sensitivity analysis, we also set up samples for stroke, chronic obstructive pulmonary disease (COPD), heart failure, and total hip replacement. We run incremental four models on these samples. Results: For-profit hospitals appear to provide better performance than other types of hospital ownership. Patient characteristics and hospital equipment as well as number of medical staff and non-medical staff explain part of differences in performance based on ownership. It remains that for-profit rehabilitation unit perform better in terms of probability of death, probability to return-to-home and improvement in both, physical score and cognitive score. This result is obtained with a more efficient patient care (less daily care’s activity per patient measured as rr-score).Considering separately Research public hospital from other public hospital centre,results obtained are very heterogeneous. 2 Conclusion: The performance level differs from type of ownership to the other. For-profit rehabilitation’s centres get better results, with control for patient’s heterogeneity of demographic aspects and level of severity. However, we do not control for the social vulnerability that impacts the profit of rehabilitation units. That raises the political question on the role of healthcare centres to support social vulnerability.

Objective: To determine the factors that affect enrollment and full participation (adherence) in the PRADO home-based postnatal coordinated care program in France after hospital discharge. Methods: A population-based retrospective study was performed using the public health insurance database for the Yvelines district in France. The study population included all affiliated women admitted for delivery and classified as low risk in 2013. These women were eligible for home-based midwifery support after their discharge from the hospital. The enrollment and full participation of the women in home-based postnatal coordinated care were modeled using a simple probit model. Full participation in the home-based postnatal coordinated care was also modeled using a probit Heckman selection model in order to assess the self-selection process of enrollment in the program. The control variables were the characteristics of the patients, the municipalities, and the hospitals. Results: 2,859 (68.3%) of the 4,189 eligible women chose to participate in the home-based postnatal coordinated care program, of whom 2,496 (59.6% of the eligible women) subsequently took part in the entire PRADO program. On the one hand, enrollment in the home-based postnatal coordinated care was influenced mostly by family context variables including the woman's age at the time of her pregnancy and the number of children in the household, the woman's level of information including prenatal education and prenatal information regarding postpartum care, as well as hospital variables including characteristics and organization of the maternity units. On the other hand, full participation in the home-based postnatal coordinated care was influenced by the accessibility to health professionals, particularly midwives. 3 Furthermore, both the woman's level of information and accessibility to health professionals correlated with the socioeconomic environment. Conclusion: Women who become pregnant at a very early or late stage of their life as well as women with low levels of prenatal education and prenatal information regarding postpartum care have a relatively low rate of participation in home-based postnatal coordinated care. A public health policy promoting awareness of prenatal as well as postnatal issues could increase the participation in this coordinated community care. In addition, reducing regional inequality is likely to have a positive impact, as the availability of midwives is a key factor for participation in home-based postnatal coordinated care.

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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. 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?.

Cesarean section rates are high and continue to rise in high-income countries. Overuse of cesarean sections increases costs and reduces quality of care. It is therefore necessary to identify the determinants of cesarean sections in order to optimize their practice.We conducted a retrospective cohort study covering deliveries in 11 maternity hospitals in the Yvelines department during 2008-2014. We estimated multilevel logit models incorporating numerous individual and hospital characteristics known to influence obstetric practices.We examined the impact of private supplementary insurance on the cesarean section practice of French hospitals under T2A. We found that private hospitals, funded by the same public payer as public hospitals, performed more cesarean sections than public hospitals. This result is explained by the additional payments covered by private supplementary insurance and billed only by private hospitals. We then examined whether hospital staffing levels affected cesarean section rates. We found that higher staffing levels of obstetricians and midwives were associated with lower cesarean section rates. Finally, we examined the impact of prenatal care on cesarean section rates as well as the effect of socioeconomic status on prenatal care attendance affecting the cesarean section decision. We found that women who did not attend childbirth preparation were more likely to have a cesarean section, and that the most disadvantaged women were less likely to attend childbirth preparation when they were more likely to have a cesarean section.

According to the health economics literature, medical practices respond to the source of hospital payments and the rules that govern them. Here, we study the impact of supplementary private health insurance within the DRG-based financing of French hospitals. We use differences between the public and private hospital sectors in managers’ and doctors’incentives (in terms of potential additional payments) and examine their effect on the practice of cesarean deliveries. We mobilize exhaustive delivery data from a French district over a 7-year period (2008-2014) and consider factors that are known to influence obstetric practices. Our empirical results show that, although private hospitals are financed by a single public payer, like those in the public sector, they perform significantly more cesarean deliveries than public hospitals. This result is partially explained by additional payments covered by private health insurance and charged by private but not public hospitals.

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How efficient is the Chinese healthcare system? Milcent examines the medication market in China against the global picture of healthcare organization, and how public healthcare insurance plans have been implemented in recent years, as well as reforms to tackle hospital inefficiency. Healthcare reforms, demographic changes and an increase in wealth inequity have altered healthcare preferences, which need to be addressed. Significantly, the patient–medical staff relationship is analysed, with new proposals for different lines of communication. Milcent puts forward digital healthcare in China as a tool to solve inefficiency and rising tensions, and generate profit. Where China is leading in the digitalization of healthcare, other countries can learn important lessons. Chinese social models are also put into context with respect to current reforms and experimentation.

Cesarean deliveries are widely used in many high-and middle-income countries. This overuse both increases costs and lowers quality of care and is thus a major concern in the healthcare industry. The study first examines the impact of prenatal care utilization on cesarean delivery rates. It then determines whether socioeconomic status affects the use of prenatal care and thereby influences the cesarean delivery decision. Using exclusive French delivery data over the 2008-2014 period, with multilevel logit models, and controlling for relevant patient and hospital characteristics, we show that women who do not participate in prenatal education have an increased probability of a cesarean delivery compared to those who do. The study further indicates that attendance at prenatal education varies according to socioeconomic status. Low socioeconomic women are more likely to have cesarean deliveries and less likely to participate in prenatal education. This result emphasizes the importance of focusing on pregnancy health education, particularly for low-income women, as a potential way to limit unnecessary cesarean deliveries. Future studies would ideally investigate the effect of promoting programs such as care participation on cesarean delivery rates.

This chapter focuses on hospital ownership and supervision. Public hospitals are mostly, but not always, under the supervision of the Health Ministry. There are a certain number of other governing bodies that are directly involved in the management of hospitals. A cross-ministry group was set up in 2006 to facilitate the implementation of hospital reforms. Apart from the organizational structure, the funding of hospitals and its evolution is studied. Between 1979 and 1991, the government introduced a co-payment system in healthcare establishments. In 1992, the Ministry of Health officially granted greater autonomy to public hospitals. They were authorized to deliver paid services and to make profits, but were made responsible for their losses and debts. By 2003, central government funding had fallen to 8% of the hospital budget. As a result, public hospitals in China behave very similarly to for-profit firms, while being governed as any traditional public structure. The next step is the current experiment of a Diagnostics Related Group-based payment in China. Along with the financial autonomy of public hospitals, different reforms have been directed at developing private hospitals, even though many obstacles still remain.

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Today, China's public hospitals manage 90% of consultations for what English-speakers would call ambulatory care or outpatient care 1 , and 90% of hospital inpatient admissions. As such, public hospitals deal with the demand for treatment by consultation just as they must deal with treatment for inpatients. China is in the midst of a paradox. There has been a spectacular upward surge in health indicators, matching a similar increase in economic indicators. It is also a colossal market, with healthcare expenditures reaching $511.3 billion in 2013. 2 That is equivalent to 5.6% of GDP. 3 On the other hand, the health system has officially been described as inefficient, and there is a toxic atmosphere between medical staff and patients.

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Cesarean deliveries are widely used in many high- and middle-income countries. This overuse both increases costs and lowers quality of care and is thus a major concern in the healthcare industry. The study first examines the impact of prenatal care utilization on cesarean delivery rates. It then determines whether socioeconomic status affects the use of prenatal care and thereby influences the cesarean delivery decision. Using exclusive French delivery data over the 2008–2014 period, with multilevel logit models, and controlling for relevant patient and hospital characteristics, we show that women who do not participate in prenatal education have an increased probability of a cesarean delivery compared to those who do. The study further indicates that attendance at prenatal education varies according to socioeconomic status. Low socioeconomic women are more likely to have cesarean deliveries and less likely to participate in prenatal education. This result emphasizes the importance of focusing on pregnancy health education, particularly for low-income women, as a potential way to limit unnecessary cesarean deliveries. Future studies would ideally investigate the effect of interventions promoting such as care participation on cesarean delivery rates.

China has around 2.79 million licensed physicians, among which 90% have received some kind of training in Western medicine in addition to Chinese traditional medicine. China has far more doctors than nurses. This is inherited from Chinese history, with the barefoot doctor system. In terms of education level, as many as 70% of healthcare suppliers did not have a bachelor degree in 2013. One of the current goals of Chinese authorities is to reinforce the training level and to ensure sufficient access to skilled healthcare personnel. Besides, there are important disparities in healthcare access between rural and urban areas. These disparities concern not only the number of medical employees per bed but also the average level of qualification available. In this chapter, we also explore the administrative status of public medical staff (bianzhi status) and their working conditions (salary, financial incentives and informal bonuses amounting to bribery). The development of the family doctor, through specific training and career paths, is usually seen as a key reform, which is now at the pilot programme stage.

Objective To investigate whether staffing levels of maternity units affect prelabor urgent, elective, and intrapartum cesarean delivery rates. Methods This population-based retrospective cohort study covers the deliveries of the 11 hospitals of a French perinatal network in 2008–2014 (N = 102 236). The independent variables were women’s demographic and medical characteristics as well as the type, organization, and staffing levels for obstetricians, anesthesiologists, and midwives of each maternity unit. Bivariate and multivariate analyses were conducted with multilevel logistic models. Results Overall, 23.9% of the women had cesarean deliveries (2.4% urgent before labor, 10% elective, and 11.5% intrapartum). Independently of individual- and hospital-level factors, the level of obstetricians, measured by the number of full-time equivalent persons (i.e., 35 working hours per week) per 100 deliveries, was negatively associated with intrapartum cesarean delivery (adjusted odds ratio, aOR 0.55, 95% confidence interval, CI 0.36–0.83, P-value = 0.005), and the level of midwives negatively associated with elective cesarean delivery (aOR 0.79, 95% CI 0.69–0.90, P-value < 0.001). Accordingly, a 10% increase in obstetrician and midwife staff levels, respectively, would have been associated with a decrease in the likelihood of intrapartum cesarean delivery by 2.5 percentage points and that of elective cesarean delivery by 3.

The structure of healthcare supply in China is very specific. Indeed, as of 2011, more than 85% of all health personnel worked in public healthcare institutions. In addition, public hospitals provide a very large part of outpatient services on top of their inpatient provision. The goal of this chapter is to explain the reasons behind this very high provision and its consequences. The background presented makes a clear differentiation between rural and urban areas. For each geographical area, a historical and longitudinal reading aims at explaining the current situation. Shortly after the creation of the People’s Republic of China in 1949, a healthcare system organized in three tiers, known as the Community Medical System (CMS), was set up in rural locations. Patients had to enter the system through the first tier and were then funnelled into other tiers for the more severe cases. Patients whose affliction required very specific treatment were transferred to urban areas, into provincial or central hospitals. In urban areas, from 1949 to 1980, healthcare access was organized at company level. If, today, the general organization of the healthcare system remains in rural areas, economic as well as administrative reforms have deeply reshaped access to healthcare in these structures.

In this paper, we address two issues: i) how hospital employment changes with local unemployment, according to the type of hospital ownership, and ii) whether this relationship changed after the implementation of a pro-competitive reform that made hospitals more similar. A 2006–2010 French panel of 1695 hospitals over five waves allows us to consider within-hospital employment changes. We first find that higher local unemployment is associated with greater employment in State-owned hospitals, but not for any other hospital ownership type: French local authorities then seem to respond to depressed local labour markets by increasing employment in State-owned hospitals. After the full implementation of the pro-competitive reform hospital funding became based only on activity and no longer on some historical budget. Theoretically, the new reimbursement system should break the relationship between public-hospital employment and local unemployment. Our results reveal that the reform worked as expected in less-deprived areas: reducing employment and eliminating the correlation between local unemployment and State-owned hospital employment. However, in higher-unemployment areas, public-hospital employment remains counter-cyclical. Poor local labour-market health then seems to trump financial incentives in determining employment in public hospitals.

Health insurance in China is the topic of this chapter. Up until the economic reforms of the 1980s, communities (a village or a group of villages) were managing the social welfare of their inhabitants. The system was extremely decentralized. With the collapse of the community medical system, existing public establishments were either replaced by private ones, or put into competition with them. As a result, the healthcare access system was no longer free of charge and became unaffordable to many. During the period of absence of a centralized public insurance system, this lack of access to treatment became a major problem. at first for the most vulnerable part of the population, and gradually for a greater and greater proportion of rural dwellers. As the question of healthcare costs causing widespread poverty became a pressing issue, different public health insurance programmes were implemented. Today, geographical inequity is still observed for these programmes. There is variability not only in terms of funding eligibility, types of illness or services to be covered, but also in terms of levels of benefits and payments methods. Concerning the private health insurance market, it was next to nothing in the early 2000s. Today, the rise of private health insurance schemes is supported by the Chinese government and is finding an audience among the emerging upper middle class.

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This chapter focuses on hospital ownership and supervision. Public hospitals are mostly, but not always, under the supervision of the Health Ministry. There are a certain number of other governing bodies that are directly involved in the management of hospitals. A cross-ministry group was set up in 2006 to facilitate the implementation of hospital reforms. Apart from the organizational structure, the funding of hospitals and its evolution is studied. Between 1979 and 1991, the government introduced a co-payment system in healthcare establishments. In 1992, the Ministry of Health officially granted greater autonomy to public hospitals. They were authorized to deliver paid services and to make profits, but were made responsible for their losses and debts. By 2003, central government funding had fallen to 8% of the hospital budget. As a result, public hospitals in China behave very similarly to for-profit firms, while being governed as any traditional public structure. The next step is the current experiment of a Diagnostics Related Group-based payment in China. Along with the financial autonomy of public hospitals, different reforms have been directed at developing private hospitals, even though many obstacles still remain.

No summary available.

China is the second largest pharmaceutical market in the world. This sector grew by 21.4% between 2002 and 2012. In OECD countries, spending on medical drugs accounted for approximately 17% of total health spending or 1.5% of gross domestic product (GDP) in 2009. That same year, spending on pharmaceutical products in China represented 43% of the total healthcare expenditure. Aware of the issue, the Chinese government has reacted. A limitation on the hospital mark-up on drugs has been implemented and a list of key drugs that are considered essential has been set up. Drugs on this list have to be accessible to everyone, with a regulated price to be kept as low as possible. To keep prices low, procurement is made through centralized bidding at provincial level, pharmaceutical companies delivering directly to medical facilities. Yet, in the field, the reality remains at times complex, with different ways to circumvent these constraints.

In this paper, we address two issues: i) how hospital employment changes with local unemployment, according to the type of hospital ownership, and ii) whether this relationship changed after the implementation of a pro-competitive reform that made hospitals more similar. A 2006-2010 French panel of 1,695 hospitals over five waves allows us to consider within-hospital employment changes. We first find that higher local unemployment is associated with greater employment in State-owned hospitals, but not for any other hospital ownership type: French local authorities then seem to respond to depressed local labour markets by increasing employment in State-owned hospitals. After the full implementation of the pro-competitive reform hospital funding became based only on activity and no longer on some historical budget. Theoretically, the new reimbursement system should break the relationship between public-hospital employment and local unemployment. Our results reveal that the reform worked as expected in less-deprived areas: reducing employment and eliminating the correlation between local unemployment and State-owned hospital employment. However, in higher-unemployment areas, public-hospital employment remains 2 counter-cyclical. Poor local labour-market health then seems to trump financial incentives in determining employment in public hospitals.

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?.

This chapter addresses the increasing role of digital healthcare in the overall Chinese healthcare system. As described in previous chapters, the healthcare system faces many issues, such as the confrontational relationship between doctors and patients, the poor access for populations in rural areas, the significant mark-up throughout distribution channels, a financially heavy burden for chronic diseases, poor quality of healthcare supply and inefficient hospital operation except Level 3 hospitals that have to deal with an over-demand. Many solutions have been proposed, such as the multiplication of healthcare suppliers, the establishment of general practitioners as gatekeepers for hospital admissions, the implementation of public health insurance schemes or the government support for reforms in favour of private health insurance and private healthcare providers. However, they have not proven sufficient to solve all problems yet. Digital healthcare is likely to play an increasing part in addressing these issues. One of the strengths of e-health is the quick and widespread adoption of mobile platforms. This may help solve access challenges, through online appointment registration systems, models of online-offline services, two-communication platforms between patients and physicians, sharing information through the Electronic Health Record (EHR) and Electronic Medical Record (EMR) systems, the generalized implementation of a DRG-based payment system, making patients more increasingly active actors in maintaining the health status, and improving the online drug market. On the flip side, this also raises many concerns regarding the confidentiality of personal medical data and the monopoly situation of some internet companies.

Is the intervention of the state in the healthcare market legitimate and efficient? To answer this question, a clear definition of a health good and its implications is needed. Can we just apply the general definition of a public good for all health goods? Should we consider different types of health goods? If yes, how do we delimit the frontier between a public good and a private good? With a rapid glance at the diversity of organizations in the healthcare system that exist in the world, it appears there is little consensus on what can and should be defined as a public good. Generally speaking, all countries have a mixed health system, combining pro-market elements with welfare state safeguards, and China is no exception: all reforms of the healthcare system implemented since the 1980s have swung between both. To understand the Chinese health system and its recent evolution, we need to start by defining the global framework in which the “health good” is set.

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China is currently experiencing an over-utilization of university hospitals and hospitals with high-tech equipment, usually located in main cities. Even though they have a large capacity, they are faced with congestion leading to long queues. In parallel, there is under-utilization of smaller institutions. The Ministry of Health estimates that 70% of patients treated in university hospitals of a higher level (Level 3) could have received adequate treatment in hospitals of a lower category, closer to their home. In 2009, the Chinese government published a large-scale development plan for the health sector, with over RMB 770 billion to be invested. Four years later, RMB 620 billion was already spent, with a public insurance scheme set-up and a network of Community Health Centres created. Yet, this key issue of the Chinese health system, that is, the concentration of demand on a small number of hospitals, still remains, eventually leading to a tense relationship between doctors and patients, and to increasingly common acts of violence. The origin of such violence as well as possible directions to restore trust, respect, and understanding between patients and medical staff is examined. The decentralization of quality care seems to be the key, but there are different ways to achieve this goal. Obviously, digital tools such as connected health object and other online services are likely to play a growing role in addressing this issue.

Is the intervention of the state in the healthcare market legitimate and efficient? To answer this question, a clear definition of a health good and its implications is needed. Can we just apply the general definition of a public good for all health goods? Should we consider different types of health goods? If yes, how do we delimit the frontier between a public good and a private good? With a rapid glance at the diversity of organizations in the healthcare system that exist in the world, it appears there is little consensus on what can and should be defined as a public good. Generally speaking, all countries have a mixed health system, combining pro-market elements with welfare state safeguards, and China is no exception: all reforms of the healthcare system implemented since the 1980s have swung between both. To understand the Chinese health system and its recent evolution, we need to start by defining the global framework in which the “health good” is set.

No summary available.

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.

Policies to reduce health inequalities based on income redistribution or on reducing the costs of access to care for the poorest are common to many countries. These policies are based on the fact that there is a relationship between individual income and health status. This dissertation analyzes this relationship using the ≪ Survey of Health Ageing and Retirement in Europe ≫ which covers Europeans aged 50 years and older. We show that individual income is positively and concavely associated with health (absolute income hypothesis), but also that income inequalities within a country affect all individuals in that country (strong version of the income inequality hypothesis). The underlying mechanisms of this hypothesis show that to reduce health inequalities associated with income inequalities, governments must promote investments in human and social capital. Also, individuals are sensitive to the lifestyle followed by the majority of people. Subsequently, we implement a simultaneous analysis of health and income using a full information maximum likelihood estimator. The bidirectional causality of income and health is highlighted, as well as the presence of unobservable individual characteristics common to them. Finally, on a concrete example, that of anti-smoking policies, this thesis simultaneously analyzes tobacco consumption, individual income, and risk aversion. The results highlight the importance of individual preferences in the decision to smoke. Indeed, European smokers aged 50 and over are present-oriented, such that they do not consider the harmful effects of smoking on health, and are either risk averse due to anxiety, or risk-averse because they accept to alter their health.

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We evaluate the effect of a pro-competition reform gradually introduced in France over the 2004-2008 period on hospital quality measured with the mortality of heart-attack patients. Our analysis distinguishes between hospitals depending on their status: public (university or non-teaching), non-profit or for-profit. These hospitals differ in their degree of managerial and financial autonomy as well as their reimbursement systems and incentives for competition before the reform, but they are all under a DRG-based payment system after the reform. For each hospital status, we assess the benefits of local competition in terms of decrease in mortality after the reform. We estimate a duration model for mortality stratified at the hospital level to take into account hospital unobserved heterogeneity and censorship in the duration of stays in a flexible way. Estimations are conducted using an exhaustive dataset at the patient level over the 1999-2011 period. We find that non-profit hospitals, which have managerial autonomy and no incentive for competition before the reform, enjoyed larger declines in mortality in places where there is greater competition than in less competitive markets.

The purpose of this article is to highlight the changes in the Chinese medical public space that have occurred in recent years, both under the impetus of reforms and through new forms of access to care, including digital technology. The Chinese population has undergone three phases in the evolution of its health space. From the 1950s until the economic reforms, the health care system was built around local services. Depending on the seriousness of the patient, he or she was redirected to more equipped facilities with more qualified personnel. These health care facilities were all the more important in terms of size (number of beds) and medical personnel as the population density was high. The population had no choice but to respect this structuring of the health space. From the 1980s onwards, the health care space was disorganized under the effect of several factors leading to the disappearance and then the redefinition of this proximity offer. The cost of care, which had previously been virtually free, followed a dizzying curve of increase. At the same time, the level of quality has also improved.

The share of healthcare expenditure in France represents 12% of the Gross Domestic Product (GDP). It is second only to the United States and the Netherlands. This share is very close to other countries such as Germany. Hospitals account for a large share of spending. However, this is the most controlled share. Hospitals now account for only 36% of health care spending in France, compared with 43% in 1983. So, yes, hospitals are expensive, but they are becoming less so.

This paper studies the variability of hospital costs for stays comparable in pathologies and procedures (GHM). At the time of the global budget, a strong variability of costs was observed between French public hospitals. What is the situation today? In theory, T2A leads hospitals to minimize their costs in order to earn the difference between the fixed price and the cost. We show a certain homogenization of costs and a real consideration of the heterogeneity of individuals. However, the GHM packages do not capture all the heterogeneity between establishments, nor between patients. Thus, the harmful effects of patient selection or a reduction in the level of quality are not avoided by the current packages.

It is widely believed that the goal of keeping health expenditures under control while increasing the quality of the healthcare system can best be achieved by giving a greater role to market forces. This column evaluates the effect of a pro-competition reform implemented in France over 2004-2008 on hospital quality. It finds that the impact on quality depends on the managerial autonomy of hospitals. And due to the French healthcare market structure, the overall effect of the reform has been limited.

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How has this administrative change affcted the healthcare providers behaviour? Using a unique longitudinal database with 145 million stays, I study the dependence of the severity classification associated with hospital stays on a financial incentive, as well as the resulting budgetary reallocations. The classification of diagnosis-related groups (DRGs) in France changed in 2009. The number of groups was multiplied by 4. Controlling for pathology indicators and hospital fixed e↵ects, I unambiguously demonstrate that a finer classification led to an “upcoding” of stays. Because of a fixed annual budget at the national level, these results directly imply that the upcoding led to a budget reallocation which increased the share of health spending that went to for-profit hospitals, at the expense of public nonresearch hospitals. This budget reallocation did not correspond to any change in the actual production of care.

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China’s public health system has gone through a number of development stages. This paper aims at showing how, from its inception as a hierarchical system, the healthcare system then lost its structure, to finally give birth to a focalised system where the first point of entry in the treatment process has become the hospital, in particular the healthcare establishments that offer the most reliable standards of care. These days, the widely-acknowledged inefficiencies of the healthcare system have led to a climate of violence between medical staff and their patients, caused by the overwhelming demand that hospitals must bear, the ambiguous status of public establishments, financial benefits and other perks for medical staff, as well as the medical staff’s civil servant status, and the implications thereof. Policies to foster the development of primary health centres are struggling to gain traction, while digital healthcare offers promising solutions and is developing fast L’organisation du système de santé chinois a connu plusieurs phases de développement.

Mortality differences between university, non-teaching public and for-profit hospitals are investigated using an exhaustive French administrative dataset of patients admitted for heart attack. Our results show that innovative procedures play a key role in explaining the effect of ownership status on hospital quality. When age, sex, diagnoses and co-morbidities are held constant, the mortality rates in for-profit and university hospitals are similar, but they are lower than in non-teaching public hospitals. When additionally controlling for innovative procedures, the mortality rate is higher in for-profit hospitals than in the two groups of public hospitals. This suggests that the quality of care in for-profit hospitals relies on their capacity to perform innovative procedures. A counterfactual exercise shows that if patients in non-teaching public hospitals were treated with innovative procedures following the assignment rule of for-profit hospitals rather than that of non-teaching public hospitals, their probability of death after a duration of 7 days would be 1.8 points lower.

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This thesis focuses on the question of variability in cancer management practices and on the study of the determinants of social and spatial inequalities in access to care, with a particular focus on cancer patients. In recent years, public authorities have noted strong variability in the rates of recourse to certain types of treatment. The first chapter of this thesis asks the question of the determinants of differences in the use of prostatectomy as a treatment for prostate cancer. The results show a strong positive influence of variables relating to the supply of care, both at the level of the department and the region, and the fight against social inequalities in health is also carried out thanks to mechanisms such as the ALD. The second chapter looks at the determinants of the use of general practitioners and specialists, differentiating between visits to the latter that are related to ALD pathology and those that are not. For visits to general practitioners, the results show that a lower socio-economic status seems to be associated with a higher use of care. Finally, since 2004, an organized breast cancer screening program has been in place for all women aged 50 to 74. The objective of the last chapter is to examine the potential influence of the density of general practitioners and specialists on the rates of recourse to this screening over the period 2005-2012. It appears that a higher density of general practitioners is significantly associated with a higher utilization rate. Conversely, an increase in the density of specialists tends to have a negative impact. The estimates also highlight a spatial effect . medical densities in neighboring departments also have an effect on the use of organized screening.

The aim of this paper is to study the variability of hospital costs for stays that are comparable in terms of pathologies and procedures (Groupe homogène de séjours _GHS). At the time of the global budget, a strong variability of costs was observed between French public hospitals. What is the situation today? The activity-based pricing system (T2A) implemented between 2004 and 2008 has introduced competition between French hospitals, whether they are public, private, non-profit or for-profit. With the T2A, hospitals are now paid on a lump sum per stay basis. In theory, a fixed-price system should lead hospitals to minimize their costs in order to earn the difference between the fixed price and the cost. The introduction of competition between hospitals should accelerate this cost minimization mechanism. We show that although the major changes in the modes of regulation have indeed led to a certain homogenization of costs and to a real consideration of the heterogeneity of individuals, fixed prices per GHM do not, however, capture all the heterogeneity between hospitals or between patients.

In 2003, a public insurance system was introduced in Chinese rural areas. In the meantime, subjective health status improved. We used a unique household longitudinal survey to analyse how the introduction of an insurance system, known as the New Cooperative Medical Scheme (NCMS), has contributed to the change. This health insurance programme was launched sequentially over counties starting in 2003, and households voluntarily chose whether to participate the programme after its launch by the county. These characteristics make it feasible to disentangle two channels of the influence of the NCMS on self-reported health status. One is the insurance effect of the coverage, which can be estimated by comparing the insured households with non-participants in the villages located in counties that have launched the programme (NCMS counties). the other is the general equilibrium effect that affects all residents in the NCMS counties, and can be estimated by comparing non-participants with the non-exposed households. The longitudinal data also allow us to examine how the effect changes with the duration of households’ subscription to the programme. The empirical findings include: first, a positive extensive margin: an individual feels better about his or her health status when covered by the NCMS. However, there is no intensive margin: there is no additional gain in the self-assessment of health status with the individual’s number of years enrolled in the programme. Second, we find a positive general equilibrium effect of introducing the NCMS programme on non-participants in the NCMS county. This effect accumulates over time.

This study is an assessment of a programme of physical activity for the elderly. The programme offers to residents of retirement homes several physical activities designed to avoid falls, and light gym regimes. The programme is evaluated using a randomised controlled trial protocol in around 30 retirement homes in Europe. The results show a clear reduction in falls and a significant improvement in subjective health indicators. A cost-benefits analysis suggests that the introduction of such programmes could be very positive, thanks to the reduction of costs generated by falls by old people in residence, notwithstanding the benefits for their wellbeing.

This note presents the results of an evaluation of a physical activity program adapted to an elderly public. The program proposes several physical activities dedicated to residents in retirement homes around the prevention of falls and light gymnastics. The program was evaluated using a randomized trial protocol in about thirty retirement homes in Europe. The results show a net reduction in the prevalence of falls and a significant improvement in subjective measures of health. A cost-benefit analysis suggests that the generalization of such physical activity programs could be very positive thanks to the reduction of costs generated by falls of elderly people in residence. In addition, the benefits to the well-being of residents may in itself justify the development of such programs.

For 17 years, the social enterprise Siel Bleu has been developing and implementing physical activity programs adapted to the needs of elderly people in institutions, with the aim of promoting active ageing, preventing the risks and chronic diseases associated with ageing and supporting dependency. Siel Bleu works with 80,000 beneficiaries in 4,000 institutions and employs 400 people. In 2012, Siel Bleu, with the support of the European Union and Danone-Ecosystème, set up an evaluation protocol for an adapted physical activity program for residents of retirement homes: HAPPIER (Healthy Activity & Physical Program Innovations in Elderly Residences). The aim was to measure the impact of the program on the residents' quality of life, as well as their cognitive and physical faculties. The protocol also planned to evaluate the effect of the program on the professional quality of life of the nursing and support staff. The challenges of this protocol are linked to the growing importance of the care of elderly and dependent people by specialized residences, due to the increase in life expectancy, particularly in Europe. Faced with this new and massive phenomenon, the quality of life of elderly people living in institutions and the cost of their care are becoming major issues. In this context, we examine the hypothesis of a benefit of sports practice on the general moral and physical health of the elderly, as well as on their risk of falling, the latter being the most serious and most frequent source of health problems among the elderly.

We here ask whether French local authorities respond to depressed local labour markets by increasing employment in State-owned hospitals. We use 2006-2010 panel data to examine within-hospital employment changes: higher local unemployment is associated with greater employment in State-owned hospitals, but not for any other hospital type. Our data cover a reimbursement reform introducing competition between hospitals. This reform reduced public-hospital employment, but had no overall effect on the relationship between public-hospital employment and local unemployment. Further analysis shows that this continuing relationship is only found in higher unemployment areas, where public-hospital employment remained counter-cyclical.

No summary available.

The aim of this paper is to study the heterogeneity of hospital costs for stays that are comparable in terms of pathology and procedures (Groupe homogène de séjours _GHS). At the time of the global budget, a strong heterogeneity of costs was observed between French public hospitals. What is the situation today? The activity-based pricing system (T2A) implemented between 2004 and 2008 has introduced competition between French hospitals, whether they are public, private, non-profit or for-profit. With the T2A, hospitals are now paid on a lump sum per stay basis. In theory, a fixed-price system should lead hospitals to minimize their costs in order to earn the difference between the fixed price and the cost. The introduction of competition between hospitals should accelerate this cost minimization mechanism. We show that, despite major changes in the modes of regulation, flat rates by GHM do not capture all the heterogeneity between hospitals or the entire patient case-mix.

Using a French exhaustive dataset, this article studies the determinants of regional disparities in mortality for patients admitted to hospitals for a heart attack. These disparities are large, with an 80% difference in the propensity to die within 15 days between extreme regions. They may reflect spatial differences in patient characteristics, treatments, hospital characteristics and local healthcare market structure. To distinguish between these factors, we estimate a flexible duration model. The estimated model is aggregated at the regional level and a spatial variance analysis is conducted. We find that spatial differences in the use of innovative treatments play a major role whereas the local composition of hospitals by ownership does not have any noticeable effect. Moreover, the higher the local concentration of patients in a few large hospitals rather than many small ones, the lower the mortality. Regional unobserved effects account for around 20% of spatial disparities.

We estimate a system of three behavioral equations for Brazilian children and teenagers (school absenteeism, health status and child labor). We relieved the assumption of independence of the disturbance terms of each equation. Moreover, if causality mechanisms between these three components (school absenteeism, health status and child labor) can occur either way, it can also be the result of a simultaneous decision-making process. Thus, to take into account both endogenous causality aspects and simultaneity, we estimate using the FIML method, which provides some improvement to the quality of the estimation, allowing us to simultaneously estimate all relevant parameters, including covariance parameters, and also to the subsequent interpretation of the results.

While much work has been done on the effect of health insurance on the demand for health care, the effect of urbanization, the industrialization process, and changes in the supply of health care have so far received little attention. The data used are from the China Health and Nutrition Survey (CHNS) covering the period 1991-2006. With the industrialization process, the number of rural inhabitants with agricultural activity is decreasing. Rural areas undergoing urbanization are developing transport systems as a priority. The supply of health care, under the impulse of the central and provincial governments, has changed. The quality of care offered has improved, public infrastructure has become more concentrated and better equipped, and private and community infrastructure has developed. At the same time, public funding of public facilities has been greatly reduced and facilities have used drugs and diagnostic procedures as a profit generator. As a result, rural residents working outside the country and with a substantial income have access to better quality care than before the economic reforms. In contrast, farmers with low incomes and little mobility were worse off.

During the 2003-2006 period, subjective health status in Chinese rural areas improved. We used a unique household longitudinal survey to analyze how the introduction of a public insurance system has contributed to the change. This program is based on a doubly voluntary process: counties decide to launch, then households decide to subscribe. We disentangle two channels of influence of the insurance: the insurance effect of the coverage and a general equilibrium effect on all residents in the insurance-adopting counties. The empirical findings include, first, a positive extensive margin: individuals feel better about their health status when covered by the NCMS. However, there is no intensive margin: an individual's self-assessed health status does not improve with the number of years enrolled in the program. Second, we find a positive general equilibrium effect of introducing the NCMS program on non-participants in NCMS counties. This effect accumulates over time.

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.

A significant proportion of deliveries are performed by cesarean section in Europe and worldwide. The objectives of this thesis are to highlight the non-medical determinants, notably economic and financial, explaining the development of this practice, as well as its consequences on women's health after childbirth, in relation to other factors such as the local concentration of hospital structures. Our analysis focuses on two countries: France and Switzerland. In the first part of the thesis, we highlight the influence of two non-medical determinants: the payment system and the behavior of obstetricians. We show that fee-for-service financing and the number of obstetricians influence the practice of cesarean section. The increase in cesarean section use between 2003 and 2006 can be attributed primarily to changes in hospital and patient characteristics. IT may indicate that coding practices are changing to account for increased use of cesarean section. Following the Shelton Brown III identification strategy, we find a potential impact of obstetrician physicians' leisure demand on emergency cesarean section practice. The second part of the thesis is devoted to the study of the quality of obstetric care. We analyze the impact of cesarean section on the occurrence of obstetric complications and the impact of the concentration of care on the quality of obstetric care. Caesarean section can be a factor ( obstetrical complications and the concentration of births has a negative impact on the quality of obstetrical care.

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.