LAMIRAUD Karine

In some countries, including France, patients can choose between consulting a physician working in the regulated sector where, in general, fees are fully covered by health insurance (whether public, private or mixed), or a physician working in the unregulated sector, where a balance billing scheme operates. In the latter, fees might not be fully covered by health insurance, and patients must make out-of-pocket payments. The paper analyses the signalling properties of this mechanism in a context where patients are heterogenous with respect to their propensity to adhere to the prescribed treatment. The model reveals that a small extra fee allows to obtain a separating equilibrium in which only patients with a high propensity to adhere to the treatment will opt for the unregulated sector and benefit of a higher care effort on behalf of their physician. We also analyse the other equilibria of the game and comment on their welfare properties.

No summary available.

Our article deals with pricing strategies in Swiss health insurance markets and focuses on the relationship between basic and supplementary insurance. We analyzed how firms’ pricing strategies (i.e., pricing of basic and supplementary products) can create switching costs in basic health insurance markets, thereby preventing competition in basic insurance from working properly. More specifically, using unique market and survey data, we investigated whether firms use bundling strategies or supplementary products as low-price products to attract and retain basic insurance consumers. To our knowledge, this is the first paper to analyze these pricing strategies in the context of insurance/health insurance. We found no evidence of bundling in the Swiss setting. We did however observe that firms used low-price supplementary products that contributed to lock in consumers. A majority of firms offered at least one of such product at a low price. None offered low-price products in both basic and supplementary markets. Low-price insurance products differed across firms. When buying a lowprice supplementary product, consumers always bought their basic contract from the same firm. Furthermore, those who opted for low-price supplementary products were less likely to declare an intention to switch basic insurance firms in the near future. This result was true for all risk category levels.

The French market for specialist physician care has a dual legal structure: physicians must exclusively work in sector 1 and charge regulated fees or in sector 2, where they can freely set their fees. Patient out-of-pocket payments in sector 2 are partially covered by private insurance. The primary differentiating factor between both sectors is the number of patients per specialist, which in turn directly affects the overall quality of the service provided. We built an equilibrium model to analyse both specialists decisions about which sector to work in, and patients choice of physician and therefore sector. More specifically, the model allowed us to study the effect of changes in prices and economy-wide patient-to-specialist ratios on profits and patients utility associated with the services provided in each sector.

No summary available.

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.

This paper analyses data collected in 2012 and 2013 at the ESSEC Business School from Kallystée, a proprietary mass-attendance business game. Company boards are simulated by teams of five students selected at random. The design manipulates the gender composition of the boards to allow for all possible gender combinations. Data show that all-men and mixed teams with four women perform significantly better than all-women teams. However, when controlling for the average tolerance to risk score of the teams, the performance advantage of all-men teams vanishes, while the team-specific economic performance of teams with four women is still positive and strong. Teams with four women take more risks than the team tolerance to risk score would predict, which suggests some form of team specific action bias or risk-shift.

Despite the claimthat technology has been one of themost important drivers of healthcare spending growth over the past decades, technology variables are rarely introduced explicitly in cost equations. Furthermore, technology is often considered exogenous. Using 1996–2007 panel data on Swiss geographical areas, we assessed the impact of technology availability on per capita healthcare spending covered by basic health insurance whilst controlling for the endogeneity of health technology availability variables. Our results suggest that medical research, patent intensity and the density of employees working in the medical device industry are influential factors for the adoption of technology and can be used as instruments for technology availability variables in the cost equation. These results are similar to previous findings: CT and PET scanner adoption is associated with increased healthcare spending, whilst increased availability of percutaneous transluminal coronary angioplasty facilities is associated with reductions in per capita spending. However, our results suggest that the magnitude of these relationships is much greater in absolute value than that suggested by previous studies that did not control for the possible endogeneity of the availability of technologies.

Applications using the standard willingness to pay (WTP) approach (where a respondent is asked his/her WTP for each option) have brought to light inherent difficulties in terms of discriminating between various options. Although an incremental WTP approach (where a less preferred option is used as a point of reference to value more preferred options) has been devised to encourage more discrimination, a theoretical basis for this approach has not been elucidated, and results from initial testing of this approach have proved inconclusive. We offer a theoretical basis for this approach, based on the theory of reference dependent preferences. We test our model in a study assessing preferences for emergency care services in France. Our empirical findings are in line with our theoretical framework, showing the standard WTP approach fails to discriminate between alternative options for which there is a strict preference ranking. The incremental approach provides discriminating values and provides a better method for determining preferences in priority-setting and policy contexts.

No summary available.

Applications of willingness to pay (WTP) have shown the difficultly to discriminate between various options. This reflects the problem of embedding in both its specific sense, of options being nested within one another, and its more-general sense, whereby respondents cannot discriminate between close substitutes or between more-disparate rivals for the same budget. Furthermore, high proportions of reversals between WTP-value and simple preference based rankings of options are often highlighted. Although an incremental WTP approach was devised to encourage more differentiated answers and a higher degree of consistency among respondents, a theoretical basis for this approach has not been elucidated, and there is little evidence to show that this approach might indeed achieve greater consistency between explicit and implicit rankings inferred from WTP values. We address both these issues. Following our theoretical exposition, standard and incremental approaches were compared with explicit ranking in a study assessing preferences for different French emergency care services. 280 persons, representative of the French adult population, were interviewed. Half received the incremental version, the other half the standard version. Results suggest that the incremental approach provides a ranking of options fully in line with explicit ranking. The standard approach was reasonably consistent with explicit ranking but proved unable to differentiate between the five most preferred providers, as predicted by theory. Our findings suggest that the incremental approach provides results which can be used in priority-setting contexts.

Despite the claim that technology has been one of the most important drivers of healthcare spending growth over the past decades, technology variables are rarely introduced explicitly in cost equations. Furthermore, technology is often considered exogenous. Using 1996-2007 panel data on Swiss geographical areas, we assessed the impact of technology availability on per capita healthcare costs covered by basic health insurance while controlling for the endogeneity of health technology availability variables. Our results suggest that medical research, patent intensity and the density of employees working in the medical device industry are influential factors for the adoption of technology and can be used as instruments for technology availability variables in the cost equation. Our results are similar to previous findings: CT and PET scanner adoption is associated with increased healthcare costs while increased availability of PTCA facilities is associated with reductions in per capita spending. Nevertheless, our results suggest that the magnitude of these relationships is much greater in absolute value than that suggested by previous studies which did not control for the possible endogeneity of the availability of technologies.

Despite the claim that technology has been one of the most important drivers of healthcare spending growth over the past decades, technology variables are rarely introduced explicitly in cost equations. Furthermore, technology is often considered exogenous. Using 1996-2007 panel data on Swiss geographical areas, we assessed the impact of technology availability on per capita healthcare costs covered by basic health insurance while controlling for the endogeneity of health technology availability variables. Our results suggest that medical research, patent intensity and the density of employees working in the medical device industry are influential factors for the adoption of technology and can be used as instruments for technology availability variables in the cost equation. Our results are similar to previous findings: CT and PET scanner adoption is associated with increased healthcare costs while increased availability of PTCA facilities is associated with reductions in per capita spending. Nevertheless, our results suggest that the magnitude of these relationships is much greater in absolute value than that suggested by previous studies which did not control for the possible endogeneity of the availability of technologies.

Abstract Applications of willingness to pay (WTP) have shown the difficultly to discriminate between various options. This reflects the problem of embedding in both its specific sense, of options being nested within one another, and its more general sense, whereby respondents cannot discriminate between close substitutes or between more-disparate rivals for the same budget. Furthermore, high proportions of reversals between WTP-value and simple preference based rankings of options are often highlighted. Although an incremental WTP approach was devised to encourage more differentiated answers and a higher degree of consistency among respondents, a theoretical basis for this approach has not been elucidated, and there is little evidence to show that this approach might indeed achieve greater consistency between explicit and implicit rankings inferred from WTP values. We address both these issues. Following our theoretical exposition, standard and incremental approaches were compared with explicit ranking in a study assessing preferences for different French emergency care services. 280 persons, representative of the French adult population, were interviewed. Half received the incremental version, the other half the standard version. Results suggest that the incremental approach provides a ranking of options fully in line with explicit ranking. The standard approach was reasonably consistent with explicit ranking but proved unable to differentiate between the five most preferred providers, as predicted by theory. Our findings suggest that the incremental approach provides results which can be used in priority-setting contexts.

No summary available.

OBJECTIVE: RA and axial SpA have an important impact on patients' lives. The objective of this study was to explore the reporting of different aspects of that impact in publications, with a focus on differences between diseases and over time. METHODS: A systematic literature review retrieved all articles reporting on the life impact of RA or axial radiographic SpA in adults published within the last 10 years and issued from European research. The data were classified into physical impact (including pain, functional assessment and fatigue), psychological impact (including psychological distress and coping) and social impact (including relationships, family and social life). The number of articles published over time was analysed by linear regression. RESULTS: In all, 1352 abstracts were screened and 149 publications (40 056 patients) were analysed: 129 articles (86.5%) concerned RA and 16 (10.7%) concerned axial SpA. The mean number of articles reporting on the physical aspects of impact was 11.4 (s.d. 4.8) per 2-year period, but increased more than 2-fold (from 7 articles in 2001-3 to 15 in 2010-11), in particular due to recent publications on fatigue, whereas the number of articles on psychological aspects [mean 12.4 (s.d. 4.0)] decreased markedly after 2006. Publications reporting on social aspects [mean 8.2 (s.d. 4.1)] remained globally stable. CONCLUSION: In the era of biologics, there is an interest in the patient-perceived life impact of RA and axial SpA in the European literature, but the impact of RA has been the subject of greater exploration. There are clearly trends over time in the reporting of impact.

BACKGROUND: Allostatic load reflects cumulative exposure to stressors throughout lifetime and has been associated with several adverse health outcomes. It is hypothesized that people with low socioeconomic status (SES) are exposed to higher chronic stress and have therefore greater levels of allostatic load. OBJECTIVE: To assess the association of receiving social transfers and low education with allostatic load. METHODS: We included 3589 participants (1812 women) aged over 35years and under retirement age from the population-based CoLaus study (Lausanne, Switzerland, 2003-2006). We computed an allostatic load index aggregating cardiovascular, metabolic, dyslipidemic and inflammatory markers. A novel index additionally including markers of oxidative stress was also examined. RESULTS: Men with low vs. high SES were more likely to have higher levels of allostatic load (odds ratio (OR)=1.93/2.34 for social transfers/education, 95%CI from 1.45 to 4.17). The same patterns were observed among women. Associations persisted after controlling for health behaviors and marital status. CONCLUSIONS: Low education and receiving social transfers independently and cumulatively predict high allostatic load and dysregulation of several homeostatic systems in a Swiss population-based study. Participants with low SES are at higher risk of oxidative stress, which may justify its inclusion as a separate component of allostatic load.

Background. Allostatic load reflects cumulative exposure to stressors throughout lifetime and has been associated with several adverse health outcomes. It is hypothesized that people with low socioeconomic status (SES) are exposed to higher chronic stress and have therefore greater levels of allostatic load. Objective. To assess the association of receiving social transfers and low education with allostatic load. Methods. We included 3'589 participants (1'812 women) aged over 35 years and under retirement age from the population-based CoLaus study (Lausanne, Switzerland, 2003-2006). We computed an allostatic load index aggregating cardiovascular, metabolic, dyslipidemic and inflammatory markers. A novel index additionally including markers of oxidative stress was also examined. Results. Men with low vs high SES were more likely to have higher levels of allostatic load (Odds ratio (OR)=1.93/2.34 for social transfers/education,95%CI from 1.45 to 4.17). The same patterns were observed among women. Associations persisted after controlling for health behaviors and marital status. Conclusions. Low education and receiving social transfers independently and cumulatively predict high allostatic load and dysregulation of several homeostatic systems in a Swiss population-based study. Participants with low SES are at higher risk of oxidative stress, which may justify its inclusion as a separate component of allostatic load.

In this paper we investigate the possible presence of switching costs when consumers are offered the opportunity to change their basic health insurance provider. We focus on the specific case of Switzerland which implemented a pure form of competition in basic health insurance markets. We identify several barriers to switching, namely choice overload, status quo bias, the possession of supplementary contracts for enrollees in bad health, firm's pricing strategies based on providing low price supplementary products, poor regulation of reserves and the limitations of the previous risk-equalization mechanism which left room for risk selection practices.

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

This work develops an economic evaluation analysis in the health field in order to compare two therapeutic strategies. The method consists in observing behaviors in individual decision situations. We postulate that patient compliance behavior could be used as a tool to reveal preferences. The microeconomic model formalizes the hypothesis that adherence results from the patient's rational trade-off between the benefits and costs associated with treatment. The econometric specification evaluates the welfare gain from therapy and analyzes the determinants of good adherence while controlling for the fact that it influences health status. We estimate a simultaneous non-linear system on panel data from observations of an HIV clinical trial. The theoretical model and the empirical results suggest that a lower level of adherence implies that the cost-benefit ratio of the therapy is higher.