FRANC Carine

This thesis makes three major contributions. The first chapter, an article published in the Revue Française d'Économie n°2/vol XXXIV, proposes a review of the literature on the implications of the regulation of genetic predisposition tests on the health insurance market. We show that current forms of regulation perform a trade-off between maximizing social welfare ex ante and encouraging prevention. This trade-off is conditioned by the way in which the acquisition of information affects agents' prevention and disclosure behaviors, the discrimination of risks by insurers, and the nature of contracts. The second chapter theoretically studies the impact of reclassification on prevention, the decision to test, and social welfare in mandatory disclosure regulation. In particular, we show that as a function of the cost of the prevention effort the individual value of genetic information with reclassification can be higher than without reclassification. In addition, we show how temporal preferences affect the individual value of genetic information. According to our results, social welfare is strictly higher without reclassification than with reclassification. The last chapter studies and characterizes incentive contracts that can be implemented to develop personalized medicine with highly effective treatments, in a context of moral hazard on the firm's effort to improve the effectiveness of the drug. We consider a model in which the health authority has three options. It can apply the same treatment (standard or new treatment) to the whole population or implement personalized medicine, i.e. use genetic information to propose the most appropriate treatment for each patient. We first characterize the drug reimbursement contract of a company producing a new treatment with a companion genetic test when the company can undertake an effort to improve drug quality. Second, we determine the conditions under which personalized medicine should be implemented when this effort is observable and when it is not. Finally, we show how the unobservability of the effort affects the health authority's decision to implement personalized medicine with highly effective treatments.

France has first experimented, in 2009, and then generalized a practice level add-on payment to promote Multi-Professional Primary Care Groups (MPCGs). Team-based practices are intended to improve both the efficiency of outpatient care supply and the attractiveness of medically underserved areas for healthcare professionals. To evaluate its financial attractiveness and thus the sustainability of MPCGs, we analyzed the evolution of incomes (self-employed income and wages) of General Practitioners (GPs) enrolled in a MPCG, compared with other GPs. We also studied the impacts of working in a MPCG on GPs’ activity through both the quantity of medical services provided and the number of patients encountered. Our analyses were based on a quasi-experimental design, with a panel dataset over the period 2008–2014. We accounted for the selection into MPCG by using together coarsened exact matching and difference-in-differences (DID) design with panel-data regression models to account for unobserved heterogeneity. We show that GPs enrolled in MPCGs during the period exhibited an increase in income 2.5% higher than that of other GPs. there was a greater increase in the number of patients seen by the GPs’ (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 showed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014. Hence, our results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

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Since January 1, 2016, private sector employers are obliged to offer and partially finance a complementary health insurance to all their employees. In this work, we simulate the welfare gains and losses to be expected from this reform on the whole population by mobilizing the expected utility theory. The results show that the reform increases collective welfare if and only if wages and premiums of the contracts remain unchanged. If we assume that individual contract premiums increase as a result of the ANI, the impact of the reform on collective welfare is almost zero. The gain in welfare of employees who benefit from the reform is then counterbalanced by the loss of welfare suffered by those covered on an individual basis or who are obliged by the reform to take out insurance. If we also consider that employers include the amount of their subsidy in their salaries, the ANI strongly reduces collective welfare.

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Using an exhaustive database, restricted to general practitioners working in private practice between 2005 and 2011, this article studies the determinants of their choice of location within a region, distinguishing four zones: suburban, central city, isolated city, and rural. While individual variables have relatively little influence on the choice of a zone, the characteristics of the local supply and demand for care, the tax exemptions that may be offered and the facilities available in each zone significantly explain their choice. These results are used to simulate the impact of three measures aimed at increasing the number of GPs setting up in rural areas.

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In any fee-for-service system, doctors may be encouraged to increase the number of services (private activity) they provide to receive a higher income. Studying private activity determinants helps to predict doctors’ provision of care. In the context of strong feminization and heterogeneity in general practitioners’ (GP) behavior, we first aim to measure the effects of the determinants of private activity. Second, we study the evolution of these effects along the private activity distribution. Third, we examine the differences between male and female GPs. From an exhaustive database of French GPs working in private practice in 2008, we performed an ordinary least squares (OLS) regression and quantile regressions (QR) on the GPs’ private activity. Among other determinants, we examined the trade-offs within the GPs’ household considering his/her marital status, spousal income, and children. While the OLS results showed that female GPs had less private activity than male GPs (−13 %), the QR results emphasized a private activity gender gap that increased significantly in the upper tail of the distribution. We also find gender differences in the private activity determinants, including family structure, practice characteristics, and case-mix variables. For instance, having a youngest child under 12 years old had a positive effect on the level of private activity for male GPs and a negative effect for female GPs. The results allow us to understand to what extent the supply of care differs between male and female GPs. In the context of strong feminization, this is essential to consider for organizing and forecasting the GPs’ supply of care.

Shortly after a special issue already devoted to this theme in 2012, the present issue of Economics and Statistics returns to the issue of health. It brings together a selection of articles from the 35 Journées des économistes de la santé français (JESF) held at the Université Paris-Est Créteil in December 2013. These days regularly result in the publication of a special issue devoted to health in a peer-reviewed journal. After the Revue Économique and, on two occasions, the journal Économie Publique, it is the turn of Économie et Statistique to host these proceedings. The fact that this subject has been taken up again at such short notice is obviously due to its importance, both socially and fiscally, and we will come back to this in a first step. But the precedent for the journal is not limited to this special issue of 2012: the theme of "health" has always had a regular and important presence. After an overview of the data available to shed light on this theme, we will detail how each of the articles in this issue drew on this mass of data, whether or not they fall within the strict domain of official statistics, and what messages could be drawn from them.

Background: In France, equality in access to screening has been one of the main thrusts of public policies implemented between 2009 and 2013 (the national cancer plan). Our aim in this study was to analyse the obstacles to and levers for breast, cervical, and colorectal cancer screening uptake and their trends over time. Methods: Based on representative data from the French Health Care and Health Insurance Survey (three independent, cross-sectional surveys: 2006, 2008, and 2010), multivariate logistic regressions were used to model the association between the nonuse of screening for the three cancers and various independent variables. Then, interactions with survey year dummies allowed the changes in the determinants of these cancer screenings over time to be estimated. Results: Whereas the incentives for screening were strengthened during the period considered, cervical and breast cancer screenings decreased, and colorectal cancer screenings increased sharply (from 18.2% (95% CI = [17.0-19.4]) in 2006 to 38.9% (95% CI = [37.4-40.5] in 2010. Under-users of the three cancer screenings were primarily unskilled workers (OR cervix = 1.64 [1.38-1.95]), individuals without complementary health insurance (OR breast = 2.05 [1.68-2.51]), or individuals with free complementary health insurance who more rarely use outpatient care. Moreover, individuals reporting either risky behaviours, namely heavy smokers (OR colorectal = 1.70) and high-risk drinkers (OR cervix = 1.42) or very safe behaviours, namely neither smoking nor drinking, underused screenings. Despite the implementation of national programmes for breast and colorectal cancer screenings, the disparities and inequalities in screening uptake did not decrease over the study period. Conclusions: These results demonstrate the need for additional primary prevention efforts targeting the identified under-users by focusing on, for instance, individuals with a very healthy lifestyle. Health authorities could also intensify their efforts to promote increased access to screening for the most disadvantaged individuals.

The objective of this article is to study the impact of the TFR on the share of the wholesaler's margin allocated to the pharmacist and on the substitution effort between brand and generic. We consider a situation in which the generic company sells its generic directly to the pharmacist and the brand company sells its originator through a wholesaler. We assume that the products are vertically differentiated and we solve a two-stage game. In the first stage, the generic company determines the share of the wholesaler's margin that it gives to the pharmacist in order to induce substitution and, if a flat rate of responsibility is introduced, the firms compete on price. In the second stage, the pharmacist chooses his substitution effort. We show that the introduction of the FIT increases the share of the wholesaler's margin allocated to the pharmacist by the generic company, but decreases the pharmacist's substitution effort.