Is it legitimate to use unplanned hospitalizations as a quality indicator for cancer patients? A retrospective French cohort study with special attention to the influence of social deprivation.

PURPOSE: Readmission indicators are used around the world to assess the quality of hospital care. We aimed to assess the relevance of this type of indicator in oncology, especially for socially deprived patients. Our objectives were (1) to assess the proportion of unplanned hospitalizations (UHs) in cancer patients, (2) to assess the proportion of UHs that were avoidable, i.e., related to poor care quality, and (3) to analyze cancer patients the effect of patients' deprivation level on the type of UH (avoidable UHs vs. unavoidable UHs). METHODS: In a French university hospital, we selected all hospitalizations over a year for a random sample of cancer patients. Based on medical records, we identified those among UHs due to avoidable health problems. We assessed the association between social deprivation, home-to-hospital distance, or home-to-general practitioner with the type of UH (avoidable vs. unavoidable) via a multivariate binary logit estimation. RESULTS: Among 2349 hospitalizations (355 patients), there were 383 UHs (16 %), among which 38% were avoidable. Among UHs, the European Deprivation Index was significantly associated with the risk of avoidable UHs, with a lower risk of avoidable UH for patients with medium or high social deprivation. CONCLUSION: Our results suggest that the use of UHs rate as a quality indicator is questionable in oncology. Indeed, the majority of UHs were not avoidable. Furthermore, within UHs, those involving patients with medium or high social deprivation are more often unavoidable in comparison with other patients.

Does the opening of an emergency department influence hospital admissions? Evidence from French private hospitals.

Although operating an emergency department (ED) can influence general admission activity of hospitals, most articles that analyze hospital care ignore the potential spillover of emergency activity. In this paper, we examine the consequences of a French reform that encouraged the creation of EDs within private-for-profit (PFP) hospitals in order to decrease congestion in EDs. We use administrative panel data on 365 French PFP hospitals observed between 2002 and 2012. Specifications including hospital fixed-effects are estimated to examine the impact of an ED opening on private hospitals' admission activity, namely inpatient and day-care admissions (ED visits are excluded, but patients admitted following an ED visit are included). We control for shocks that can impact demand for care in hospitals, and we estimate yearly changes before and after the opening. We find that an ED opening is followed by an increase in the number and proportion of inpatient admissions, and by an increase in the length of inpatient stays. A transitory increase in the bed occupancy rate is also observed. In many countries, public and private hospitals compete to some extent. The former provide a public service, while the latter are profit-maximizers that are allowed to specialize in profitable activities. They generally focus on day-care admissions. We provide empirical evidence that private hospitals experience a significant change in the composition of their admissions when they start providing emergency care. Opening an ED creates a new non-selective entryway to private hospitals, resulting in admissions of inpatients with health problems that are more severe. Hence, involving PFP hospitals in the provision of emergency care is likely to make the structure of admissions of private hospitals closer to that of public hospitals.

Does higher perceived risk of morbidity and mortality decrease risk-taking?

Previous studies have shown that people change their behaviour in response to negative shocks such as economic downturns or natural catastrophes. Indeed, the optimal behaviour in terms of inclusive fitness often varies according to a number of parameters, such as the level of mortality risk in the environment. Beyond unprecedented restrictions in everyday life, the COVID-19 pandemic has profoundly affected people's environment. In this study, we investigated how people form their perception of morbidity and mortality risk associated with COVID-19 and how this perception in turn affects psychological traits, such as risk-taking and patience. We analysed data from a large survey conducted during the first wave in France on 3353 nationally representative people. We found that people use public information on COVID-19 deaths in the area where they live to form their perceived morbidity and mortality risk. Using a structural model approach to lift endogeneity concerns, we found that higher perceived morbidity and mortality risk increases risk aversion. We also found that higher perceived morbidity and mortality risk leads to less patience, although this was only observed for high levels of perceived risk. Our results suggest that people adapt their behaviour to anticipated negative health shocks, namely the risk of becoming sick or dying of COVID-19.

Individual Uncertainty About Longevity.

This article presents an assessment of individual uncertainty about longevity. A survey performed on 3,331 French people enables us to record several survival probabilities per individual. On this basis, we compute subjective life expectancies (SLE) and subjective uncertainty regarding longevity (SUL), the standard deviation of each individual's subjective distribution of her or his own longevity. It is large and equal to more than 10 years for men and women. Its magnitude is comparable to the variability of longevity observed in life tables for individuals under 60, but it is smaller for those older than 60, which suggests use of private information by older respondents. Our econometric analysis confirms that individuals use private information-mainly their parents' survival and longevity-to adjust their level of uncertainty. Finally, we find that SUL has a sizable impact, in addition to SLE, on risky behaviors: more uncertainty on longevity significantly decreases the probability of unhealthy lifestyles. Given that individual uncertainty about longevity affects prevention behavior, retirement decisions, and demand for long-term care insurance, these results have important implications for public policy concerning health care and retirement.

Fairness in cost-benefit analysis: A methodology for health technology assessment.

We evaluate the introduction of various forms of antihypertensive treatments in France with a distribution-sensitive cost-benefit analysis. Compared to traditional cost-benefit analysis, we implement distributional weighting based on equivalent incomes, a new concept of individual well-being that does respect individual preferences but is not subjectively welfarist. Individual preferences are estimated on the basis of a contingent valuation question, introduced into a representative survey of the French population. Compared to traditional cost-effectiveness analysis in health technology assessment, we show that it is feasible to go beyond a narrow evaluation of health outcomes while still fully exploiting the sophistication of medical information. Sensitivity analysis illustrates the relevancy of this richer welfare framework, the importance of the distinction between an ex ante and an ex post approach, and the need to consider distributional effects in a broader institutional setting.

Does Health Insurance Encourage the Rise in Medical Prices? A Test on Balance Billing in France.

We evaluate the causal impact of an improvement in insurance coverage on patients' decisions to consult physicians who charge more than the regulated fee. We use a French panel data set of 43,111 individuals observed from 2010 to 2012. At the beginning of the period, none of them were covered for balance billing; by the end, 3819 had switched to supplementary insurance contracts that cover balance billing. Using instrumental variables to deal with possible non-exogeneity of the decision to switch, we find evidence that better coverage increases demand for specialists who charge high fees, thereby contributing to the rise in medical prices. People whose coverage improves increased their average amount of balance billing per consultation by 32%. However, the impact of the coverage shock depends on the supply of physicians. For people residing in areas where few specialists charge the regulated fee, better coverage increases not only prices but also the number of consultations, a finding that suggests that balance billing might limit access to care. Conversely, in areas where patients have a genuine choice between specialists who balance bill and those who do not, we find no evidence of a response to better coverage. Copyright © 2016 John Wiley & Sons, Ltd.

The influence of supplementary health insurance on switching behaviour: evidence from Swiss data.

This paper focuses on the switching behaviour of enrolees in the Swiss basic health insurance system. Even though the new Federal Law on Social Health Insurance (LAMal) was implemented in 1996 to promote competition among health insurers in basic insurance, there is limited evidence of premium convergence within cantons. This indicates that competition has not been effective so far, and reveals some inertia among consumers who seem reluctant to switch to less expensive funds. We investigate one possible barrier to switching behaviour, namely the influence of supplementary insurance. We use survey data on health plan choice (a sample of 1943 individuals whose switching behaviours were observed between 1997 and 2000) as well as administrative data relative to all insurance companies that operated in the 26 Swiss cantons between 1996 and 2005. The decision to switch and the decision to subscribe to a supplementary contract are jointly estimated.Our findings show that holding a supplementary insurance contract substantially decreases the propensity to switch. However, there is no negative impact of supplementary insurance on switching when the individual assesses his/her health as 'very good'. Our results give empirical support to one possible mechanism through which supplementary insurance might influence switching decisions: given that subscribing to basic and supplementary contracts with two different insurers may induce some administrative costs for the subscriber, holding supplementary insurance acts as a barrier to switch if customers who consider themselves 'bad risks' also believe that insurers reject applications for supplementary insurance on these grounds. In comparison with previous research, our main contribution is to offer a possible explanation for consumer inertia. Our analysis illustrates how consumer choice for one's basic health plan interacts with the decision to subscribe to supplementary insurance.

Gender differences in hospital mortality and use of percutaneous coronary intervention in acute myocardial infarction: microsimulation analysis of the 1999 nationwide French hospitals database.

BACKGROUND: Women with acute myocardial infarction have a higher hospital mortality rate than men. This difference has been ascribed to their older age, more frequent comorbidities, and less frequent use of revascularization. The aim of this study is to assess these factors in relation to excess mortality in women. METHODS AND RESULTS: All hospital admissions in France with a discharge diagnosis of acute myocardial infarction were extracted from the national payment database. Logistic regression on mortality was performed for age, comorbidities, and coronary interventions. Nonparametric microsimulation models estimated the percutaneous coronary intervention and mortality rates that women would experience if they were "treated like men." Data were analyzed from 74,389 patients hospitalized with acute myocardial infarction, 30.0% of whom were women. Women were older (75 versus 63 years of age; P<0.001) and had a higher rate of hospital mortality (14.8% versus 6.1%; P<0.0001) than men. Percutaneous coronary interventions were more frequent in men (7.4% versus 4.8%; 24.4% versus 14.2% with stent; P<0.001). Mortality adjusted for age and comorbidities was higher in women (P<0.001), with an excess adjusted absolute mortality of 1.95%. Simulation models related 0.46% of this excess to reduced use of procedures. Survival benefit related to percutaneous coronary intervention was lower among women. CONCLUSIONS: The difference in mortality rate between men and women with acute myocardial infarction is due largely to the different age structure of these populations. However, age-adjusted hospital mortality was higher for women and was associated with a lower rate of percutaneous coronary intervention. Simulations suggest that women would derive benefit from more frequent use of percutaneous coronary intervention, although these procedures appear less protective in women than in men.

Health expenditure growth: reassessing the threat of ageing.

In this paper we evaluate the respective effects of demographic change, changes in morbidity and changes in practices on growth in health care expenditures. We use microdata, i.e. representative samples of 3441 and 5003 French individuals observed in 1992 and 2000. Our data provide detailed information about morbidity and allow us to observe three components of expenditures: ambulatory care, pharmaceutical and hospital expenditures. We propose an original microsimulation method to identify the components of the drift observed between 1992 and 2000 in the health expenditure age profile. On the one hand, we find empirical evidence of health improvement at a given age: changes in morbidity induce a downward drift of the profile. On the other hand, the drift due to changes in practices is upward and sizeable. Detailed analysis attributes most of this drift to technological innovation. After applying our results at the macroeconomic level, we find that the rise in health care expenditures due to ageing is relatively small. The impact of changes in practices is 3.8 times larger. Furthermore, changes in morbidity induce savings which more than offset the increase in spending due to population ageing.

The sources of hospital cost variability.

Hospital heterogeneity is a major issue in defining a reimbursement system. If hospitals are heterogeneous, it is difficult to distinguish which part of the differences in costs is due to cost containment efforts and which part cannot be reduced, because it is due to other unobserved sources of hospital heterogeneity. In this paper, we apply an econometric approach to analyse hospital cost variability. We use a nested three-dimensional database (stays-hospitals-years) in order to explore the sources of variation in hospital costs, taking into account unobservable components of hospital cost heterogeneity. The three-dimensional structure of our data makes it possible to identify transitory and permanent components of hospital cost heterogeneity. Econometric estimates are performed on a sample of 7314 stays for acute myocardial infarction (AMI) observed in 36 French public hospitals over the period 1994-1997. Transitory unobservable hospital heterogeneity is far from negligible: its estimated standard error is about 50% of the standard error we estimate for cost variability due to permanent unobservable heterogeneity between hospitals.

Fixed fees and physician-induced demand: a panel data study on French physicians.

This paper investigates on the existence of physician-induced demand (PID) for French physicians. The test is carried out for GPs and specialists, using a representative sample of 4500 French self-employed physicians over the 1979-1993 period. These physicians receive a fee-for-services (FFS) payment and fees are controlled. The panel structure of our data allows us to take into account unobserved heterogeneity related to the characteristics of physicians and their patients. We use generalized method of moments (GMM) estimators in order to obtain consistent and efficient estimates. We show that physicians experience a decline of the number of consultations when they face an increase in the physician:population ratio. However this decrease is very slight. In addition, physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care.