Brigitte Dormont

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.

Labor and investment demand at the firm level: A comparison of French, German and U.S. manufacturing, 1970-79

We investigate how labor and investment demand at the firm level (gross as well as net and replacement investment separately) differs in French, German and U.S. manufacturing, and has changed since the 1974–75 crisis. We use three consistent panel data samples of large firms for 1970–79, and rely on simple models of the accelerator-profits type. We find that the accelarator effects and the profits effects did not vary much between 1970–73 and 1976–79, and were quite comparable in the three countries, the former being of a more permanent nature and the latter more transitory. To a large extent these effects account for the important changes and differences in labor and investment demand between the two subperiods and across the three countries.

How to Regulate Heterogeneous Hospitals

In many areas of health care financing, there is controversy over the sources of cost variability and about the respective roles of inefficiency versus legitimate heterogeneity. This paper proposes a payment system that creates incentives to increase hospital efficiency when hospitals are heterogeneous, without reducing the quality of care. We consider an extension of Shleifers yardstick competition model and apply an econometric approach to identify and evaluate observable and unobservable sources of cost heterogeneity. Moral hazard can be seen as the result of two components :long-term moral hazard (hospital management can be permanently inefficient) and transitory moral hazard. The latter is linked to the managers transitory cost-reducing effort. For instance, he or she can be more or less rigorous each year when bargaining prices for supplies delivered to the hospital by outside firms. The use of a three-dimensional nested database makes it possible to identify transitory moral hazard and to estimate its effect on hospital cost variability. Econometric estimates are performed on a sample of 7,314 stays for acute myocardial infarction observed in 36 French public hospitals over the period 1994–1997. We obtain two alternative payment systems. The first takes all unobservable hospital heterogeneity into account, provided that it is time invariant, whereas the second ignores unobservable heterogeneity. Simulations show that substantial budget savings—at least 20%—can be expected from the implementation of such payment rules. The first method of payment has the great advantage of reimbursing high-quality care. It leads to substantial potential savings because it provides incentives to reduce costs linked to transitory moral hazard, whose influence on cost variability is far from negligible. This payment rule could be extended to other areas of health care financing, such as Adjusted Average Per Capita Cost to calculate Medicare Managed Care reimbursements in the United States.

Causes of Health Expenditure Growth: the Predominance of Changes in Medical Practices Over Population Ageing

On the basis of French individual data, this paper compares the effects of demographic change, changes in morbidity and changes in practices on the growth in health expenditures that occurred between 1992 and 2000. Micro simulations show that the rise in expenditures due to ageing is relatively small and that 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.

Equity in Health And Equivalent Incomes

We compare two approaches to measuring inequity in the health distribution. The first is the concentration index. The second is the calculation of the inequality in an overall measure of individual well-being, capturing both the income and health dimensions. We introduce the concept of equivalent income as a measure of well-being that respects preferences with respect to the trade-off between income and health, but is not subjectively welfarist since it does not rely on the direct measurement of happiness. Using data from a representative survey in France, we show that equivalent incomes can be measured using a contingent valuation method. We present counterfactual simulations to illustrate the different perspectives of the approaches with respect to distributive justice.

Looking for Labor Demand Heterogeneity

The aim of this paper is to examine whether the estimation of labor demand can be affected by individual behavior heterogeneity. We shall consider an error-components model with variable-coefficients, where the coefficients are random and vary accross firms according to the values of time constant explanatory variables and to a random firm-specific effect. The specification of labor demand which stems from the variable coefficients hypothesis is estimated by the generalized method of moments on a panel of 810 French manufacturing firms. Heterogeneities appear to be strongly significant. When the share of skilled workers is higher, the ajustment speed is lower and the influence of wages on labor demand decreases (in absolute value) as well as that of sector demand shocks. Moreover, a higher market-share leads to a smaller adjustment speed and to an increased influence of wages and industry

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.

Individual Uncertainty on Longevity

The aim of this paper is to provide an assessment of individual uncertainty regarding length of life. We have collected original data through a survey performed in 2009 on a representative sample of 3,331 French people aged 18 or more. The survey design recorded several survival probabilities per individual, which makes it possible to compute (i) subjective life expectancy, defined as the first moment of the individual’s subjective distribution of personal longevity; (ii) the standard error of this distribution, which provides insight on the individual’s uncertainty regarding his or her own longevity. There is considerable between-individual variability in subjective life expectancies, in (small) part explained by age, illnesses, risky behavior, parents’ death and socioeconomic variables. The second main finding is that individual subjective uncertainty about length of life is quite large, equal on average to more than 10 years for men and women. It is logically decreasing with age, but apart from age, very few variables are correlated with it. These results have important consequences for public health and retirement policy issues.

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.

Does it pay to be a general practitioner in France

The aim of this paper is to determine if the profession of GP is financially attractive in France. Using longitudinal data, we created two samples of 1,389 self-employed GPs and 4,825 salaried executives observed from 1980 to 2004. These two professions require high qualification levels, but the studies to become a GP are longer. To measure if GPs get returns that compensate for their investment in education, we analyze GPs.and executives.career profiles and construct a measure of individual wealth that takes into account all earnings from the age of 24, including years with no or low income for GPs before they set up their practice. Econometric analysis shows that after an initial period of patient recruitment, physicians experience a fatter career profile than executives. We also find that GP incomes for recent cohorts are favored by the low numerus clausus applied when they were in medical school. Stochastic dominance analysis shows that, for men, wealth distributions do not differ significantly between GPs and executives, but, for women, GP wealth distribution dominates executive wealth distribution at the first order. Hence, the relative return on medical studies is higher for women. While for men there is no monetary advantage or disadvantage in being a GP, for women, it is more profitable to be a GP than an executive. This can explain the large proportion of female GPs and the strong increase in the share of women among medical students.