Curriculum vitae

Dormont Brigitte

Professeur des universités

Brigitte.DORMONTping@dauphinepong.fr
Tel : 01 44 05 40 85
Bureau : P104bis

Publications

Articles

Dormont B., Péron M. (2016), Does Health Insurance Encourage the Rise in Medical Prices? A Test on Balance Billing in France, Health Economics

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

Dormont B., Samson A-L. (2015), Does it pay to be a general practitioner in France?, Annals of Economics and Statistics, 119-120, p. 149-178

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 salariedexecutives observed from 1980 to 2004. These two professions require high qualification levels,but studying to become a GP takes longer. To measure if GPs get returns that compensate fortheir investment in education, we analyze GPs' and executives' career profiles and construct ameasure of individual wealth that takes into account all earnings from the age of 24, includingyears 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 experiencea flatter career profile than executives. We also find that GP incomes for recent cohorts arefavored by the low numerus clausus applied when they were in medical school.Stochastic dominance analysis shows that, for men, wealth distributions do not differ significantlybetween GPs and executives, but, for women, GP wealth distribution dominates executive wealthdistribution 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 ismore profitable to be a GP than an executive. This can explain the large proportion of femaleGPs and the strong increase in the share of women among medical students.

Dormont B., Geoffard P-Y., Tirole J. (2014), Refonder l'assurance-maladie, Les Notes du Conseil d'analyse économique, 12, p. 12

Dormont B., Paris V., Askenazy P., Geoffard P-Y. (2013), Pour un système de santé plus efficace, Les Notes du Conseil d'analyse économique, 8, p. 12

Dormont B. (2013), Do we spend sufficiently for health care?, Médecine des maladies Métaboliques, 7, 3, p. 228–231

La croissance des dépenses de santé résulte principalement de la dynamique des innovations médicales, et non du vieillissement démographique. Dépensons-nous trop, ou pas assez, pour la santé ? Répondre à une telle question nécessite d'évaluer en unités monétaires la valeur créée par les gains en santé et en longévité obtenus en contrepartie de ces dépenses. Pour les États-Unis, les résultats obtenus suggèrent que les gains associés aux dépenses de soins seraient très largement supérieurs à leur coût. Au lieu de concevoir d'emblée les dépenses de santé comme un coût à comprimer, il est urgent d'organiser, en France, un débat public sur leur niveau désirable, c'est-à-dire conforme aux préférences collectives. Mais il est crucial de gagner en efficience : afin de favoriser l'adhésion des citoyens aux prélèvements obligatoires nécessaires à un système de couverture équitable, il faut améliorer l'organisation du système de soins et les arbitrages sur le panier de soins remboursés.

Health expenditure growth is mostly driven by the dynamic of medical innovations and not by population ageing. Do we spend too much, or not enough, for health care? To answer to such a question, one needs an evaluation in monetary units of the value of health and longevity gains obtained as a counterpart of health expenditures. Computations implemented for the United States of America show that benefits due to health care are much larger than their costs. Instead of conceiving health expenditure as a cost to reduce, there is an urgent need in France for a public debate about their optimal level, i.e. the level in accordance with citizen preferences. However, gains in efficiency play a key role: to favor citizen adherence to taxes that finance equality in coverage, it is of major importance to improve efficiency in health care provision and public decision regarding treatments that are reimbursed.

Dormont B., Milcent C. (2013), How to evaluate productivity and efficiency of public and private hospitals? The issue of price convergence, Economie et statistique, 455-456, p. 143-173

Dormont B., Geoffard P-Y., Lamiraud K. (2013), Health Insurance in Switzerland: Does Additional Insurance Affect Competition in the Basic Insurance?, Economie et statistique, 455-456, p. 71-87

De nombreux pays ont introduit des mécanismes concurrentiels en assurance maladie, tout en instaurant une régulation pour éviter la sélection des risques et garantir une solidarité entre malades et bien portants. Le modèle de la « concurrence régulée » est ainsi appliqué pour l'assurance maladie de base en Suisse, aux Pays-Bas, en Allemagne, en Israël. Il inspire la réforme de l'assurance maladie aux États-Unis. Cet article analyse le fonctionnement d'un tel système en considérant le cas de la Suisse, où l'on s'intéresse aux interférences potentielles entre le marché des assurances supplémentaires et celui de l'assurance de base. L'organisation actuelle de l'assurance maladie en France diffère de celle du système suisse. Mais la question d'une régulation du marché des assurances complémentaires pourrait être posée à terme. Douze ans après l'introduction de la concurrence régulée, les résultats observés en Suisse sont décevants. Bien que les écarts de primes constatés entre les compagnies d'assurance soient très importants, la proportion d'assurés qui changent de caisse reste faible. Tout se passe comme si les assurés ne faisaient pas jouer la concurrence. Notre analyse montre que la faible mobilité des assurés résulte de la coexistence de deux marchés d'assurance maladie soumis à des règles différentes : le marché de l'assurance de base, où la sélection des risques est interdite, et celui de l'assurance supplémentaire, où elle est autorisée. Les estimations montrent que la propension à changer de caisse est beaucoup plus faible chez les détenteurs d'une assurance supplémentaire qui estiment que leur santé n'est pas excellente. Comme il est préférable pour des raisons pratiques d'avoir son assurance de base et son assurance supplémentaire dans la même caisse, il existe un lien de fait entre les deux marchés. Le droit de sélectionner les candidats à la souscription pour l'assurance supplémentaire nuit à la concurrence sur l'assurance de base.

Dormont B., Jusot F. (2012), L'avenir de la protection sociale, Esprit, 384, p. 86-89

Samson A-L., Dormont B. (2011), Multiple effects of fee-for-service payment on general practitioners' income. Results of several econometric studies in France, Revue Française des Affaires Sociales, 2, 2-3, p. 156-179

Cet article propose une synthèse des connaissances sur les revenus des médecins en France, issues de travaux économétriques menés à partir d'un panel représentatif de médecins généralistes. Il examine l'influence du paiement à l'acte sur les comportements d'offre de soins et la régulation de la médecine ambulatoire. Nos estimations montrent l'impact décisif de la densité médicale sur les revenus des médecins : fortes disparités de rémunération en fonction du département ou de la région d'exercice, comportements de demande induite et influence durable de la démographie médicale au moment de l'installation (liée aux fluctuations du numerus clausus). Du fait de leur exercice libéral, les médecins ont, par ailleurs, une grande liberté dans l'allocation de leur temps de travail au cours de leur vie professionnelle, ce dont témoigne le profil atypique de leurs honoraires au cours de leur carrière ainsi que l'existence de médecins à faibles revenus. Enfin, en tenant compte de la longueur spécifique des études de médecine, nous montrons que les revenus cumulés des médecins, sur l'ensemble de leur carrière, sont d'un montant comparable à ceux des cadres supérieurs du secteur privé.

This article offers a synthesis of current knowledge concerning the income of doctors in France. Drawing on econometric studies of a representative panel of general practitioners, it examines the influence of fee-for-service payment on their health care supply behaviour and on outpatient medicine regulation. The authors highlight the crucial impact of local medical density on doctors' income : sharp discrepancies according to the district or region, supply-induced demand, lasting influence of medical demography when a doctor settles in a new area (depending on numerous clausus fluctuations). On the other hand, as independent operators, private doctors enjoy considerable freedom in terms of work schedules, as shown by their atypical and widely discrepant income profiles. Finally, factoring in the lengthy medical studies that doctors have to follow in their youth, the authors show that their cumulative comparable earnings over their entire career are comparable to those of senior managers in the private sector.

Dormont B. (2010), Le vieillissement ne fera pas exploser les dépenses de santé, Esprit, 366, p. 93-106

Dormont B. (2010), Liberté ou solidarité : le dilemme des complémentaires, Les Tribunes de la santé, 28, p. 65-74

Pour couvrir des dépenses de santé en croissance continue, la stratégie actuellement retenue en France consiste à geler le taux des prélèvements obligatoires et à élargir le champ des assurances complémentaires, tout en réaffirmant leur caractère facultatif. Mais il y a conflit entre la liberté individuelle de s'assurer et l'égalisation des conditions d'accès aux soins grâce à la mutualisation des risques. Il faut établir une distinction entre assurance supplémentaire (soins non essentiels pour la santé) et assurance complémentaire (soins de base). Pour une société comme la nôtre, qui décide de faire jouer la solidarité pour l'accès aux soins de base, l'assurance complémentaire doit être obligatoire et régulée de façon à exclure la segmentation des contrats et la sélection des risques. Le débat doit se concentrer sur la définition du panier de base et son évolution avec le progrès technique médical. Quels sont les services de santé auxquels tous doivent avoir accès ? Pour ces services, une société qui donne la priorité à la solidarité ne peut pas accorder la liberté de ne pas s'assurer.

The strategy currently adopted in France to deal with the ever-growing health expenditures is one of freezing compulsory deductions and broadening the scope of complementary insurance, while at the same time reaffirming that such insurance is optional. But individual freedom to take out insurance conflicts with using the mutualization of risk to ensure that all have equal access to health care. A distinction must be drawn between supplementary insurance (care that is not essential to health) and complementary insurance (basic health care). In a society such as France, which has decided to use the solidarity principle to underpin access to basic health care, complementary insurance must be compulsory, and so regulated as to rule out contract segmentation and risk selection. The debate must focus on defining the basic basket and the way it changes with technical progress in medicine. Which health care services must be available to all? For these services, a society that prioritizes solidarity cannot grant the freedom to choose not to be insured.

Dormont B. (2009), Un système si parfait ..., Regards croisés sur l'économie, 5, p. 11-26

Samson A-L., Dormont B. (2009), Démographie médicale et carrières des médecins généralistes : les inégalités entre générations, Economie et Statistique, 414, p. 3-30

En France, l'offre de soins ambulatoires est régulée depuis 1971 par le numerus clausus, qui fixe le nombre d'étudiants admis en deuxième année de médecine. Fixé initialement à 8 588 places, il n'a vraiment diminué qu'à partir de 1978, jusqu'à atteindre 3 500 places en 1993. L'arrivée des cohortes nombreuses du baby-boom et la faiblesse des restrictions initiales ont permis l'installation de générations nombreuses de médecins débutants. Ce n'est qu'à partir de 1987 (soit neuf ans après 1978, du fait de la durée des études médicales) que l'on observe un impact du numerus clausus sur le nombre de médecins débutants. Un panel représentatif des généralistes du secteur 1 sur la période 1983-2004 permet d'analyser les déterminants de leurs honoraires et l'impact des fluctuations du numerus clausus sur leurs carrières. La localisation et les revalorisations tarifaires ont un impact considérable sur les honoraires. Les profils de carrières des médecins diffèrent fortement de ceux des salariés : toutes choses égales par ailleurs, leurs honoraires progressent rapidement en début de carrière pour diminuer en moyenne dès la douzième année d'expérience. Tout se passe comme si les médecins préféraient concentrer leur effort au début de leur expérience professionnelle pour alléger ensuite leur charge de travail. Les honoraires des médecins dépendent fortement de la situation de la démographie médicale lors de leur installation. L'écart entre les honoraires permanents des différentes cohortes peut atteindre 20 %, toutes choses égales par ailleurs. Les cohortes installées dans les années 1980 subissent les impacts conjoints du baby-boom et d'un numerus clausus élevé : elles perçoivent les honoraires les plus faibles. La diminution du numerus clausus a permis d'améliorer la situation des cohortes ultérieures. Une comparaison des distributions d'honoraires en termes de dominance stochastique montre que les écarts liés à l'hétérogénéité non observée ne compensent pas les différences

Dormont B., Geoffard P-Y., Lamiraud K. (2009), The influence of supplementary health insurance on switching behaviour : evidence from Swiss data, Health Economics, 18, 11, p. 1339-1356

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.

Bahrami S., Holstein J., Chatellier G., Le Roux Y., Dormont B. (2008), Using administrative data to assess the impact of length of stay on readmissions : Study of two procedures in surgery and obstetrics, Revue d'épidémiologie et de santé publique, 56, 2, p. 79-85

Position du problème La mise en place de la tarification à l'activité pour les hôpitaux de court séjour pourrait entraîner une diminution des durées de séjour pour raisons financières. L'impact potentiel de ce phénomène sur la qualité des soins n'est pas connu. Les réadmissions identifiées à l'aide des données administratives hospitalières sont, pour certaines situations cliniques, des indicateurs de qualité des soins valides. Méthode Étude rétrospective du lien entre la durée de séjour et la survenue de réadmissions imprévues liées au séjour initial, pour les cholécystectomies simples et les accouchements par voie basse sans complication, à partir des données du programme de médicalisation des systèmes d'information de l'Assistance publique-Hôpitaux de Paris des années 2002 à 2005. Résultats Pour les deux procédures, la probabilité de réadmission suit une courbe en « J ». Après ajustement sur l'âge, le sexe, les comorbidités associées, l'hôpital et l'année d'admission, la probabilité de réadmission est plus élevée pour les durées de séjour les plus courtes : pour les cholécystectomies, odds ratio : 6,03 [IC95 % : 2,67-13,59] pour les hospitalisations d'un jour versus trois jours ; pour les accouchements, odds ratio : 1,74 [IC95 % : 1,05-2,91] pour les hospitalisations de deux jours versus trois jours. Conclusion Pour deux pathologies communes, les durées de séjour les plus courtes sont associées à des probabilités de réadmission plus élevées. L'utilisation routinière des données du programme de médicalisation des systèmes d'information peut permettre d'assurer le suivi de la relation entre la réduction de la durée de séjour et les réadmissions.

Background The prospective payment system for the French short-stay hospitals creates a financial incentive to reduce length of stay. The potential impact of the resulting decrease in length of stay on the quality of healthcare is unknown. Readmission rates are valid outcome indicators for some clinical procedures. Methods Retrospective study of the association between length of stay and unplanned readmissions related to the initial stay, for two procedures: cholecystectomy and vaginal delivery. Data Administrative diagnosis-related groups database of "Assistance publique-Hôpitaux de Paris", a large teaching hospital, for years 2002 to 2005. Results The risk of readmission according to length of stay, taking age, sex, comorbidity, hospital and year of admission into account, followed a J-shaped curve for both procedures. The probability of readmission was higher for very short stays, with odds ratios and 95% confidence intervals of 6.03 [2.67-13.59] for cholecystectomies (1- versus 3-night stays), and of 1.74 [1.05-2.91] for vaginal deliveries (2- versus 3-night stays). Conclusion For both procedures, the shortest lengths of stay are associated with a higher readmission probability. Suitable indicators derived from administrative databases would enable monitoring of the association between length of stay and readmissions.

Samson A-L., Dormont B. (2008), Medical demography and intergenerational inequalities in general practitioners' earnings, Health Economics, 17, 9, p. 1037-1055

This article examines the link between restrictions on the number of physicians and general practitioners' (GPs) earnings. Using a representative panel of 6016 French self-employed GPs over the years 1983-2004, we estimate an earnings function to identify experience, time and cohort effects. The estimated gap in earnings between good and bad cohorts can be as large as 25%. GPs who began their practices during the eighties have the lowest permanent earnings: they belong to the large cohorts of the baby-boom and face the consequences of an unlimited number of places in medical schools. Conversely, the decrease in the number of places in medical schools led to an increase in permanent earnings of GPs who began their practices in the mid-nineties. A stochastic dominance analysis shows that unobserved heterogeneity does not compensate for average differences in earnings between cohorts. These findings suggest that the first years of practice are decisive for a GP. If competition between physicians is too intense at the beginning of their careers, they will suffer from permanently lower earnings. To conclude, our results show that the policies aimed at reducing the number of medical students succeeded in buoying up physicians' permanent earnings.

Milcent C., Dormont B., Durand-Zaleski I., Steg P. (2007), Gender differences in hospital mortality and use of percutaneous coronary intervention in acute myocardial infarction : microsimulation analysis of the 1999 nationwide french hospitals database, Circulation, 115, 7, p. 833-839

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.

Huber H., Grignon M., Dormont B. (2006), Health expenditure growth : reassessing the threat of ageing, Health Economics, 15, 9, p. 947 - 963

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.

Huber H., Dormont B. (2006), Les causes de la croissance des dépenses de santé : la prédominance des changements de pratiques sur le vieillissement, Annales d'Economie et de Statistique, 83-84, p. 187-217

Cet article compare, sur données individuelles françaises, les effets sur la croissance des dépenses de santé, observée entre 1992 et 2000, des changements démographiques, des changements de pratiques médicales et des changements de morbidité. Des micro-simulations montrent que la croissance des dépenses attribuable au vieillissement est relativement faible. L'impact des changements de pratique est 3.8 fois plus élevé. En outre, les changements de morbidité induisent des économies qui compensent largement l'effet du vieillissement.

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.

Dormont B., Milcent C. (2005), How to regulate heterogeneous hospitals ?, Journal of Economics and Management Strategy, 14, 3, p. 591-621

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 Shleifer's 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 manager's 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.

Dormont B., Milcent C. (2005), Innovation diffusion under budget constraints : Microeconometric evidence on heart attack in France, Annales d'Economie et de Statistique, 79-80, p. 697-726

This paper studies the relationship between the diffusion of innovative procedures for the treatment of heart attack and distributions of the cost and length of hospital stays. Using a sample of 5,681 stays observed in French public hospitals, we use microsimulation techniques to highlight various effects on the shifts in the overall distribution of the costs and length of stays : (i) the effect of the adoption of new techniques by hospitals (between hospital diffusion) ; (ii) the effect of the diffusion of technological progress within hospitals ; (iii) the effect of changes in patients' characteristics (age, comorbidities). This decomposition approach is used in the studies on the relationship between education and income distribution where observed distributions are compared to counterfactual distributions built by replacing some estimated parameters with their counterparts estimated from another country or time period. Our work shows that between 1994 and 1997 hospitals faced two main causes of rises in costs : firstly, diffusion of technological progress, with increasing use of costly innovative procedures such as angioplasty ; secondly, patients'epidemiological state worsened, since they became older and had more secondary diagnoses. These two factors induced sizeable shocks in cost distribution. Over this period, French public hospitals were financed by a global budget, and their budgets increased very slowly. However, international comparison shows that diffusion of technological progress for AMI treatment was similar in France and in comparable countries. How did French hospitals deal with their financial constraints ? Our study shows that they greatly reduced the length of stays for patients at the bottom of the distribution. This reduction in the length of stays appears to have enabled hospitals to finance the diffusion of angioplasty. Obviously, such a strategy cannot be sustained in the long run without jeopardizing the quality of care.

Dormont B., Milcent C. (2004), The sources of hospital cost variability, Health Economics, 13, 10, p. 927-939

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.

Dormont B., Milcent C. (2004), Hospital payment systems : Taking heterogeneity into account, Annales d'Economie et de Statistique, 74, p. 47-82

Cet article étudie les coûts des hôpitaux publics français dans la perspective d'une réforme de la tarification. Des données à trois dimensions hôpital-séjour-année permettent d'identifier l'hétérogénéité non observée des hôpitaux et la composante de la variabilité du coût attribuable à l'aléa moral transitoire. Celle-ci, loin d'être négligeable, s'élève à 50 % de la variabilité des coûts due à l'hétérogénéité non observée des hôpitaux. Les simulations montrent que l'on peut attendre des économies budgétaires de 16 % environ de l'application d'une tarification qui prend en compte les hétérogénéités non observées entre les hôpitaux et n'élimine que l'aléa moral transitoire.

The purpose of this paper is to study hospital costs in the event of introduction of a Prospective Payment System in France. We use a nested three dimensional database (stays-hospitals-years) to identify hospital unobservable heterogeneity and a transitory moral hazard component of cost variability. Transitory moral hazard is about 50% of the standard error we estimate for cost variability due to permanent unobervable heterogeneity between hospitals. Simulations show that a cost reduction of about 16% can be expected from implementation of a payment system which allows for permanent unobserved heterogeneity and eliminates only transitory moral hazard.

Mairesse J., Dormont B. (1985), Labor and investment demand at the firm level: A comparison of French, German and U.S. manufacturing, 1970-79, European economic review, 28, 1-2, p. 201-231

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.

Ouvrages

Dormont B. (2009), Les dépenses de santé : une augmentation salutaire ?, Paris, Editions Rue d'Ulm, 78 p.

B. Dormont entend combattre l'idée selon laquelle les dépenses de santé vont croître du fait du vieillissement de la population. L'augmentation serait due, d'après elle, aux changements de pratiques dans la consommation des soins, laquelle tient en partie aux innovations médicales, ce qui entraîne une demande élargie de la part des patients.

Dormont B. (2007), Introduction à l'économétrie. 2e édition, Paris, Montchrestien, 518 p.

Les principes des méthodes économétriques présentés avec un commentaire visant à donner l'intuition des raisonnements effectués. Les notions introduites sont systématiquement illustrées d'exemples d'applications économétriques.

Chapitres d'ouvrage

Dormont B., Fleurbaey M., Luchini S., Schokkaert E., Thébaut C., Van de Voorde C. (2013), Equity in Health And Equivalent Incomes, in Rosa Dias P. (eds), Health and Inequality, Research on Economic Inequality, p. 131-156

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.

Dormont B. (2013), Comment améliorer la prise en charge de la dépendance ?, in Cohen D., Askenazy P. (dir.), 5 crises : 11 nouvelles questions d'économie contemporaine, Paris, Albin Michel, p. 629-633

Dormont B. (2011), Health insurance, efficiency and equity: French debates, in Schokkaert E., Van de Voorde C. (eds), Belgium's health care system. Should the communities/regions take it over? Or the sickness funds?, Brussels, Re-Bel e-book, p. 11

Dormont B., Oliveira Martins J., Pelgrin F., Suhrcke M. (2010), Health, Expenditure, Longevity and Growth, in Garibaldi P., Oliveira Martins J., van Ours J. (eds), Ageing, Health, and Productivity : The Economics of Increased Life Expectancy, London, Oxford University Press

Dormont B. (2010), Les dépenses de santé : une augmentation salutaire ?, in Cohen D., Askenazy P. (dir.), 16 nouvelles questions d'économie contemporaine, Paris, Albin Michel, p. 387-436

Dormont B. (2010), Comment financer les dépenses de santé?, in Cohen D., Askenazy P. (dir.), 16 nouvelles questions d'économie contemporaine, Paris, Albin Michel, p. 437-444

Dormont B. (2009), Vieillissement et dépenses de santé, in Tabuteau D., de Pouvourville G., Bras P-L. (dir.), Traité d'économie et de gestion de la santé, Paris, Les Presses de Sciences Po, p. 123-130

Communications

Dormont B., Péron M. (2014), Does health insurance encourage the rise in medical prices? A test on balance billing in France, AFSE 2015 64th Congress, Rennes, France

In this paper, we estimate the causal impact of a positive shock on supplementary health insurance coverage on the use of specialists who balance bill. For that purpose, we evaluate the impact on patients' behavior of a shock consisting of better coverage of balance billing, while controlling for supply side drivers, i.e. proportions of physicians who balance bill and physicians who do not. We use a panel dataset of 58,336 individuals observed between January 2010 and December 2012, which provides information, at the individual level, on health care claims and reimbursements provided by basic and supplementary insurance. Our data makes it possible to observe enrollees that are heterogeneous in their propensity to use physicians who balance bill. We observe them when they are all covered by the same supplementary insurer, with no coverage for balance billing, and after 5,134 of them switched to other supplementary insurers which offer better coverage. Our estimations show that better coverage contributes to a rise in medical prices by increasing the demand for specialists who balance bill. On the whole sample, we find that better coverage leads individuals to raise their proportion of consultations of specialists who balance bill by 9 %, which results in a 34 % increase in the amount of balance billing per consultation. However, the effect of supplementary health insurance clearly depends on the local supply side organization. The inflationary impact arises when specialists who balance bill are numerous and specialists who do not are relatively scarce. When people have a real choice between physicians, a coverage shock has no impact on the use of specialists who balance bill. When the number of specialists who charge the regulated fee is sufficiently high, there is no evidence of limits in access to health care, nor of an inflationary effect of supplementary coverage.

Samson A-L., Thébaut C., Dormont B., Fleurbaey M., Luchini S., Schokkaert E., Van de Voorde C. (2014), Using Equivalent Income Concept in Blood Pressure Lowering Drugs Assessment. How Include Inequality Aversion in Cost/Benefit Analysis?, HTAi 2014, Washington, United States

Health equivalent income concept [...]

Dormont B., Luchini S., Samson A-L., Schokkaert E., Thébaut C., Van de Voorde C. (2012), Fair Cost-Benefit Evaluation of Health Care: a Case Study of Blood Pressure Lowering Drugs in France, 34ème journée des économistes de la santé français, Reims, FRANCE

Milcent C., Dormont B. (2011), Ownership and Hospital Productivity : The Impact of Inefficiency and the Roles of Patient Characteristics and Production Characteristics, 8th World Congress on Health Economics, Toronto, Canada

The French hospital industry is one example of a market where public, private nonprofit and private for-profit hospitals co-exist in significant proportions. Recently, several administrative reports have shown that in France public and private nonprofit hospitals are more costly than for-profit hospitals, suggesting that productivity is rather low for the former. Defenders of public and nonprofit hospitals argue that this productivity gap is related to their mandate to deliver hospital care in relation to social welfare considerations. The purpose of this paper is to examine to what extent differences in stay composition might explain productivity differences between public, private nonprofit and private for-profit hospitals. The model of yardstick competition supposes that hospitals are identical and that any heterogeneity in cost for a stay in a given DRG derives from heterogeneity in cost reduction efforts provided by hospitals' managers. Actually, there are many other sources of cost heterogeneity, such as quality of care, patient characteristics, returns to scale, and scope economies. Dealing with adverse selection due to hospital heterogeneity is an important issue on the research agenda. However, most of the literature focuses on reimbursement of stays in a given DRG, without paying attention to the potential influence of the composition of stays that form the whole hospital activity. In order to satisfy needs, many governments put mandates on some hospitals (public or nonprofit) that are not shared by their for-profit counterparts. Should payments be adjusted for differences in the hospital production composition? This issue is of major importance when yardstick competition is implemented between hospitals with different mandates. In France, a prospective payment system with a fixed payment per stay was introduced in 2004 for all hospitals. Two payment schedules are used, one for nonprofit hospitals, one for private for profit hospitals. Currently, payments per stay in a given DRG are on average 27 % higher in the public and nonprofit sector. The current government is planning convergence of payments between the nonprofit and for profit sectors by 2018. Our purpose is to question the relevance of the convergence objective by analyzing the causes of productivity differences between hospital types. We use quasi-exhaustive information from an administrative file recording stays for acute care. The empirical analysis is performed on a panel of 1,604 French hospitals observed over the years 1998 to 2003: 642 are public, 126 private nonprofit and 836 private for-profit. For the year 2003, this database represents more than 13 millions stays, covering about 90 % of total discharges. Using a stochastic production frontier approach combined with hospital 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 (severity) and production characteristics (proportion of surgical stays). Once patient and production characteristics are taken into account, public hospitals appear to be more efficient than private hospitals. As a result, payment convergence would provide incentives for public hospitals to modify the types of care they supply.

Dormont B., Martin C. (2011), L'efficacité des EHPAD en France, 33è Journées des Économistes de la Santé Français, Clermont-Ferrand, France

L'efficacité-coût des EHPAD en France est étudiée en appliquant plusieurs méthodes d'analyse de frontière : estimation sur données en coupe par maximisation de vraisemblance et modèle de données de panel à erreurs composées. La robustesse des résultats est testée par comparaison avec une méthode de régression quantile. Cette étude nous fournit une estimation de l'impact de la qualité de la prise en charge, de la forme institutionnelle et de la taille des établissements sur leurs coûts.

Dormont B. (2011), Vieillissement et dépenses de santé, Conférences du Collège de France : "La mondialisation de la recherche. Compétition, coopérations, restructurations ", Paris, France

Samson A-L., Dormont B. (2010), Est-il profitable d'être médecin généraliste ? Carrières comparées des médecins généralistes et des cadres supérieurs, 59e Congrès de l'AFSE (Association Française de Science Economique), Nanterre, France

Dans cet article, nous évaluons le positionnement des médecins généralistes en comparant leurs revenus à ceux de salariés situés dans le haut de la hiérarchie salariale : les cadres supérieurs. Les syndicats de médecins évoquent régulièrement la durée des études de médecine, les responsabilités importantes et la durée du travail pour justifier un revenu plus élevé. Les revenus des médecins généralistes sont-ils vraiment insuffisants? Pour répondre à cette question, nous utilisons les données du panel d'omnipraticiens libéraux (CNAMTS) et du panel des déclarations annuelles des données sociales (INSEE), sur la période 1980-2004. Nous comparons la valeur des carrières des médecins et des cadres et mesurons l'avantage relatif à être médecin. Le manque à gagner des médecins en début de carrière, lié à des études plus longues, est-il compensé par leur supplément de revenus au cours de leur carrière? Nous suivons 7 cohortes de médecins et de cadres (une cohorte étant définie par l'année à laquelle l'individu a eu 24 ans), comprises entre 1978 et 1990. Nous montrons que les revenus des médecins ne dépassent ceux des cadres qu'à partir de l'âge de 34 ans. En examinant les différences de revenus cumulés, nous montrons que l'investissent dans les études consenti par les médecins généralistes ne devient rentable qu'à partir de l'âge de 43 ans. Jusqu'à l'âge de 50 ans (âge maximum observé dans nos données), il n'existe pas de différence significative dans la valeur des carrières des médecins et des cadres. Il n'existe donc aucun avantage financier à être médecin généraliste plutôt que cadre.

Dormont B., Samson A-L. (2009), Carrières comparées des médecins et des cadres supérieurs, 26èmes Journées de Microéconomie appliquée, Dijon, France

Dans cet article, nous évaluons le positionnement des médecins généralistes en comparant leurs revenus à ceux de salariés situés dans le haut de la hiérarchie salariale : les cadres supérieurs. Les syndicats de médecins évoquent régulièrement la durée des études de médecine, les responsabilités exercées par le praticien et la durée de son travail pour justi er un revenu plus élevé. Les revenus des médecins généralistes sont-ils vraiment insu¢ sants? Pour répondre à cette question, nous utilisons les données du panel d omnipraticiens libéraux (CNAMTS) et du panel des déclarations annuelles des données sociales (INSEE), sur la période 1984-2004. Nous comparons la valeur des carrières des médecins et des cadres et mesurons l avantage relatif à être médecin. Les études durent plus longtemps pour les médecins et ils débutent leur carrière plus tardivement que les cadres. Le manque à gagner des médecins en début de carrière est-il compensé par leur supplément de revenus au cours de leur carrière? L analyse montre qu il existe un très net avantage nancier à être médecin généraliste et que cet avantage s est accru au cours du temps. Sur l ensemble de leur carrière observée, les médecins des cohortes 1980 à 1985 gagnent, en moyenne, 4% de plus que les cadres; ce chi¤re s élève à 6% pour les médecins des cohortes 1986 à 1992 et à 81% pour les médecins des cohortes 1993 à 2003. L existence d une rente pour les médecins résulte du concours à l entrée des études de médecine. Cette rente a évolué positivement avec les restrictions sur le numerus clausus.

Dormont B., Oliveira Martins J., Pelgrin F., Suhrcke M. (2007), Health expenditures, longevity and growth, IX annual conference of the Fondazione Rodolfo de Benedetti on Health, longevity and productivity, Limone sul Garda, ITALY

This paper offers an integrated view of the relationships between health spending, medical innovation, health status, growth and welfare. Health spending triggers technological progress, which is a potential source of better outcomes in terms of longevity and quality of life, a direct source of growth for the bio-tech industries and an indirect source of growth through improved of human capital. The latter contributes to GDP per capita through two main channels: higher participation of the population in the labour force and higher labour productivity levels. In turn, income growth induces an increase in health expenditure, as richer countries tend to spend a higher share of their income on health. To analyse these interactions, the paper first focuses on demographic facts, disentangling the role of longevity and carrying out some 'thought experiments' on the indexation of active life on longevity. It then analyses the links between health care expenditures, technology and health status from a micro-level perspective. We investigate empirically the relation between GDP growth and health expenditures and develop a projection method to assess the size of total aggregate expenditures that could be channeled to the health sector up to 2050 for the US, Europe and Japan. We finally assess the potential impact of these health expenditures and better health status on potential growth and productivity.

Samson A-L., Dormont B. (2007), Régulation de la démographie médicale et carrières des médecins français : les inégalités entre générations, 56ème congrès annuel de l'AFSE (Association française de science économique), Paris, France

Documents de travail

Samson A-L., Dormont B. (2014), Does it pay to be a doctor in France?, Documents de travail du LEGOS, Paris, Université Paris Dauphine, 26

This paper examines whether general practitionersí(GPsí) earnings are high enough to keep this profession attractive. We set up two samples, with longitudinal data relative to GPs and executives. Those two professions have similar abilities but GPs have chosen a longer education. To measure if they get returns that compensate for their higher investment, we study their career proÖles and construct a measure of wealth for each individual that takes into account all earnings accumulated from the age of 24 (including zero income years when they start their career after 24). The stochastic dominance analysis shows that wealth distributions do not differ significantly between male GPs and executives but that GP wealth distribution dominates executive wealth distribution at the first order for women. Hence, while there is no monetary advantage or disadvantage to be a GP for men, it is more profitable for women to be a self-employed GP than a salaried executive.

Dormont B., Milcent C. (2012), Productivité et efficacité des hôpitaux publics et privés, Documents de travail, Paris, CEPREMAP, 45

En France les cliniques privées jouent un rôle important dans l'offre de soins hospitaliers. En 2007, 56% des séjours ont eu lieu dans des hôpitaux publics, 8% dans des hôpitaux privés à but non lucratifs, qui participent au service public hospitalier (PSPH) et 36 % dans des hôpitaux privés à but lucratif (cliniques). Plusieurs rapports administratifs ont récemment montré qu'un séjour dans un hôpital public ou PSPH était plus coûteux que dans une clinique privée, suggérant que la productivité du secteur public était relativement faible. Cet article a pour but de comprendre les différences de productivité observées en France entre les hôpitaux publics, les hôpitaux PSPH et les cliniques privées. L'introduction de la Tarification à l'Activité (T2A) en 2004 visait à améliorer l'efficacité de la dépense pour les soins hospitaliers. La mise en oeuvre du nouveau paiement est progressive, avec une application intégrale à partir de 2008. Dès le départ, les tarifs différaient selon que le séjour avait lieu dans un hôpital public ou un hôpital privé à but lucratif. Actuellement, les paiements par séjour dans une pathologie donnée sont en moyenne 27 % plus élevés dans le secteur public que dans le secteur privé. Une convergence des grilles tarifaires des secteurs public (et PSPH) et privé était prévue à l'horizon 2018. Cet objectif a été abandonné par le gouvernement élu en 2012. Mettre en place cette convergence reviendrait à supposer que les différences de coûts sont exclusivement dues à des différences d'efficacité, qui seraient éliminées par l'introduction d'une concurrence entre les deux secteurs. Notre objectif est d'examiner s'il existe une influence de la composition des séjours sur la productivité des hôpitaux en matière de soins aigus. Si tel est le cas, introduire de la concurrence entre les établissements sur la base de la T2A crée de fortes pressions en faveur d'une réorganisation de l'offre de soins. Ces changements sont souhaitables s'ils permettent d'améliorer l'efficacité dans la délivrance des soins hospitaliers. En revanche, il n'est pas souhaitable que le système de tarification crée des incitations à la sélection de patients ou à l'arrêt de la production de soins qui seraient importants du point de vue du bien-être collectif. Les données utilisées proviennent de deux bases administratives: les données du PMSI et celles de la SAE. La base finale contient 1 604 hôpitaux sur la période 1998-2003, dont 642 sont publics, 126 sont PSPH et 836 sont privés. Pour les soins aigus cette base est proche de l'exhaustivité : en 2003, elle représente 90% de l'ensemble des séjours de soins aigus en France métropolitaine. L'analyse couvre les six années précédant l'introduction de la T2A en France afin d'observer précisément la situation qui préexistait avant la mise en place de nouvelles incitations. Ce travail permet d'avoir un référentiel sur la situation du tissu hospitalier français et les performances comparées des établissements publics, PSPH et privés, avant la mise en place de la réforme. En synthétisant l'activité "multiproduit" de l'hôpital par un produit homogène défini selon des critères identiques, quel que soit le statut de l'hôpital, nous montrons que le diagnostic sur l'efficacité productive des hôpitaux publics dépend de la définition de la frontière de production : lorsque l'on utilise une fonction de production classique mettant en relation les inputs et l'output, les scores d'efficacité des hôpitaux publics sont inférieurs à ceux des hôpitaux PSPH, eux-mêmes inférieurs à ceux des cliniques privées. Mais l'ordre des performances relatives s'inverse lorsque l'on tient compte des caractéristiques de la patientèle et la composition des séjours des hôpitaux : à l'exception des petits établissements, les hôpitaux publics et PSPH apparaissent alors plus efficaces que les cliniques privées. Ces résultats doivent être interprétés à la lumière des différences de cahiers des charges encadrant les activités des hôpitaux publics et privés. Il est frappant de constater que la prise en compte d'indicateurs concernant la structure de l'activité et la composition de la patientèle modifie radicalement le diagnostic sur l'efficacité productive des hôpitaux publics. La plus faible productivité des hôpitaux publics s'explique principalement par le nombre de lits, des personnels médico-techniques en sureffectifs, la composition de leur patientèle et celle de leurs séjours (caractérisée entre autres par une faible proportion de séjours chirurgicaux). Elle ne s'explique pas par une moindre efficacité des hôpitaux publics.

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.

Samson A-L., Dormont B. (2011), Are GPs paid enough in France ?, Document de travail du LEDa-LEGOS, Paris, université Paris Dauphine, 10

Nous comparons la valeur actualisée des revenus cumulés des médecins généralistes et des cadres supérieurs sur les données individuelles, pour la période 1980-2004, du panel d'omnipraticiens libéraux (Cnamts) et du panel des Déclarations Annuelles des Données Sociales (Insee). Nous trouvons que les médecins généralistes libéraux ont des revenus cumulés de même niveau que ceux des cadres supérieurs du privé. Ce résultat est obtenu en sélectionnant le haut de la hiérarchie des cadres supérieurs, en tenant compte de la durée spécifique des études médicales et en comparant pour les deux professions la valeur actualisée des flux de revenus nets cumulés entre 24 et 50 ans. Il est maintenu si l'on simule les carrières jusqu'à l'âge de 60 ans.

Using a representative panel of French GPs and a representative panel of French top executives observed both between 1980 and 2004, we compare the discounted value of cumulated earnings of GPs and top executives over their career. We take into account that GPs begin their career later than top executives, given the length of their studies. We find no monetary advantage to be a GP: there is no significant difference between the discounted cumulated earnings of GPs and top executives between 24 and 50 years old. This result is maintained when we simulate the careers until the age of 60.

Dormont B., Samson A-L. (2007), Intergenerational inequalities in GPs' earnings: experience, time and cohort effects, Institute of Health Economics and Management (IEMS), Working Papers, Lausanne, University of Lausanne, 26

This paper analyses the regulation of ambulatory care and its impact on physicians'careers, using a representative panel of 6; 016 French self-employed GPs over the years 1983 to 2004. The beginning of their activity is influenced by the regulated number of places in medical schools, named in France numerus clausus. We show that the policies aimed at manipulating the numerus clausus strongly affect physiciansípermanent level of earnings. Our empirical approach allows us to identify experience, time and cohort effects in GPs'earnings. The estimated cohort e§ect is very large, revealing that intergenerational inequalities due to fluctuations in the numerus clausus are not negligible. GPs beginning during the eighties have the lowest permanent earnings : they faced the consequences of an unlimited number of places in medical schools in the context of a high density due to the baby-boom numerous cohorts. Conversely, the decrease in the numerus clausus led to an increase in permanent earnings of GPs who began their practice in the mid nineties. Overall, the estimated gap in earnings between "good" and "bad" cohorts may reach 25%. We performed a more thorough analysis of the earnings distribution to examine whether individual unobserved heterogeneity could compensate for average differences between cohorts. Our results about stochastic dominance between earnings distributions by cohort show that it is not the case.

Dormont B., Grignon M., Huber H. (2005), Health expenditures and the demographic rhetoric : reassessing the threat of ageing, Institute of Health Economics and Management (IEMS), Working papers, Lausanne, University of Lausanne, 43

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