Research

Publications in peer-reviewed journals

[1] The Introduction of Pay-for-Performance: What Impact on General Practitioners' Activity in France? [Link]

with Brigitte Dormont and Anne-Laure Samson

in Économie et Statistique / Economics and Statistics, 2021.

Abstract : In 2009, a system of pay-for-performance (P4P) was offered to physicians in France via the Contrat d’Amélioration des Pratiques Individuelles (CAPI). This study assesses the causal impact of CAPI on their behaviour in terms of care provision. Based on a panel of general practitioners in private practice observed before (2005 and 2008) and after (2011) its introduction, we use an instrumental variables approach, applied to a model in first-differences in order to correct the endogeneity biases linked to the fact that signing up to CAPI is a choice. We show that, unlike other practitioners, those who have signed up to CAPI have not reduced their number of consultations per patient or the amount of prescriptions per patient. They have also increased, to a greater extent than others, the proportion of their patients who they treat as the primary care doctor(i.e. the médecin traitant). Moreover, CAPI has enabled them to increase their fees per patient with, as a consequence, a higher treatment cost for the Social Security system.

[2] Can financial incentives improve access to care? Evidence from a French experiment on specialist physicians [Link]

in Social Science & Medicine, 2024.

Abstract :

In France, addressing balance billing is essential for equitable healthcare access and reducing physician income disparities. The National Health Insurance (NHI) introduced financial incentive programs, namely the “Contract for Access to Care” (CAS) in 2014 and the “Option for Controlled Pricing” (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzed the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. The dataset comprised 9891 surgical specialists (30,972 observations) and 6926 medical specialists (21,650 observations) between 2005 and 2017.

Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" method, the study examined CAS and/or OPTAM membership effects on physicians' activity and fees. The results indicate that both the CAS and OPTAM successfully enhance access to care. Physicians treat more patients, particularly those with lower incomes who might have previously avoided care because of the extra fees. However, an increased patient load translates to a higher workload for physicians. Despite a fee increase, it was observed to be smaller than the surge in activity.

Furthermore, if all physicians are appropriately rewarded for their efforts, this improvement in access comes at a cost to NHI. This study's findings provide crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the tradeoff between improved access and increased NHI costs. Ultimately, these findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in pursuit of a more equitable healthcare system.

Work in progress

Abstract : This paper evaluates the impacts of balance billing restrictions on GPs and specialists' provision of care and fees using a French reform that restricted, in 1990, the possibility for some physicians to overbill. We use an exhaustive and administrative dataset on self-employed physicians practicing in France in 2008 and 2011 that we restrict to 5 specialists: technical specialists (dermatologists and otorhinolaryngologists), medical specialists (pediatricians and psychiatrists) as well as GPs. We use a fuzzy regression discontinuity design to estimate the causal impacts of price regulation on care provision and fees on a population of compliers, ie. on physicians who established practice in 1990 and who were constrained by the new regulation to charge regulated prices. Our results show that technical specialists and GPs react by providing more acts, and especially more surgical and non-surgical procedures for technical specialists. About half of this increase is directed at new patients, suggesting that lower prices increased access to care. On the contrary, medical specialists constrained to charge regulated fees experience a decrease in their prices, that
they do not compensate by an increase in their total level of activity.

[1] French physicians' response to balance billing restrictions with Anne-Laure Samson (Working paper upon request)

[3] Impact of unmet needs on the risk of falls among frail older adults in Europe with John McHugh, Thomas Rapp and Jonathan Sicsic

Submitted in a peer-reviewed journal

[4] A Scoping Review on Preferences towards Digital Health Technologies with Silvana Briones Piedrafita, Thomas Rapp and Jonathan Sicsic

Under review in a peer-reviewed journal

[5] A scoping review on digital therapeutics (DTx) with Pauline Chauvin, Thomas Rapp and Jonathan Sicsic