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.

Work in progress

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

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.

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

Under review (1st revision) in April 2024

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

Working paper soon !

[4] A scoping review on preferences towards medical innovations with Silvana Briones Piedrafita, Thomas Rapp and Jonathan Sicsic

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

Abstract : In France, addressing balance billing is essential for equitable access to healthcare and reducing income disparities among physicians. The National Health Insurance (NHI) introduced financial incentive programs, namely the “Contrat d'accès aux soins” (CAS) in 2014 and the “Option Pratique Tarifaire Maîtrisée” (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzes the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" (CEM) method, the study examines CAS and/or OPTAM membership effects on physicians' activity and fees. Results indicate that both CAS and OPTAM successfully enhanced access to care. Physicians treated more patients, particularly those with lower incomes who might have previously avoided care due to extra fees. However, the increased patient load translated 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 the NHI. The study provides crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the trade-off between improved access and increased costs for NHI. Ultimately, the findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in the pursuit of a more equitable healthcare system.