Le résumé en français n'a pas été communiqué par l'auteur. / Le résumé en anglais n'a pas été communiqué par l'auteur.

Le résumé en français n'a pas été communiqué par l'auteur. / This thesis investigates several topics in health economics, and each of the three chapters is a self-contained paper. It aims to contribute to the design of health care systems and provides suggestions to policy makers. The first two chapters comes from my job market paper entitled "Reference Dependent Decisions on Noncommunicable Diseases: Prevention, Treatment and Optimal Health Insurance". In Chapter 1, I develop a reference dependent theory that accounts for people’s decisions on their prevention and treatment of noncommunicable diseases. Patients are predicted to have the same willingness to pay for the treatment of NCDs, and to go bankrupt if the willingness to pay exceeds their income.It imposes more realistic assumptions of health decisions, and the reference dependent theory better fits people’s decision patterns regarding NCDs. It also leads to different policy implications regarding the design of social insurance. Chapter 2 is the application of the theory in the design of social health insurance. It investigates how individuals with reference dependent preferences respond to various forms of social insurance. It shows that health insurance with copays can either encourage or discourage prevention, even when the efforts are not observable to the insurance provider. Moreover, deductible insurance is found to be financially unfeasible with ex-post moral hazard. The chapter then derives the analytical results of optimal social health insurance with the presence of ex-ante and ex-post moral hazard. The inverse relationship between income and prevention serves as a justification of redistribution. The third chapter, co-authored with Catarina Goulão, studies the impact of patient mobility on different health care systems that compete using waiting time and price respectively. We use a Hotelling model with two regions with different types of public health care systems to study the impact of patient mobility on their interaction, and on the regional welfare. We first characterize the autarky scenarios where patient mobility is no allowed, and shows that price and waiting time have different welfare impacts on regional welfare. We then explore equilibrium price and waiting time if patient mobility is allowed, and compare with the autarky scenario, and discuss the possible impacts on regional welfare.

Le résumé en français n'a pas été communiqué par l'auteur. / This dissertation consists of four essays on health and demographic economics. In the first chapter, I explore the implementation of the theory of equality of opportunity (EOp) developed by Roemer (1998) to health in a joint work with Guillem Lopez and Frederic Udina. A common impediment to the achievement of EOp applications with given resources constraints is that it is unlikely that public policies can fully compensate for existing unfair inequalities. This scenario is particularly relevant in the case of health policy, where public spending coexists with a large private spending component. We argue that if social justice is not attainable, social deliberation should not only focus on choosing the circumstances that ought to be compensated but also reflect on which groups suffering unfair inequalities should be prioritized. The second chapter examines the impact of income-related reporting heterogeneity on the measurement of health inequality. While most studies of health inequality rely on self-reported measures of health, recent research has studied the possibility that part of the existing differences in self-reported health could be due to systematic differences in reporting across socioeconomic groups. The concern is that part of the existing inequalities may not be founded on differences in the “true” health status of individuals. In particular, some studies have concluded that reliance on self-reported health might have resulted in an overstatement on the degree of health inequality of some countries. I study the income-related reporting heterogeneity hypothesis in the 2006 wave of the Catalan Survey of Health and I find that the main contributor to health inequality is the disproportionate concentration of the prevalence of reported conditions in lower income groups. The third chapter, joint with Hippolyte d'Albis and Loesse Jacques Esso, studies the trends in mortality convergence across developed countries from 1960 to 2008. While the epidemiological transition has provided a theory behind the expectation of convergence in mortality patterns, our results reject the convergence hypothesis for a sample of industrialized countries. We study the disparities across the mortality distributions of the countries and our sample and find no evidence of convergence towards a common mortality distribution.The fourth and final chapter of this dissertation examines the relationship between unemployment and fertility. I offer a possible explanation for the apparent contradiction between the empirical work that finds a negative relationship between unemployment and fertility and the theoretical work that emphasizes the lower opportunity cost of childbearing while unemployed. I reconcile these perspectives by distinguishing two forms of unemployment. The first form is structural unemployment while the second is cyclical unemployment, a less permanent component of unemployment that is linked to the economic cycle. I study both effects over the life cycle using cohort data on a panel of developed countries. I find that while structural unemployment has an unambiguous negative effect on fertility, reactions to cyclical unemployment depend on the age at which it is experienced.

En France, les prix des EHPAD sont élevés au regard d'une qualité qui semble insuffisante. Des projets de réformes sont en discussion, mais les pouvoirs publics sont face à un dilemme : toute recherche de réduction des coûts risque de dégrader la qualité plus qu'elle ne l'est déjà et toute amélioration de la qualité serait probablement inflationniste.L'objectif de cette thèse est d'étudier si ce dilemme peut être résolu, en analysant en particulier le rôle de la concurrence, réelle et par comparaison, qui pourrait être introduite dans ce secteur. Par une approche micro-économétrique, nous organisons notre analyse autour de trois questions de recherche : (i) que peut-on attendre des réformes proposées de la tarification et de l'augmentation de la capacité des établissements ? (ii) comment le développement du secteur privé lucratif pourrait permettre de réduire les prix et d'améliorer la qualité ? (iii) existe-t-il des contraintes environnementales responsables de la faible qualité des EHPAD? Nous observons, d'une part, que les projets de réforme permettraient de réduire l'inefficacité et donc éventuellement les prix des EHPAD, mais au détriment de leur qualité. D'autre part, nous constatons que l'essor des EHPAD lucratifs s'accompagne d'une augmentation des tarifs et d'une dégradation de la qualité de la prise en charge, qui pourraient être modérées par une structure de marché plus concurrentielle. Enfin, les EHPAD sont confrontés à des difficultés locales de fidélisation du personnel soignant qui affectent leur qualité et qui ne semblent pas pouvoir être résolues par un ajustement des salaires. Ces résultats peuvent servir de repères à la mise en place d'une politique publique adaptée.

Cette thèse examine plusieurs questions relatives à la qualité des soins hospitaliers, à travers les prismes disciplinaires de l’économie et de la santé publique.Le premier chapitre introduit la notion de qualité des soins en santé publique et en économie. L’examen du traitement classique de cette notion dans les deux disciplines met en évidence la convergence des définitions de la qualité des soins proposées et la complémentarité des approches de la régulation promues par les deux disciplines.La concurrence à prix fixes, telle que celle induite par la tarification à l’activité, devrait conduire à une amélioration de la qualité des soins si la demande est sensible à la qualité. Dans le deuxième chapitre, nous exploitons des données relatives à la diffusion publique de palmarès hospitaliers pour estimer, à partir d’un panel d’établissements français et pour plusieurs situations cliniques, l’élasticité de la demande de soins vis-à-vis de la qualité, pour les secteurs public et privé. Nous mettons en évidence un impact des palmarès sur l’activité des hôpitaux privés, pour l’une des situations cliniques considérées. En revanche, la demande adressée au secteur public ne semble pas influencée par la publication des palmarès. Ces résultats questionnent l’hypothèse d’une concurrence en qualité dans le secteur public en France.Le troisième chapitre s’intéresse au coût de stratégies de lutte contre les infections nosocomiales, dans une perspective hospitalière. Nous avons évalué les coûts associés à des interventions de promotion de mesures d’hygiène générale ou de dépistage ciblé des bactéries multi-résistantes, dans le cadre de deux essais cliniques multi-centriques européens en soins intensifs et en chirurgie. Nos résultats soulignent la plus grande variabilité des coûts des stratégies de promotion globales et, pour les interventions dont l’efficacité a été démontrée dans le cadre de ces études, un coût de mise en œuvre compatible avec l’hypothèse que ces interventions sont coût-efficaces. / This work takes the perspectives of economics and public health to study issues related to the quality of hospital care.The first chapter introduces the concept of quality of care in economics and public health. We show that the two fields use similar definitions of the concept but explore differing and complementary approaches towards its regulation.Fixed price competition between hospitals, as implemented by a prospective payment system, should lead to an improvement of care quality, provided that the demand for care is increasing with quality. The second chapter evaluates the sensitivity to quality of demand for hospital care in France, using ranking lists published by the lay media as a measure of information on quality available to potential patients. We estimate changes in hospital demand caused by ranking lists on a panel of hospitals located in the Paris area, for several pathologies. We find a sizeable and significant demand shift towards hospitals belonging to the top list in the forprofit sector for one pathology. No effect is observed for non-profit hospitals, or for other pathologies in the for profit sector. Competition for quality may thus not be a feasible regulation approach for French public hospitals.The third chapter provides evidence regarding the cost of hospital infection control strategies targeting antimicrobial resistant bacteria. We estimated the burden and costs associated with two types of strategies, relying on targeted screening or on general hygiene promotion strategies, in two multinational controlled clinical trials, in surgical and intensive care units.Our results highlight the variability of costs associated with broad, non-specific hygiene promotion interventions, and, for interventions which were found to be effective by the clinical trials, costs that are consistent with the hypothesis that these interventions are costeffective.

In this thesis I apply the concepts of Behavioral Economics to the analysis of the individual health care behavior. In the first chapter I provide a theoretical explanation of the link between loss aversion and health anxiety leading to infrequent preventive testing. In the second chapter I analyze this link empirically based on the general population questionnaire study. In the third chapter I theoretically explore the effects of motivational crowding-in and crowding-out induced by external or self-rewards for the self-control involving tasks such as weight loss or smoking cessation.<p><p>Understanding psychological factors behind the reluctance to use preventive testing is a significant step towards a more efficient health care policy. Some people visit doctors very rarely because of a fear to receive negative results of medical inspection, others prefer to resort to medical services in order to prevent any diseases. Recent research in the field of Behavioral Economics suggests that human's preferences may be significantly influenced by the choice of a reference point. In the first chapter I study the link between loss aversion and the frequently observed tendency to avoid useful but negative information (the ostrich effect) in the context of preventive health care choices. I consider a model with reference-dependent utility that allows to characterize how people choose their health care strategy, namely, the frequency of preventive checkups. In this model an individual lives for two periods and faces a trade-off. She makes a choice between delaying testing until the second period with the risk of a more costly treatment in the future, or learning a possibly unpleasant diagnosis today, that implies an emotional loss but prevents an illness from further development. The model shows that high loss aversion decreases the frequency of preventive testing due to the fear of a bad diagnosis. Moreover, I show that under certain conditions increasing risk of illness discourages testing.<p><p>In the second chapter I provide empirical support for the model predictions. I use a questionnaire study of a representative sample of the Dutch population to measure variables such as loss aversion, testing frequency and subjective risk. I consider the undiagnosed non-symptomatic population and concentrate on medical tests for four illnesses that include hypertension, diabetes, chronic lung disease and cancer. To measure loss aversion I employ a sequence of lottery questions formulated in terms of gains and losses of life years with respect to the current subjective life expectancy. To relate this measure of loss aversion to the testing frequency I use a two-part modeling approach. This approach distinguishes between the likelihood of participation in testing and the frequency of tests for those who decided to participate. The main findings confirm that loss aversion, as measured by lottery choices in terms of life expectancy, is significantly and negatively associated with the decision to participate in preventive testing for hypertension, diabetes and lung disease. Higher loss aversion also leads to lower frequency of self-tests for cancer among women. The effect is more pronounced in magnitude for people with higher subjective risk of illness.<p><p>In the third chapter I explore the phenomena of crowding-out and crowding-in of motivation to exercise self-control. Various health care choices, such as keeping a diet, reducing sugar consumption (e.g. in case of diabetes) or abstaining from smoking, require costly self-control efforts. I study the long-run and short-run influence of external and self-rewards offered to stimulate self-control. In particular, I develop a theoretical model based on the combination of the dual-self approach to the analysis of the time-inconsistency problem with the principal-agent framework. I show that the psychological property of disappointment aversion (represented as loss aversion with respect to the expected outcome) helps to explain the differences in the effects of rewards when a person does not perfectly know her self-control costs. The model is based on two main assumptions. First, a person learns her abstention costs only if she exerts effort. Second, observing high abstention costs brings disutility due to disappointment (loss) aversion. The model shows that in the absence of external reward an individual will exercise self-control only when her confidence in successful abstention is high enough. However, observing high abstention costs will discourage the individual from exerting effort in the second period, i.e. will lead to the crowding-out of motivation. On the contrary, choosing zero effort in period 1 does not reveal the self-control costs. Hence, this preserves the person's self-confidence helping her to abstain in the second period. Such crowding-in of motivation is observed for the intermediate level of self-confidence. I compare this situation to the case when an external reward is offered in the first period. The model shows that given a sufficiently low self-confidence external reward may lead to abstention in both periods. At the same time, without it a person would not abstain in any period. However, for an intermediate self-confidence, external reward may lead to the crowding-out of motivation. For the same level of self-confidence, the absence of such reward may cause crowding-in. Overall, the model generates testable predictions and helps to explain contradictory empirical findings on the motivational effects of different types of rewards. / Doctorat en Sciences économiques et de gestion / info:eu-repo/semantics/nonPublished

En France, les prix des EHPAD sont élevés au regard d’une qualité qui semble insuffisante. Des projets de réformes sont en discussion, mais les pouvoirs publics sont face à un dilemme : toute recherche de réduction des coûts risque de dégrader la qualité plus qu’elle ne l’est déjà et toute amélioration de la qualité serait probablement inflationniste.L’objectif de cette thèse est d’étudier si ce dilemme peut être résolu, en analysant en particulier le rôle de la concurrence, réelle et par comparaison, qui pourrait être introduite dans ce secteur. Par une approche micro-économétrique, nous organisons notre analyse autour de trois questions de recherche : (i) que peut-on attendre des réformes proposées de la tarification et de l’augmentation de la capacité des établissements ? (ii) comment le développement du secteur privé lucratif pourrait permettre de réduire les prix et d’améliorer la qualité ? (iii) existe-t-il des contraintes environnementales responsables de la faible qualité des EHPAD? Nous observons, d’une part, que les projets de réforme permettraient de réduire l’inefficacité et donc éventuellement les prix des EHPAD, mais au détriment de leur qualité. D’autre part, nous constatons que l’essor des EHPAD lucratifs s’accompagne d’une augmentation des tarifs et d’une dégradation de la qualité de la prise en charge, qui pourraient être modérées par une structure de marché plus concurrentielle. Enfin, les EHPAD sont confrontés à des difficultés locales de fidélisation du personnel soignant qui affectent leur qualité et qui ne semblent pas pouvoir être résolues par un ajustement des salaires. Ces résultats peuvent servir de repères à la mise en place d’une politique publique adaptée. / High prices and insufficient quality of care are observed in nursing homes in France. Reforms are currently under discussion, but governments are facing a dilemma : any measure of price cut is likely to affect quality and any improvement in quality would probably be inflationary. This work analyzes if this dilemma can be solved by focusing more particularly on the potential effect of real and yardstick competition that could be introduced in this long term care sector. Using a micro-econometric framework, we organize this analysis into three research issues : (i) What might be expected from the pricing reform and the increase in the number of beds in nursing homes currently proposed ? (ii) How the development of for-profit nursing homes could reduce prices and improve quality ? (iii) Are there local difficulties responsible for the poor quality of nursing homes ? Several implications for public policy may be involved. Using cost frontier estimates, we demonstrate that the reform plans would reduce inefficiency and nursing home prices, but at the expense of their quality. The rise of for-profit nursing homes leads to high prices and a deterioration of the quality of care which could be tempered however by a more competitive market structure. Nursing homes face local difficulties in nursing staff retention, affecting their quality and which do not seem to be solved by adjusting wages.

In this thesis, I apply the sophisticated tools made available by the econometrics of panel data and treatment models to a range of different issues. In the first Chapter, an ECM model is used to test on the existence of financing constraints in firms’ investment and R&D, taken a proxy for the efficiency of market institutions and governance rules in different countries. In the second chapter we test an agency model linking pay-performance contracts of CEOS to the financial situation of a firm by using a UK panel data. In the third chapter I use a sophisticated treatment model to evaluate the effectiveness of Italian public subsidies to R&D. Finally, in the fourth chapter I try to evaluate the efficiency of Italian regional systems of public healthcare by controlling for socio-economic factors and quality of healthcare in a composite model using panel data estimation and efficient frontier techniques.<p>The first Chapter analyzes the investment behavior of a sample of R&D intensive firms which are quoted on the stock market from USA, UK and Japan for the period 1990-1998. By using an error correction model we test the elasticity of investment and R&D to cash flow in these countries to see by which measure different market institutions and corporate governance rules affects the cost of external financing. Contrary to previous studies, we find significant differences in the sensitivity to cash flow of the two types of investment, with R&D expenditure being much less sensitive than ordinary investment. This is not surprising given the more long-term nature of R&D expenditures. For what concerns the comparison between the different systems/countries, the USA stock markets confirms as the most efficient market providing outside financing at a much lower cost compared to other markets, especially for young, smaller firms.<p>The second Chapter is a joint work with Biagio Speciale. It uses the data on a panel of quoted UK firms over the period 1995–2002 to study the effects of financial leverage on managerial compensation. The change in the investors’ expectations that caused the recent collapse of the stock market tech bubble is a perfect example of natural experiment that has been used as a source of plausibly exogenous variation in the firm’s debt. The estimates show that pay-for-performance sensitivity is increasing in financial leverage, with the exception of the 10% most levered firms, giving rise at the end to a non-linear (inverted U-shape) relationship between the two variables. The chapter includes also a theoretical model accounting for this relationship where an higher leverage increases both the expected returns and the expected variance of investment returns: the first effect (determining increased pay-performance sensitivity) prevails for low leverage values and the second effect (determining decreased pay-performance sensitivity) prevails for high leverage values.<p>The third Chapter undertakes an empirical estimation of the additionality of public funding on both the propensity to initiate R&D activity and the intensity of R&D spending of Italian enterprises for the period 1998-2000, using data from the Third Community Innovation Survey and from firms' financial accounts. The chosen methodology (Endogenous Switching Type II-Tobit) takes into account the possibility that decisions about both starting an R&D activity (sample selection effect) and applying for/obtaining public funding (essential heterogeneity) are influenced by private knowledge of enterprises' idiosyncratic propensities in R&D spending. The present analysis shows that both these effects are indeed important and that they contribute to explain most of the additionality found with less sophisticated models.<p>The fourth Chapter investigates the underlying causes of variability of public health expenditure per capita (SSPC henceforth) between Italian regions. A fixed-effect panel data estimate on the SSPC (for the period 1997-2006) is used in the first part of the paper to account for regional differences in terms of physical, demographic, socio-economic characteristics and in terms of other variables that affect demand and supply of health services. In the second part, we take the ‘adjusted’ SSPC and proceed to estimate an "efficient production function" of the quality of health services through Data Envelopment Analysis. This procedure allows us to separate the share of expenditure used for the improvement of the quality from the one that can be traced only to an inefficient use of financial resources. A comparison of regional SSPC after factoring out the socio-economic factors and the quality of healthcare shows that big differences still remain and are even exacerbated, signalling big pockets of inefficiency and correspondingly a huge potential for cost savings. Finally, a preliminary analysis shows a positive correlation between the efficiency of regional public spending in healthcare and the level of social capital. / Doctorat en Sciences économiques et de gestion / info:eu-repo/semantics/nonPublished

Dans la première partie de cette thèse, nous considérons plusieurs problèmes d'estimation de paramètre de dimension finie pour les séquences de Markov dans l'asymptotique des grands échantillons. Le comportement asymptotique des estimateurs bayésiens et les estimateurs obtenus par la méthode des moments sont décrits. Nous montrons que sous les conditions de régularité ces estimateurs sont consistants et asymptotiquement normaux et que l'estimateur bayésien est asymptotiquement efficace. Les estimateur-processus du maximum de vraisemblance un-pas et deux-pas sont étudiés. Ces estimateurs nous permettent de construire des estimateurs asymptotiquement efficaces sur la base de certainsestimateurs préliminaires, par exemple, les estimateurs obtenus par la méthode des moments ou l'estimateur deBayes et la structure de l'estimateur du maximum de vraisemblance un-pas. Nous proposons notamment des processus autorégressifs non linéaires comme exemple et nous illustrons les propriétés de ces estimateurs à l'aide de simulations numériques. Dans la deuxième partie, nous donnons les applications de processus de Markov en économie de la santé. Nous comparons les modèles de Markov homogènes et non-homogènes pour l'analyse coût-efficacité de l'utilisation depansements transparents contenant un gel de gluconate de chlorhexidine par rapport aux pansements transparents standard. Le pansement antimicrobien protège les accès vasculaire centrale et réduit le risque de bactériémies liées aux cathéters. L'impact de l'approche de modélisation sur la décision d'adopter des pansements antimicrobiens pour les patients gravement malades est discuté. / In the first part of this dissertation we consider several problems of finite-dimensional parameter estimation for Markov sequences in the asymptotics of large samples. The asymptotic behavior of the Bayesian estimators and the estimators of the method of moments are described. It is shown that under regularity conditions these estimators are consistent and asymptotically normal. We show that the Bayesian estimator is asymptotically efficient. The one-step and two-step maximum likelihood estimator-processes are studied. These estimators allow us to construct the asymptotically efficient estimators based on some preliminary estimators, say, the estimators of the method of moments or Bayes estimator and the one-step maximum likelihood estimator structure. We propose particular non-linear autoregressive processes as examples and we illustrate the properties of these estimators with the help of numerical simulations. In the second part we give theapplications of Markov processes in health economics. We compare homogeneous and non-homogeneous Markov models for cost-effectiveness analysis of routine use of transparent dressings containing a chlorhexidine gluconate gel pad versus standard transparent dressings. The antimicrobial dressing protects central vascular accesses reducing the risk of catheter-related bloodstream infections. The impact of the modeling approach on the decision of adopting antimicrobialdressings for critically-ill patients is discussed.

Dans un contexte de grandes transformations de la médecine générale, cette thèse s’intéresse aux déterminants de l’offre de soins des médecins généralistes. Nous avons développé différentes stratégies micro-économétriques pour dans premier temps comprendre l’effet de la féminisation sur les revenus des médecins généralistes et plus particulièrement sur leurs comportements d’activité en termes de volume de soins fournis mais également de composition de l’activité. Dans un deuxième temps, nous cherchons à étudier les déterminants du choix du lieu d’installation des jeunes médecins généralistes, au sein d’une région et à identifier les leviers qui pourraient améliorer leur répartition sur le territoire. Nos résultats confirment que les femmes ont d’une part une offre de soins quantitativement plus faible que celle des hommes et que le contenu de leur offre est également différent. Toutefois, ils adoptent des comportements d’installation similaires. Les facteurs qui influencent le choix du lieu d’installation sont plutôt des caractéristiques du lieu, comme les caractéristiques associées à l’offre de soins, à la demande de soins, ou aux équipements. L’objectif de ce projet de recherche est, à travers une approche micro-économétrique, de mieux appréhender les préférences des médecins. Nous souhaitons comprendre ces préférences à travers les arbitrages travail/loisir du médecin et donc l’intensité de l’offre de travail (arbitrage entre nombre d’actes et durée de consultation), mais aussi selon les choix d’installation du médecin tant par le choix du lieu que par les modalités de cette installation, à savoir une activité libérale et ou salariée tout en sachant que ces décisions dépendent fortement des revenus espérés et donc de contextes différenciés de demande de soins. / In the context of changes of general practice (uneven distribution of young general practitioners (GPs) across the country, strong feminisation), this thesis focuses on the determinants of the outpatient care supply of general practitioners. Using different micro-econometric analyses, firstly we want to understand the impact of feminization on the incomes of general practitioners and specifically on their private practice behaviours in terms of volume of care provided but also composition of the activity (consultations, home visits). Secondly, we study the determinants of the practice location choice within the region and we identify the levers that could improve the distribution of GPs in the area. Our results confirm that female GPs provide fewer services than male GPs and they also have a different composition of private practice activity. However, we show that male and female GPs adopt a similar practice location choice. Factors characterizing the place of installation as the characteristics associated with the supply of care, the demand for care, or equipment influence the practice location choice.