This paper delivers the first evaluation of the 2005 French Disability Act, which was introduced to promote the employment of disabled people. The Act relies primarily on a legal employment quota for disabled people, with levies imposed in cases of non-compliance. We apply panel data methods equivalent to double and triple difference methods to the French Santé et Itinéraire Professionnel (SIP) survey (Survey on Health and Labour Market Histories). First, we estimate the effect of disability on the employment rate, finding a strong negative effect which is most pronounced among men and the oldest workers. However, since some observable characteristics of disabled workers, such as age, gender and education, vary over time, we extend our model to isolate the causal effect of the reform on the employment rate of disabled workers by taking into account the pre-reform (1991–2004) and post-reform (2005–2009) periods. Our findings suggest that the 2005 Act has met its initial objective, positively impacting the employment rate of disabled individuals, particularly in the private sector. The reform appears to have compensated for approximately half of the effect of disabilities on the employment rate. We also find that the reform's effect has been stronger for workers with secondary education.

Delegating tasks to paramedics is a fairly recent development in France. So far it has essentially been developed in hospitals and is incipient in general practice. This paper focuses on the willingness of general practitioner to do so. A 2012 survey of 2,000 GPs might help anticipate GPs' willingness to delegate. This paper tests whether a more favourable funding system might help increase GP willingness. We implement a quasi-experimental design wherein GPs are randomly selected to form three groups of equal size, each of them being exposed to a different funding scheme when declaring their willingness to delegate tasks to nurses: Fully Funded (FF) by the social security administration, self-funded by GPs' revenues (Self-Funded, SF) and half-funded by both the social security administration and GPs (Half-Funded, HF). GPs' likelihood to favour task delegation is estimated with a probit model that especially considers a GP's attitude towards risk (aversion or tolerance) among a set of covariates, such as age, gender, rural/urban area, GP density and funding scheme. This article shows that, first, GPs are more likely to favour delegation, when they share a lower proportion of the cost. Second, the effect of risk aversion on the likelihood of favouring delegation is not altered by the funding scheme.

Background General practitioners (GPs) face quantitative and qualitative changes in patient demand and doctor shortages. Objectives To investigate how GPs cope with doctor shortage issues. Materials and methods Two cross-sectional surveys of a representative panel of 1530 GPs in 2019 and 2022 about their perceptions of physician shortages, working hours worked (WHW), and adaptive behaviors. Hierarchical clustering enabled identification of profiles with different adaptation patterns. Multiple Poisson or logistic regression models studied associations between GPs’ profiles and professional characteristics. Results 87.4 % of GPs applied at least one adaptation to control patients’ healthcare demand. 24 % adopted task-shifting while their average WHW decreased by 3.6 h between 2019 and 2022. Four GP profiles were identified. “Low adapters/low workload” and “Low adapters/high workload” (25 % of the sample each) reported 2.4 adaptive measures: 75.5 % refused to be new patients' preferred doctor in the former group (vs 5.1 %). “High adapters/unchanged consultations” (30.7 %) and “High adapters/shortened consultations” (18.9 %) reported 4.8 and 6.1 adaptations, respectively. They were more likely to practice in medically underserved areas. Conclusion These results call into question GPs’ gatekeeper role in the French healthcare system. Moreover, the marked reduction in WHW in underserved areas is likely to exacerbate their uneven distribution nationwide. Encouraging vertical integration between HCPs while enhancing cooperation and task-shifting is probably a pathway toward improving the relative GP shortage.

In France, the joint evolution of both primary care supply-with a GP shortageand demand have led to an increasing imbalance. The trend towards horizontal and vertical integration in primary care, with the support given to the development of multi-professional primary care groups (MPCGs) or Primary Care Team (PCTs) combine with practice pay-for-coordination mechanism, aims to improve the productive efficiency. Using exact matching and difference-in-differences estimations on panel data (2013-2017 period), we find that practicing in MPCG with pay-for-coordination significantly increases general practitioners (GPs)' number of working days, patients seen and visits. Stratification tests point out that our findings especially hold for female, young and GPs practicing in medically underserved areas. Results are mainly driven by organizational design and not by pay-for-coordination schemes.

La raréfaction de l’offre de soins en médecine générale et une demande de soins croissante et évolutive exacerbent les déséquilibres préexistants. La promotion de l’intégration horizontale et verticale sous la forme de maisons de santé pluriprofessionnelles (MSP) et l’introduction d’une rémunération collective à la coordination ont vocation à générer des gains d’efficience productive. Nous montrons, à partir de données en panel sur la période 2013-2017, d’un appariement exact et d’estimations en différence-de-différences, que l’exercice en MSP couplé au paiement à la coordination accroît significativement les nombres de jours travaillés et de patients rencontrés par les médecins généralistes ainsi que leur nombre de consultations au cabinet. Ces effets sont particulièrement concentrés sur les médecins femmes, jeunes et exerçant dans des territoires sous-dotés médicalement. Ils sont principalement liés au mode d’organisation et non au paiement à la coordination . Classification JEL : C33, I11, J22, L23.

The integration of primary care organizations and interprofessional cooperation is encouraged in many countries to both improve the productive and allocative efficiency of care provision and address the unequal geographical distribution of general practitioners (GPs). In France, a pilot experiment promoted the vertical integration of and teamwork between GPs and nurses. This pilot experiment relied on the staffing and training of nurses; skill mixing, including the authorization to shift tasks from GPs to nurses; and new remuneration schemes. This article evaluates the overall impact of this pilot experiment over the period 2010-2017 on GP activities based on the following indicators: number of working days, patients seen at least once, patients registered, and visits delivered. We control for endogeneity and reduce selection bias by using a case-control design combining coarsened exact matching and difference-in-differences estimates on panel data. We find a small positive impact on the number of GP working days (+1.2%) following enrollment and a more pronounced effect on the number of patients seen (+7.55%) or registered (+6.87%). However, we find no effect on the number of office and home visits. In this context, cooperation and teamwork between GPs and nurses seem to improve access to care for patients.

Objectives: The objective of this population-based study was to identify factors associated with insulin pump therapy initiation in adults with insulin-requiring diabetes in France in 2015. Method: People with insulin-requiring diabetes and their characteristics were identified from the national health data system. Factors associated with insulin pump therapy initiation were identified by logistic regression analysis. Results: The study focused on 614,913 adults with diabetes treated by multiple daily injections before 2015: 4083 of them initiated insulin pump therapy during the year (71% of them had type 1 diabetes, T1D). Factors associated with insulin pump therapy initiation were the number of consultations with an endocrinologist within the past 2 years (2 vs. 0, odds ratio [OR] = 1.5, P < 0.01), the presence of a chronic cardiovascular or neurovascular disease (OR = 1.6 for T1D, OR = 1.3 for type 2 diabetes [T2D], P < 0.01) and treatment with antidepressants/anxiolytics (OR = 1.2 for T1D, OR = 1.4 for T2D, P < 0.01). The other determinants were female gender (OR = 1.5, P < 0.01) and history of hospitalization for acute metabolic complications (OR = 1.14, P < 0.01) in T1D. Factors associated with less insulin pump therapy initiation were age, duration of diabetes, end-stage renal disease, and social deprivation (OR = 0.662, P < 0.01, T1D only). Conclusion: Predictive factors of insulin pump therapy initiation in people with insulin-requiring diabetes in 2015 in France were globally consistent with clinical practice guidelines. Age, male gender, and social deprivation are still associated with a lower rate of insulin pump therapy initiation in adults with T1D.

In many countries, policies have explicitly encouraged the integration of primary care organisations and interprofessional cooperation to improve the productive and allocative efficiency of care provision and to address the unequal geographical distribution of physicians. In France, the Social Security Department of the Ministry of Health (DSS) and a not-for-profit organisation called Asalee ("Action de sante liberate en equipe" meaning Teamwork in self-employed medical practice) set up an experiment to promote vertical integration and teamwork between general practitioners and nurses, notably based on nurses' staffing and training as well as authorisation of task substitution between general practitioners and nurses and new remuneration schemes. This article evaluates the extension of this experiment over the period 2010-2016 by studying the joint effect of the cooperation between general practitioners and nurses, the specific organization of Asalee and the underlying economic incentives on general practitioners' activity based on the following indicators: number of working days, patients seen at least once or listed and visits delivered (office and/or home). We control, as much as possible, for endogeneity and reduce selection biases by using a case-control design, consisting of exact matching methods and difference-indifferences estimations on panel data. We highlight a positive but relatively modest effect of entering into the Asalee pilot on the number of GPs' working days (+1.2 %) and a more pronounced effect on the number of patients seen (+7.55 %) or listed (+6.87 %). Yet, we find no effect on the number of office and home visits.

Dans de nombreux pays, les politiques et réformes ont explicitement encouragé l’intégration des organisations de soins primaires et la coopération pluri-professionnelle afin d’améliorer l’efficience productive et allocative de l’offre de soins et lutter contre l’inégale répartition géographique des médecins. En France, la Direction de la Sécurité sociale et une association dénommée Asalée (« Action de santé libérale en équipe », depuis 2004) ont mis en place une expérimentation destinée à favoriser l’intégration verticale et le travail en équipe entre médecins généralistes et infirmières par la mise en place de nouveaux modes de rémunération et la formation d’infirmières sélectionnées. Cet article évalue l’extension de cette expérimentation sur la période 2010-2016 en étudiant l’influence de cette coopération, mais aussi de l’organisation et des incitations financières à l’œuvre, sur l’activité des médecins généralistes appréhendée à partir de trois indicateurs : le nombre de jours travaillés, de patients rencontrés (en file active et, parmi eux, ceux inscrits médecin traitant) et d’actes (consultations au cabinet et visites à domicile). Nous contrôlons autant que possible des biais d’endogénéité et de sélection en recourant à un design cas-témoins, selon une méthode d’appariement exact, et des méthodes d’estimation en différence de différences sur données de panel. Dans ce cadre, nous montrons un effet positif du dispositif mais relativement modeste sur le nombre de jours travaillés par les médecins (+1,2 %) et un effet plus marqué sur le nombre de patients rencontrés (+7,55 %) et inscrits médecin traitant (+6,87 %). En revanche, aucun effet significatif n’est mis en évidence sur le nombre de consultations et visites. Codes JEL : C31, C33, I11, J22, L23

Within hospital settings, delegation to paramedics is fairly recent in France. Whether General Practit ioners are likely to follow hospital consultants is unknow n. A 2012 survey of 2,000 GPs might help foresee GP s willingness to do so. This paper tests whether a mo re favourable funding system might help increasing GPs willingness. We implement a quasi-experimental des ign wherein GP’s are randomly selected to form thre e groups of equal size, each of them being exposed to a different funding scheme when declaring their willingness to delegate tasks to nurses: fully fund ed (FF) by the social security administration, self -funded by GPs’ revenues (Self Funded, SF) and half-funded by both the social security administration and GPs (Ha lf Funded, HF). GP’s likelihood to be in favour of task delegation is estimated with a Probit model which especially considers GP’s attitude toward risk (aversion or pr eference), among a set of covariates such as age, g ender, rural/urban area, GP’s density and funding scheme. This article shows that, firstly GPs are more likel y to favour delegation where they share a lower proporti on of the cost. Secondly, the effect of risk aversi on on the likelihood of being in favour of delegation is not al ered by the funding scheme. JEL Codes : I12, I18, J33, M55.

This paper presents the first evaluation of the French Disabled Workers Act of 1987, which aimed to promote the employment of disabled people in the private sector. We use a panel data set, which includes both the health and the labour market histories of workers. We account both for unobserved heterogeneity and for the change in the disabled population over time. We find that the law had a negative impact on the employment of disabled workers in the private sector. This counterproductive effect likely comes from the possibility to pay a fine instead of hiring disabled workers.

In France, the 1987 Law set up a legal quota of disabled workers in more than 20 employees companies. In order to encourage employers to better promote the employment of disabled people, this law decreed financial penalties for non-compliance. The aim of this paper is to evaluate the impact of this law on the employment of disabled people. We use a double difference approach combined with dynamic exact matching and weighting methods in order to disentangle the pure effect of the legislation by controlling for both observable and unobservable correlated heterogeneities. Using a panel data set built from the “Santé et itinéraire professionnel” (lit. Health and Labour Market Histories) survey conducted in France in 2006-2007, we investigate whether disabilities have a significant impact on people’s employment, by distinguishing between the public and private sectors. We compare the labour trajectories of disabled people before (1968-1986) and after (19882006) the implementation of the law. Our findings highlight a negative impact of the law on the employment of disabled people. By enabling firms to abide by the legal employment obligation without hiring any disabled workers, this measure has probably had a counterproductive impact on the employment of disabled people. Nevertheless, only disabled people working in the private sector undergo a significant unfavorable shock on their career. JEL: C33, C52, I10, J20, J31.

This study analyses the causal impact of long-term handicaps relative to short-term handicaps on employment status in the short and medium run (1-5 years), by taking into account the effects of activity sector (public or private), gender and handicap origin (accidents or diseases). We uses the Health and Professional Career survey ( Sante et Itineraires Professionnels - S IP ), conducted in France in 2006-2007, in order to evaluate the effect of long-term handicaps on individual’s career. In this perspective, we build an individual/year panel and used the difference-in-differences with exact matching method by distinguishing according to the sector of activity (public or private). We proceed with matching including lagged effects of activity so as to control for the endogeneity between employment and handicaps’ onset. Men and women are not affected in the same way by short-term handicaps, men’s jobs being more threatened that those of women. Moreover, long-term handicaps seem to have a greater effect on the transition towards both inactivity and long-term unemployment, notably for low-skilled workers. Handicaps (linked to illness) thus drastically affect careers. Although short-term handicaps more strongly affect low-skilled workers’ employment, permanent handicaps seem more detrimental to the employment of the high-skilled workers. But, above all, the public sector appears to completely protect individuals from losing their jobs in case of short-term handicaps and greatly reduces the likelihood of losing their job following a long-term handicap.

This work intends to check, from an empirical pe rspective, if economic incentives can have a detrimental effect on GPs’ intrinsic motivations, w hich is called “crowding-out effect of intrinsic mo tivations” since the seminal work of Frey (1993), in the parti cular field of health prevention services. We use a “randomized experiment” on a panel of 1875 GPs prac ticing in five regions of France to identify the im pact of different amounts and types of economic incentives on their intentions to carry out two different type s of tasks in prevention field (doing a prevention check-up durin g a given consultation, attending a vocational trai ning on therapeutic patient education). Our sample was rand omly divided into three equal groups of GPs who wer e submitted to different scenarios of payment schemes encouraging them to realize these tasks. Our resul ts does not highlight a crowding-out effect of economic inc e tives on GPs’ intrinsic motivations in prevention field. However, we show that the effectiveness of incentiv s is conditioned by the type of task rewarded and by GPs’ work-related well-being, estimated through a psycho sociological indicator of work engagement. Résumé : Ce travail se donne pour objectif de vérifier empir iquement si les incitations économiques peuvent avoir un effet contreproductif sur les motivations i trinsèques des médecins généralistes, que l’on qu alifie généralement d’effet d’éviction des motivations int rinsèques depuis l’article fondateur de Frey (1993) , dans le domaine de la prévention. A partir d’un panel de 18 75 médecins généralistes exerçant dans 5 régions de France, nous utilisons un dispositif « expérimental » rando misé afin d’identifier l’impact de différents nivea ux et types d’incitations économiques sur l’intention qu’ont ce s médecins d’effectuer deux tâches différentes dans le domaine de la prévention (consacrer du temps additi onnel à faire de la prévention dans le cadre d’une consultation donnée, participer à une journée de fo rmation dans le domaine de l’éducation thérapeutiqu e d patient). Notre échantillon de médecins généraliste s a été divisé aléatoirement en trois groupes de ta ill équivalente, chacun ayant été soumis à différents s cénarii de paiements censés les inciter à réaliser le tâches en question. Nos résultats ne plaident pas pour l’exis t nce d’un effet d’éviction des motivations intrins èques par les incitations économiques dans le domaine de la préve ntion. En revanche, ils montrent que l’efficacité d es incitations économiques est conditionnée par le typ de tâches récompensées et par le sentiment de bie n-être au travail des individus que nous appréhendons grâce à un indicateur psychosociologique d’engagement au t ravail.

Objective Poor people receive shorter consultations in general practice than more affluent people. Our aim was to study the two reasons generally advanced for this for patients consulting with mental health problems: people of low socioeconomic status (SES) demand shorter consultations or they tend to match with practitioners who devote little time to their patients. Methods Of 600 general practitioners (GPs), 144 agreed to participate. During the study period (2005), 713 patients consulted with mental health problems of whom 405 (56.8%) completed questionnaires. Of these, 144 (34.8%) were defined as suffering from Major Depressive Disorder (MDD). Multilevel modelling was used to explore the relationship between patient and GP characteristics, and duration of the consultation. Results A multivariate model found two significant patient variables for the consultation duration: severity of MDD symptoms (P = 0.01) and SES (proxied by education level, P = 0.05). The multilevel model including GPs’ characteristics demonstrated that the apparent correlation between patients’ SES and consultation length was due to a confounding factor: low SES patients were visiting GPs who are, generally, providing shorter consultations (P < 0.001). With the SES variable no longer significant: P = 0.2, although severity of symptoms remained in the model (P = 0.001). Conclusion The shortness of the consultation length is due to a supply-side effect, implicating dissatisfaction for patients with mental health problems. This may not be generalizable to other patients. Findings are in favour of a specific intervention aimed at giving poor people equal access to GPs’ time.