Skip to main content

Advertisement

SpringerLink
Log in

How French general practitioners respond to declining medical density: a study on prescription practices, with an insight into opioids use

  • Original Paper
  • Published:
The European Journal of Health Economics Aims and scope Submit manuscript

Abstract

Disparities in physicians' geographical distribution lead to highly unequal access to healthcare, which may impact quality of care in both high and low-income countries. This paper uses a 2013–2014 nationally representative survey of French general practitioners (GPs) matched with corresponding administrative data to analyze the effects of practicing in an area with weaker medical density. To avoid the endogeneity issue on physicians' choice of the location, we enriched our variable of interest, practicing in a relatively underserved area, with considering changes in medical density between 2007 and 2013, thus isolating GPs who only recently experienced a density decline (identifying assumption). We find that GPs practicing in underserved areas do shorter consultations and tend to substitute time-consuming procedures with alternatives requiring fewer human resources, especially for pain management. Results are robust to considering only GPs newly exposed to low medical density. Findings suggest a significant impact of supply-side shortages on the mix of healthcare services used to treat patients, and point to a plausible increased use of painkillers, opioids in particular.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. This comparison should be interpreted with caution, since the functioning of the health systems is not similar across countries.

  2. From 2010 to 2030, population is expected to increase by 9%, and the population aged over 60 by 30%, according to the French national statistical institute (INSEE). Especially due to this ageing population, the proportion of the population with chronic diseases increases too. For instance, from 14,4% in 2011 to 16,0% in 2016 [8].

  3. Total number of consultations divided by declared working hours; denominator derived from 2013 question on working hours: “During last/a typical week, how much time did you spend on your private GP activities?” adjusted for vacations [21].

  4. We computed the variance inflation factor (VIF) to test for multicollinearity and interpreted VIF values less than five as presenting no multicollinearity issues.

  5. In France, private practice GPs are paid based on the fee-for-service system (25 euros per consultation). This regulated-fee results from a negotiation between the government, Social Security and physician representatives. A physician faces a choice: either she accepts regulated-fee remuneration (irrevocable option) or she can charge “with tact and moderation” an excess fee (unregulated fee, can switch to regulated fee afterwards). However, there has been no possibility for new GPs to opt for unregulated fees since 1990.

  6. These threshold values correspond to 16% and 42% of GPs in our sample.

  7. No differences found between respondents giving and refusing consent.

  8. We find a Pearson correlation coefficient between GP density and physical therapists equal to 0.45 in 2013, at health areas level. The correlation coefficient with self-employed nurses density is equal to 0.26, but it doesn’t take into account nurses employed in health centers. Both coefficients are significant at the 5% level.

  9. As mentioned in the Results section, the introduction of ‘paramedics density’ in the econometric model of paramedics prescription tends to suppress the significance of the GP density indicator. This seems to suggest that, as far as paramedics underutilization is concerned, low GP density is not an issue per se, but only through its strong correlation with paramedics’ spatial distribution. Two effects might take place: either the GP internalizes the shortage of paramedics and prescribes less paramedics visits, or the GP prescribes just as many paramedics visits, but the patients never carry out the visit, so there are no records in the Social Security dataset.

References

  1. OECD Health Statistics 2016 - OECD. https://www.oecd.org/els/health-systems/health-data.htm. Accessed 11 Feb 2020

  2. Bodenheimer, T., Pham, H.H.: Primary Care: current problems and proposed solutions. Health Aff. 29(5), 799–805 (2010)

    Article  Google Scholar 

  3. Goddard, M., Gravelle, H., Hole, A., Marini, G.: Where did all the Gps go? Increasing supply and geographical equity in England and Scotland. J. Health. Serv. Res. Policy 15(1), 28–35 (2010)

    Article  Google Scholar 

  4. Correia, I., Veiga, P.: Geographic distribution of physicians in Portugal. Eur. J. Health Econ. 11(4), 383–393 (2010)

    Article  Google Scholar 

  5. Ramos, P., Alves, H., Guimarães, P., Ferreira, M.A.: Junior doctors’ medical specialty and practice location choice: Simulating policies to overcome regional inequalities. Eur. J. Health Econ. 18(8), 1013–1030 (2017)

    Article  Google Scholar 

  6. Hartmann, L., Ulmann, P., Rochaix, L.: Access to regular health care in Europe. Revue Française Des Affaires Sociales 2, 121–139 (2006)

    Article  Google Scholar 

  7. Chevillard, G., Lucas-Gabrielli, V., Mousquès, J.: ‘‘Medical deserts’’ in France: Current state of research and future directions. L’Espace géographique 47(4), 362–380 (2018)

    Article  Google Scholar 

  8. Grangier J. (2018) Le vieillissement de la population entraîne une hausse des dépenses de santé liées aux affections de longue durée [The aging of the population leads to increasing health care spending related to chronic diseases], Études et Résultats, n°1077

  9. Bachelet M, Anguis M (2017) Les médecins d’ici à 2040 : une population plus jeune, plus féminisée et plus souvent salariée [GPs in 2040: younger, female and salaried GPs]. Etudes et Résultats. 1011

  10. Buddeberg-Fischer, B., Stamm, M., Buddeberg, C., Klaghofer, R.: The new generation of family physicians-career motivation, life goals and work-life balance. Swiss Med Wkly 138, 305–312 (2008)

    PubMed  Google Scholar 

  11. Masseria, C., Irwin, R., Thomson, S., Gemmill, M., Mossialos, E.: Primary care in Europe. Policy brief, European Commission (2009)

    Google Scholar 

  12. Ferrer, R.L., Hambidge, S.J., Maly, R.C.: The essential role of generalists in health care systems. Ann Intern Med 142, 691–699 (2005)

    Article  Google Scholar 

  13. Deveugele, M., Derese, A., van den Brink-Muinen, A., Bensing, J., Maeseneer, J.D.: Consultation length in general practice: cross sectional study in six European countries. BMJ 325, 472 (2002)

    Article  Google Scholar 

  14. van Hassel, D., Verheij, R., Batenburg, R.: Assessing the variation in workload among general practitioners in urban and rural areas: An analysis based on SMS time sampling data. Int J Health Plann Manage 34, e474–e486 (2019)

    Article  Google Scholar 

  15. Steinhaeuser, J., Joos, S., Szecsenyi, J., Miksch, A.: A comparison of the workload of rural and urban primary care physicians in Germany: analysis of a questionnaire survey. BMC Fam Pract 12, 112 (2011)

    Article  Google Scholar 

  16. Kann, I.C., Biørn, E., Lurås, H.: Competition in general practice: prescriptions to the elderly in a list patient system. J. Health Econ. 29(5), 751–764 (2010)

    Article  Google Scholar 

  17. Scott, A., Shiell, A.: Analysing the effect of competition on General Practitioners’ behaviour using a multilevel modelling framework. Health Econ. 6(6), 577–588 (1997)

    Article  CAS  Google Scholar 

  18. Silhol, J., Ventelou, B., Zaytseva, A., Marbot, C.: Physicians’ behaviours and practices: does it make a difference to practice in underserved areas? Revue française des affaires sociales 1(2), 213 (2019)

    Article  Google Scholar 

  19. Le Marechal M, Fressard L, Agrinier N, Verger P, Pulcini C (2017) General practitioners’ perceptions of vaccination controversies: a French nationwide cross-sectional study. Clin Microbiol Infect

  20. French Republic, Arrêté du 13 novembre 2017 relatif à la méthodologie applicable à la profession de médecin pour la détermination des zones prévues au 1° de l’article L. 1434–4 du code de la santé publique [Decree relative to methodology used to define health areas as intended by article L. 1434–4 of the code of public health]

  21. Jakoubovitch S, Bournot M-C, Cercier É, Tuffreau F (2012) Les emplois du temps des médecins généralistes [GPs agenda]. Etudes et Résultats. 797

  22. Minor, M.A., Sanford, M.K.: The role of physical therapy and physical modalities in pain management. Rheumatic Dis Clin North America 25(1), 233–248 (1999)

    Article  CAS  Google Scholar 

  23. Miller CA. (2009). Nursing for wellness in older adults. Lippincott, Williams & Wilkins

  24. Michel-Lepage, A., Ventelou, B.: The true impact of the French pay-for-performance program on physicians’ benzodiazepines prescription behavior. Eur. J. Health Econ. 17(6), 723–732 (2016)

    Article  Google Scholar 

  25. Ruhm, C.J.: Drivers of the fatal drug epidemic. J Health Econ 64, 25–42 (2019)

    Article  Google Scholar 

Download references

Acknowledgements

We thank Gwenaëlle Maradan and her survey team from Observatoire Régional de la Santé, and our panel of GPs. We also thank ‘bureau de professions de santé’ of DREES, in particular Helene Chaput, Claire Marbot and Martin Monziol, at the French ministry of health, for their continuous and valuable support throughout the data collection process.

Funding

This work was supported by French National Research Agency grant ANR-17-EURE-0020 and French Institute for Public Health Research grant n°IReSP-LI-AAP18-HSR-008. A.Z. received a PhD grant from the (non-profit) Sud Provence-Alpes-Côte d'Azur regional council.

Author information

Authors and Affiliations

  1. Institut National de la Statistique et des Etudes Economiques (Insee), Montrouge, France

    Julien Silhol

  2. Aix-Marseille University, CNRS, EHESS, Centrale Marseille, AMSE, Marseille, France

    Julien Silhol, Bruno Ventelou & Anna Zaytseva

Authors
  1. Julien Silhol
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Bruno Ventelou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anna Zaytseva
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bruno Ventelou.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 36 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Silhol, J., Ventelou, B. & Zaytseva, A. How French general practitioners respond to declining medical density: a study on prescription practices, with an insight into opioids use. Eur J Health Econ 21, 1391–1398 (2020). https://doi.org/10.1007/s10198-020-01222-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10198-020-01222-8

Keywords

JEL Classification

Search

Navigation