The preferred doctor scheme: A political reading of a French experiment of Gate-keeping

Study objective: Since January 2005 France is exploring a new scheme termed "preferred doctor" (médecin traitant) which can be considered as an innovative version of Gate Keeping in order to reduce the excess of postulated excess in health consumption, more especially access to specialist care. This paper describes the political process which lead to it's implementation, tries to relate some of the scheme specific features with it's results after one year implementation and tries to catch a glimpse for the next steps of the reform. Material and methods: In order to measure the scheme impact on the "patient treatment pathway" and on physician income, we used a sample of 7198 individual from the 2006 "French health, Health Care and Insurance Survey "(ESPS),"including health, socioeconomic and insurance status and through a set of questions relating to patient's understanding of the scheme and different data bases of the national sickness fund as well as different studies done by regulatory agencies. Results and discussion: First results after one year implementation show that most patients chose a preferred doctor, who in a vast majority happened to be their family doctor. A vast majority of patients also considered the scheme as mandatory. Impact on access to specialist care, as measured through self assessed unmet need for specialist care, appears not negligible, especially for the less well off and those not covered by a complementary insurance. In term of financial impact, the new constraints on access to ambulatory care seem to have been offset by rises in the fee schedules for the specialities which lost direct access We discuss why these short term weak outcomes are linked with a wicked system of the health system governance and to the political and professional context in which the scheme unfolded strongly and determined its structure and implementation pathway. On a more long range perspective, we analyse how the new scheme may nevertheless lead up to reinforced managed care reforms.Managed Care, Gate keeping, health care services utilization, unmet needs.

Psychosocial resources and social health inequalities in France: Exploratory findings from a general population survey

We study the psychosocial determinants of self-assessed health in order to explain social inequalities in health in France. We use a unique general population survey to assess the respective impact on self-assessed health status of subjective perceptions of social capital, social support, and sense of control, controlling for standard socio-demographic factors (SES, income, education, age and gender). The survey is unique in that it provides a variety of measures of self-perceived psychosocial resources (trust and civic engagement, social support, sense of control, and self-esteem. We find empirical support for the link between the subjective perception of psychosocial resources and health. Sense of control at work is the most important correlate of health status after income. Other important ones are civic engagement and social support. To a lesser extent, sense of being lower in the social hierarchy is associated with poorer health status. On the contrary, relative deprivation does not affect health in our survey. Since access to psychosocial resources is not equally distributed in the population, these findings suggest that psychosocial factors can partially explain of social inequalities in health in France.social capital, social support, relative deprivation, sense of control, social health inequalities, France

Psychosocial resources and social health inequalities in France: Exploratory findings from a general population survey

We study the psychosocial determinants of health, and their impact on social inequalities in health in France. We use a unique general population survey to assess the respective impact on selfassessed health status of subjective perceptions of social capital controlling for standard socio-demographic factors (occupation, income, education, age and gender). The survey is unique for two reasons: First, we use a variety of measures to describe self-perceived social capital (trust and civic engagement, social support, sense of control, and selfesteem). Second, we can link these measures of social capital to a wealth of descriptors of health status and behaviours. We find empirical support for the link between the subjective perception of social capital and health. Sense of control at work is the most important determinant of health status. Other important ones are civic engagement and social support. To a lesser extent, sense of being lower in the social hierarchy is associated with poorer health status. On the contrary, relative deprivation does not affect health in our survey. Since access to social capital is not equally distributed in the population, these findings suggest that psychosocial factors can explain a substantial part of social inequalities in health in France.social capital, social support, relative deprivation, sense of control, social health inequalities, France

Social health inequalities : a French analysis based on the migrant population.

Using a representative survey of the French population, the Health, Health Care and Insurance Survey (ESPS: “Enquête sur la santé et la protection sociale”), this article aims to study the links between migration, region of origin and health status in France. Firstly, we have compared the health status between migrants and the native population in discerning an identifiable difference between first-generation and second-generation migrants. Following this, in order to explain the heterogeneity of health status amongst the migrant population, we have refined our analysis by integrating their country of origin into our estimation and then exploring the health differences between individuals who have emigrated from South-East Mediterranean (SEM) countries and individuals who have emigrated from all other countries. Our findings show that there exist health inequalities that are related to immigration, when compared with the health status of the native population in France. First and second generation migrants have a higher risk than the native French born population to report a poor health status. By introducing country of origin into our analysis we are able to confirm the health heterogeneity within both groups of migrants. Individuals coming from SEM countries are more likely to report poor health status than the native French born population (for both generation migrants) and this risk seems significantly higher for individuals who have emigrated from Turkey. These inequalities are partly explained by the poor socio-economic conditions of the migrant population and a general lack of social integration in France.Health Care; Immigration; France;

Les comparaisons internationales d'etat de sante subjectif sont-elles pertinentes ? Une evaluation par la methode des vignettes-etalon

Lorsque les modalités de réponse à une question de santé subjective sont utilisées différemment par différents individus, on dit que celles-ci sont affectées d’un effet DIF. Nous présentons une méthode non-paramétrique de détection et de correction de tels effets dans les auto-évaluations de santé subjective. Nous illustrons cette méthode par la mise en évidence d'un effet DIF potentiel dans le cas de l'auto-évaluation du niveau de douleur physique ressenti par des personnes âgées issues de différents pays européens et montrons comment le prendre en compte dans l’analyse statistique.Subjective Health Measurement, differential item functioning, vignettes, international comparisons

Are International Comparisons of Subjective Health Status Relevant? An Assessment Using Anchoring Vignettes,

When, in a survey question, response items are used in different ways by respondents, the answers are said to be affected by an item bias or by a DIF (Differential Item Functioning) effect. In such a case, the responses must be corrected before they can be used to formulate comparative hypotheses on the subjective health status of subpopulations. In this paper, we present a method for detecting and correcting for DIF effects in self-assessments of subjective health. The method is based on the individuals' assessment of health status for hypothetical situations described in short vignettes. It is exemplified by detecting a possible DIF effect in the self-assessment of physical pain, according to the geographical origin of the samples from the Share 2004 survey. Correcting for this effect leads to different conclusions than the original self-assessments concerning the respective subjective health status of the Swedish and Dutch samples.Subjective Health Measurement, Differential Item Functioning, Anchoring Vignettes, International Comparisons

Etat de santé des populations immigrées en France

Cet article étudie les liens existant entre nationalité, migration et état de santé à partir des données de l'Enquête décennale Santé menée en 2002-2003 en France. Les résultats montrent l'existence d'inégalités face à la santé des personnes d'origine étrangère, liées à l'existence d'un effet de sélection à la migration compensé à long terme par un effet délétère de la migration, expliqué en partie seulement par la situation sociale difficile des immigrés. Cette analyse suggère également un effet non négligeable à long terme des caractéristiques économiques et sanitaires du pays de naissance, propre à expliquer les disparités d'état de santé observées au sein de la population immigrée.santé, nationalité, immigrés, situation économique

Health, Ageing and Retirement in Europe

Health, Ageing, Survey Methodology, International Comparisons

Leveraging implementation science to reduce inequities in children’s mental health care: Highlights from a multidisciplinary international colloquium

Background and purposeAccess to evidence-based mental health care for children is an international priority. However, there are significant challenges to advancing this public health priority in an efficient and equitable manner. The purpose of this international colloquium was to convene a multidisciplinary group of health researchers to build an agenda for addressing disparities in mental health care access and treatment for children and families through collaboration among scholars from the United States and Europe engaged in innovative implementation science and mental health services research.Key highlightsGuided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework, presentations related to inner, outer, and bridging context factors that impact the accessibility and quality of mental health evidence-based practices (EBPs) for children and families. Three common topics emerged from the presentations and discussions from colloquium participants, which included: 1) the impact of inner and outer context factors that limit accessibility to EBPs across countries, 2) strategies to adapt EBPs to improve their fit in different settings, 3) the potential for implementation science to address emerging clinical and public health concerns.ImplicationsThe common topics discussed underscored that disparities in access to evidence-based mental health care are prevalent across countries. Opportunities for cross-country and cross-discipline learnings and collaborations can help drive solutions to address these inequities, which relate to the availability of a trained and culturally appropriate workforce, insurance reimbursement policies, and designing interventions and implementation strategies to support sustained use of evidence-based practices