General Insurance Scheme Research Articles

RIGHTS AND OBLIGATIONS OF THE SUBJECTS OF PRE-LITIGATION PROCEEDINGS IN THE RETIREMENT MATTERS OF THE GENERAL INSURANCE SYSTEM

The rights and obligations of the parties to pre-judicial proceedings in matters relating to pensions under the general insurance scheme are inextricably linked to the legal relationship of the insurance company. It determines the connections and relationships between the subjects that they participate in the guarantee phase, which during the implementation phase of the legal relationship the mutual rights and obligations of the entities involved in proceedings before the pension authority depend on those relationships. Therefore, it is particularlyimportant to separate them from all entities that may participate in the procedure and to establish their logical relations and scopes. It is also important to determine whether to in any case, the law of one person will be matched by the obligation of the other, and vice versa.

Economic burden of HIV disease from 2012 to 2017 based on the French national claim database (SNDS)

Abstract Background The aim of this study was to assess the economic burden of HIV disease in France, by analyzing structure and trends of expenditure between 2012 and 2017. Methods We identified people with HIV disease among beneficiaries of the health insurance general scheme (covering more than 57 million people, 87% of the French population), applying algorithms combining inpatient and outpatient diagnoses and claims for specific drug treatments or laboratory examinations. The individuals’ expenditure (26 different items) reimbursed for hospitalizations, ambulatory care and cash payments were included. A top-down method was used to attribute expenditure to HIV disease based on the average expenditure calculated for individuals with only HIV disease. To analyze trends, we applied the same methodology from 2012 through 2017. Results In 2017, HIV disease was identified for 131 800 individuals (0.2% of the population) and expenditure attributed to HIV disease corresponded to €1.3 billion (1% of the 140.1 billion reimbursed by the general insurance scheme). Drug treatment accounted for 85% of total expenditure reimbursed (1.2 billion). Between 2012 and 2017, the number of HIV patients identified increased steadily (+16,800 patients with an annual growth rate of 2.8%) and expenditure attributed to HIV disease increased by €8 billion. However, annual expenditure growth was variable, as a result of instability in the average annual cost per patient, ranging from 9,700€to 11,100€per year per patient. This reflects changes in practice and drug prices. Conclusions The detailed analysis of expenditures attributed to HIV disease showed that drug treatments account for the large majority of total reimbursements. Annual variation in total expenditure could therefore reflect evolution in prescription practices, such as the extension of treatment indications; or in drug prices, with the availability of combined treatments. Key messages Drug treatments account for the large majority of total reimbursements among HIV patients. Variation in total expenditure attributed to HIV disease is mainly driven by prescription practices and drug prices.

PIN35 GLOBAL ANNUAL COSTS OF PEOPLE LIVING WITH HIV IN FRANCE IN 2013 FROM A NATIONAL INSURANCE CLAIMS DATABASE (SNIIRAM)

The study assesses the global annual cost of people living with HIV (PLWHIV) in France in 2013 and affiliated to the general insurance scheme during 2008-2015. We performed a retrospective cohort study in the SNIIRAM database containing individualized data on all reimbursed health expenses for the French population. PLWHIV were identified by specific chronic diseases status and/or reimbursement of HIV laboratory tests and/or HIV-related hospitalizations and/or reimbursements of antiretroviral drugs in 2013. Each patient was followed two years after his inclusion. Hospital and outpatient costs were estimated and categorized in 13 subgroups: antiretroviral drugs, daily sick leave benefits, other drugs, paramedical visits, general practitioner visits, specialist visits, medical devices, transports, laboratory tests, other outpatient costs, hospital stays, hospital outpatient consultations and hospital at home. Costing was performed considering French official tariffs for 2013 and 2014 and expressed in 2019 euros. A cohort of 96,423 PLWHIV was identified. Mean age was 47.5 years old (±12), 65% were men, and most frequent treatments outside HIV drugs were treatments for cardiovascular disease (20%), psychotropic treatments (16%) and liver disease (15%). The total annual cost of PLWHIV was calculated to €1.4 billion, split into antiretroviral drugs for 63% (870M€), hospital stays for 11% (154M€), daily sick leave benefits for 8% (116M€), other drugs for 5% (73M€). The median annual cost per patient was estimated to be €12,094 [±10,801, Q1: 9,001, Q3: 16,795], varying from €618 for 0-10 years old PLWHIV to €13,725 for 51-60 years old PLWHIV, €11,969 for incident patients (N=3,373), and €13,560 for patients with at least one comorbidity. This study shows that the global annual cost of PLWHIV is mainly charged to antiretroviral drugs cost. Only thin disparities in total cost were observed in each group (age, incident, comorbidity), advanced analyses such as Machine Learning could identify significantly overexpressing cost profiles.

PIN150 ANALYSIS OF TREATMENT SEQUENCES FROM THE FRENCH NATIONAL SNIIRAM DATABASE: CASE STUDY OF INCIDENT PEOPLE LIVING WITH HIV IN 2013

The study purpose was to describe the changes and discontinuations of antiretroviral combination therapy (cART) (number of treatments, occurrence, duration) over the cohort of incident people living with HIV (PLWHIV) in 2013, included in the French national Health Insurance database (SNIIRAM). It also aims at experimenting data mining methods to study treatment sequences. From the SNIIRAM, we extracted PLWHIV affiliated to the general insurance scheme (N=96,423) through specific chronic diseases status and/or reimbursement of HIV laboratory tests and/or HIV-related hospitalizations and/or reimbursements of antiretroviral drugs in 2013. Incident patients (N=3,373) were followed for 2 years to identify their cART, categorized as single, double, triple or quadruple+ combination therapies. The treatment sequences were arranged according to a similarity criterion. It was performed by an Agglomerative Clustering algorithm configured with the Hamming distance and the Ward linkage method. The result is a graph containing one discretized timeline per patient. The lines were put in order one above the other and follow the 2-year follow-up. Finally, a smoothing was applied to the image to homogenize and highlight distinctive patterns. The combination of Agglomerative Clustering and of image processing forms an innovative methodology called TAK: Time-sequence Analysis through K-clustering. Over the 3,373 incident patients, 363 (11%) received no antivirals drugs during the follow-up, 385 (11%) were only treated after 6 months and 255 (8%) stopped cART at least one period during follow-up. 1,675 (50%) patients solely received a triple therapy over the follow-up, 484 (14%) changed at least once from a triple therapy to a single/double. In 2013, a triple therapy was the reference treatment and 30% of the patients had a 6-month period without any cART. This study validates the relevance of combining clustering methods with image processing to visualize the treatment sequences of a cohort in a clear and synthetic way.

Determinants of Case Fatality After Hospitalization for Stroke in France 2010 to 2015.

Background and Purpose- The aims of this study were to (1) describe early and late case fatality rates after stroke in France, (2) evaluate whether their determinants differed, and (3) analyze time trends between 2010 and 2015. Methods- Data were extracted from the Système National des données de santé database. Patients hospitalized for stroke each year from 2010 to 2015, aged ≥18 years, and affiliated to the general insurance scheme were selected. Cox regressions were used to separately analyze determinants of 30-day and 31- to 365-day case fatality rates for each stroke type (ischemic, intracerebral hemorrhage, and subarachnoid hemorrhage). Results- In 2015, of the 73 124 persons hospitalized for stroke, 26.8% died in the following year, with the majority of deaths occurring within the first 30 days (56.9%). Nonadmission to a stroke unit, older age, and having comorbidities were all associated with a poorer 30-day and 31- to 365-day prognosis. Female sex was associated with a lower 31- to 365-day case fatality rate for all patients with stroke. Living in an area with a high deprivation index was associated with both higher 30-day and 31- to 365-day case fatality rates for all stroke types. Between 2010 and 2015, significant decreases in both 30-day and 31- to 365-day case fatality rates for ischemic patients were observed. Conclusions- Case fatality rates after stroke remained high in 2015 in France, despite major improvements in stroke care and organization. Improvement in stroke awareness and preparedness, particularly in the most deprived areas, together with better follow-up after the acute phase are urgently needed.

Where Next for Long‐Term Care?

Where Next for Long‐Term Care?

Exchangeable Femoral Neck (Dual-Modular) THA Prostheses Have Poorer Survivorship Than Other Designs: A Nationwide Cohort of 324,108 Patients

BackgroundExchangeable neck stems, defined as those with a dual taper (that is, a modular junction between the femoral head and the femoral neck and an additional junction between the neck and the stem body), were introduced in THA to improve restoration of joint biomechanics (restoring anteversion, offset, and limb length) and reduce the risk of dislocation. However exchangeable necks have been reported to result in adverse effects such as stem fractures and acute local tissue reaction. Whether they result in a net improvement to or impairment of reconstructive survivorship remains controversial.Questions/Purposes(1) To compare the prosthetic survivorship and all-cause revision risk of exchangeable femoral neck THAs versus fixed neck THAs, taking known prosthetic revision risk factors into account; and (2) to compare the cause-specific revision risk of exchangeable femoral neck THAs versus fixed neck THAs, adjusting for known prosthetic risk factors.MethodsUsing French national health-insurance databases, we identified all French patients older than 40 years who underwent primary THA from 2009 through 2012. To ensure accuracy of the data, we considered only beneficiaries of the general insurance scheme (approximately 77% of the population). Characteristics of the prosthesis and the patients receiving an exchangeable femoral neck THA were compared with those receiving a fixed femoral neck THA (defined as femoral stem with only the head being exchangeable). Revision was the event of interest. Followup started on the date the THA was performed, until the patient experienced revision, died, was lost to followup, or until the followup period ended (December 31, 2014), whichever came first. Competing risk THA survivorship was calculated and compared (purpose 1), as were cause-specific Cox regression models (purpose 2). The study cohort included 324,108 individuals with a mean age of 77 years. A total of 24% underwent THA for acute trauma, and 3% of the group received an exchangeable neck THA. During the median 45-month followup (mean, 42 months; minimum, 1 day; maximum, 6 years), 11,968 individuals underwent prosthetic revision.ResultsThe cumulative revision incidence was 6.5% (95% CI, 5.8%–7.3%) for exchangeable neck THAs versus 4.7% (95% CI, 4.6%–4.8%) for fixed neck THAs (p < 0.001). After controlling for potential confounding variables including age, sex, comorbidities, indication for THA, cementation, bearing surface, and the characteristics of the center where the implantation was performed, we found that the exchangeable femoral neck THA was associated with an increased hazard ratio (HR) of revision of 1.26 (95% CI, 1.14–1.38; p < 0.001) compared with the fixed neck THA. When dealing with cause-specific revision, exchangeable neck THAs had a higher incidence of revision for implant failure or periprosthetic fracture, and for mechanical complications; adjusted HRs were, respectively, 1.68 (95% CI, 1.24–2.27; p < 0.001) and 1.27 (95% CI, 1.13–1.43; p < 0.001), for exchangeable neck THAs compared with fixed ones.ConclusionsExchangeable neck THAs had poorer survivorship independent of other prosthetic revision risk factors. Accordingly, expected anatomic and functional benefits should be carefully assessed before choosing this design.Level of EvidenceLevel III, therapeutic study.

Dépistage du cancer du sein dans treize départements français

In France, breast cancer screening programme, free of charge for women aged 50-74 years old, coexists with an opportunistic screening and leads to reduction in attendance in the programme. Here, we reported participation in organized and/or opportunistic screening in thirteen French departments. We analyzed screening data (organized and/or opportunistic) of 622,382 women aged 51-74 years old invited to perform an organized mammography screening session from 2010 to 2011 in the thirteen French departments. The type of mammography screening performed has been reported according to women age, their health insurance scheme, the rurality and the socioeconomic level of their area or residence. We also represented the tertiles of deprivation and participation in mammography screening for each department. A total of 390,831 (62.8%) women performed a mammography screening (organized and/or opportunistic) after the invitation. These women were mainly aged from 55-69 years old, insured by the general insurance scheme and lived in urban, semi-urban or affluent areas. The participation in mammography screening (organized and opportunistic) in France remains below the target rate of 70% expected by health authorities to reduce breast cancer mortality through screening.

The West German health and social services: A comparison with their British equivalents

An analysis has been made of the German local government, health and social services, with particular reference to West Berlin. A comparative study of these with those of Great Britain show many points of similarity but also reveal several fundamental differences. These are:— o (i) Federal, Land and Local Government .—The Land , like the American State, is the sovereign power in the federal system. Its local government units are based on regional groupings which incorporate both town and country and control almost all public utilities and services which are situated within their own area. (ii) Health Services .—( a ) By their almost complete devolution of authority from the Land to the local unit of authority, the latter's health department has the opportunity of offering a much more comprehensive co-ordination of all social, health and welfare agencies at community level. ( b ) Insurance medical practice is still a part of the general insurance scheme. Great Britain would have had a comparable scheme if, in 1948, the National Health Insurance's range of medical care had been extended to cover dependents and all forms of institutional treatment. (iii) Social Insurance .—( a ) The insurance schemes run by public corporations, are actuarial in that they are self-supporting and, within an upper and a lower limit, the more a man earns the greater his contributions and his eventual benefits. As these schemes are entirely independent of the Land finances, the individual contributions are much higher than those in Great Britain. ( b ) These insurance schemes show, incidentally, that the Germans have accepted the principle of equal pay for equal work. In the salaried groups the pay is weighted for both marriage and children. (iv) Labour Department .—( a ) Unemployment benefits include a rent assessment and so are relatively higher than those in Britain. There is, however, a tighter means test employed for those on assistance. ( b ) The German trade unions have advanced beyond joint consultation in industry to an active share in industrial policy decisions.