Research

Work in Progress

• Hospital ownership and input efficiency: evidence from France (Latest Version),. joint work with Solèn Croiset and Robert Gary-Bobo -  R&R at JEEA

Abstract : Using an almost exhaustive panel of French hospitals during the pre-Covid period, 2015-2019, we studied the comparative efficiency of ordinary public hospitals, teaching public, for-profit and not-for-profit private hospitals. Our comparison is based on the estimation of conditional labour-demand functions, explaining the employment levels of several categories of personnel, including doctors and nurses, as a function of a list of hospital outputs. We show that there exist large, significant and robust differences in the employment levels of various categories of personnel between the four groups of hospitals, conditional on the same vector of outputs. The public hospitals employ on average much more nurses and assistant-nurses than the for-profit hospitals, conditional on the same list of outputs. The public teaching hospitals, i.e., the largest hospitals in France, are the least efficient, from this point of view. These results are obtained while controlling finely for the severity of cases (i.e., the casemix), the age of patients, the research and training (i.e., higher education) activities. For instance, we find that the teaching hospitals employ around 40% more registered nurses than the private for profit hospitals, conditional on the same output vector.

• Estimating the impact of hospital closure in France (Latest Version), joint work with Titouan Le Calvé

Abstract :   During the last years, dozens of hospitals have closed in France, in many cases without opening of new facilities to compensate. This study examines the causal impact of these closures on patient outcomes, distinguishing two key mechanisms through which these closures affect patient care: the relocation effect and the hospital response. The relocation effect occurs when patients who would have been treated at the closed hospital must seek care at another facility. The hospital response effect arises when hospitals face a demand shock that affects the quality of care either through overcrowding or through strategic adaptations to changes in the competitive landscape. To assess these effects, the study employs a hospital choice model to estimate counterfactual hospital selection—that is, the hospital a patient would likely have chosen had the closure not occurred. We find that, in contrast to studies in other countries, definitively closed French hospitals did not systematically provide lower-quality care than those that remained open, leading to heterogeneous relocation effects. In contrast, hospitals that relocated to larger, more modern facilities increased patient volumes while delivering higher quality than surrounding hospitals. Finally, all types of closures lead to a deterioration in outcomes at competing hospitals, with a significant increase in complication rates occurring alongside a slight increase in patients’ length of stay.  

• The impact of hospitals mergers on the service provision and quality, joint work with Daniel Herrera 

Abstract : The French for-profit hospital sector has become markedly more concentrated, with the ten largest hospital network increasing their share of private hospital activity from 45% in 2013 to over 65% in 2019. Yet, the consequences of this rapid consolidation for healthcare quality and organization remain largely unexplored. Economic theory suggests that reduced competition may lead to lower quality of care, while hospital groups might also reallocate and specialize services across facilities to enhance efficiency, potentially compromising access to care. Using a difference-in-differences approach, we find that smaller hospitals tend to specialize following a merger, whereas larger hospitals exhibit declines in quality, reflected in higher risk-adjusted mortality rates and longer risk-adjusted lengths of stay.