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The French Health Care System

by Isabelle Durand-Zaleski, AP-HP and Université Paris-Est, Paris, France

What is the role of government?

The provision of health care in France is a national responsibility. The Ministry of Social Affairs, Health, and Women’s Rights is responsible for defining national strategy. Over the past two decades, the state has been increasingly involved in controlling health expenditures funded by statutory health insurance (SHI).1

Planning and regulation within health care involve negotiations among provider representatives, the state, and SHI. Outcomes of these negotiations are translated into laws passed by Parliament.

In addition to setting national strategy, the responsibilities of the central government include allocating budgeted expenditures among different sectors (hospitals, ambulatory care, mental health, and services for disabled residents) and, with respect to hospitals, among regions. The ministry is represented in the regions by the regional health agencies, which are responsible for population health and health care, including prevention and care delivery, public health, and social care. Health and social care for elderly and disabled people come under the jurisdiction of the General Councils, which are the governing bodies at the local (departmental) level.

Who is covered and how is insurance financed?

Publicly financed health insurance: Total health expenditures constituted 12 percent of GDP (EUR257 billion, or USD310 billion) in 2014, of which 76.6 percent was publicly financed.

SHI is financed by employer and employee payroll taxes (50%); a national earmarked income tax (35%); taxes levied on tobacco and alcohol, the pharmaceutical industry, and voluntary health insurance companies (13%); and state subsidies (2%).

Coverage is universal and compulsory, provided to all residents by noncompetitive SHI. As of January 2016, SHI eligibility is universally granted under the PUMA (Protection universelle maladie, or universal health care coverage) law.2 Citizens can opt out of SHI only in rare cases—for example, individuals employed by foreign companies.

The state finances health services for undocumented immigrants who have applied for residence. Visitors from elsewhere in the European Union (EU) are covered by an EU insurance card. Non-EU visitors are covered for emergency care only.

Private health insurance: Most voluntary health insurance (VHI) is complementary, covering mainly the copayments for usual care, balance billing, and vision and dental care (minimally covered by SHI). Complementary insurance is provided mainly by not-for-profit, employment-based mutual associations or provident institutions, which are allowed to cover only copayments for care provided under SHI; 95 percent of the population is covered either through employers or via means-tested vouchers. Private for-profit companies offer both supplementary and complementary health insurance, but only for a limited list of services.

VHI finances 13.5 percent of total health expenditure.3 The extent of VHI coverage varies widely, but all VHI contracts cover the difference between the SHI reimbursement rate and the service fee according to the official fee schedule. Coverage of balance billing is also commonly offered, and most contracts cover the balance for services billed at up to 300 percent of the official fee.

In 2013, standards for employer-sponsored VHI were established by law to reduce inequities in coverage stemming from variations in access and quality. By 2017, all employees will benefit from employer-sponsored insurance (for which they pay 50% of the cost), which will cover at least 125 percent of SHI fees for dental care and EUR100 (USD121) for vision care per year.4 The population of beneficiaries without supplementary insurance is estimated at 4 million. Choice among insurance plans is determined by the industry in which the employer operates.

What is covered?

Services: Lists of procedures, drugs, and medical devices covered under SHI are defined at the national level and apply to all regions of the country. The health ministry, a pricing committee within the ministry, and SHI funds set these lists, rates of coverage, and prices.

SHI covers hospital care and treatment in public or private rehabilitation or physiotherapy institutions; outpatient care provided by general practitioners, specialists, dentists, and midwives; diagnostic services prescribed by doctors and carried out by laboratories and paramedical professionals; prescription drugs, medical appliances, and prostheses that have been approved for reimbursement; and prescribed health care–related transportation and home care. It also partially covers long-term hospice and mental health care and provides only minimal coverage of outpatient vision and dental care.

While preventive services in general receive limited coverage, there is full reimbursement for targeted services, such as immunization, mammography, and colorectal cancer screening, as well as targeted populations. A measure of the “Touraine law,” adopted on April 14, 2015, mandated the legalization of drug-use centers over a subsequent six-year period. These centers will be used exclusively for treatment of especially vulnerable drug addicts, under the supervision of health professionals.5

Cost-sharing and out-of-pocket spending: Cost-sharing takes three forms: coinsurance; copayments (the portion of fees not covered by SHI); and balance billing in primary and specialist care. In 2014, total out-of-pocket spending made up 8.5 percent of total health expenditures (excluding the portion covered by supplementary insurance), a lower percentage than in previous years—possibly because of the agreement signed between physicians’ unions and government to limit balance billing in exchange for its voluntary capping at twice the official fee. This contract offers patients partial reimbursement of balance billing by SHI and reduced social charges for physicians.

Most out-of-pocket spending is for dental and vision services, for which official fees are very low, not more than a few euros for glasses or hearing aids and a maximum of EUR200 (USD241) for dentures, but all of these are commonly balance-billed at more than 10 times the official fee. The share of out-of-pocket spending on dental and optical services is decreasing, however. At the same time, out-of-pocket expenditures on drugs are increasing, owing to increased VHI coverage of dental and optical care and increasing numbers of delisted drugs, as well as a rise in self-medication.

Coinsurance rates are applied to all health services and drugs listed in the benefit package and vary by:

  • type of care (inpatient, 20%; doctor visits, 30%; and dental, 30%)
  • the effectiveness of prescription drugs (highly effective drugs, like insulin, carry no coinsurance; rates for all other drugs are 15% to 100%, depending on therapeutic value)
  • compliance with the recently implemented gatekeeping system

The table below lists nonreimbursable copayments for various services. These apply up to an annual ceiling of EUR50 (USD60). There are no deductibles.

ServiceCopayment
EurosU.S. Dollars
Inpatient hospital day18.0022.00
Doctor visit1.001.20
Prescription drug0.500.60
Ambulance2.002.40
Hospital18.0022.00

Safety net: People with low incomes are entitled to free or state-sponsored VHI, free vision care, and free dental care, with the total number of such beneficiaries estimated at around 10 percent of the population.6 Exemptions from coinsurance apply to individuals with any of 32 specified chronic illnesses (13% of the population, with exemption limited to treatment for those conditions); individuals who benefit from either complete state-sponsored medical coverage (3%) or means-tested vouchers for complementary health insurance (6%); and individuals receiving invalidity and work-injury benefits (2%).7 Hospital coinsurance applies only to the first 31 days in hospital, and some surgical interventions are exempt. Children and people with low incomes are exempt from paying nonreimbursable copayments.

How is the delivery system organized and financed?

Collective agreements between representatives of the health professions and SHI, signed at the national level, apply to all but those professionals who expressly opt out. These agreements set the fee schedule as well as coordination and quality incentives.

Primary care: There are roughly 221,000 general practitioners (GPs) and 119,000 specialists in France (a ratio of 3.4 per 1,000 population). About 59 percent of physicians are fully or partly self-employed (67% of GPs, 51% of specialists).8 Over 50 percent of GPs, predominantly younger doctors, are in group practices. An average practice is made up of two to three physicians. Seventy-five percent of practices are made up exclusively of physicians; the remaining practices comprise a range of allied health professionals, typically paid fee-for-service.

There is a voluntary gatekeeping system for adults age 16 and older, with financial incentives offered for registering with a GP or specialist.

Self-employed GPs are paid mostly fee-for-service (currently EUR23, or USD28, to be increased to EUR25, or USD30, in 2017) and can receive a yearly capitated per-person payment of EUR40 (USD48) to coordinate care for patients with a chronic condition. In addition, up to EUR5,000 (USD6,024) annually is provided for achieving targets related to the use of computerized medical charts, electronic claims transmission, delivery of preventive services such as immunization, compliance with guidelines for diabetic and hypertensive patients, generic prescribing, and limited use of psychoactive drugs for elderly patients.

Since 2013, GPs also can enter into a contractual agreement under which they are guaranteed a monthly income of EUR6,900 (USD8,313) if they set up their practice in a region with insufficient physician supply. For those who elect to work full-time in medical centers, the guaranteed salary is around EUR50,000 (USD60,240).

The average income of primary care doctors in 2011 was EUR82,020 (USD98,820), 94 percent of which came from fees and the remainder from financial incentives and salary.9 Fees, set by the health ministry and SHI, have been frozen since 2011, but revenues from other sources have increased.

Experimental GP networks providing chronic care coordination, psychological services, dietician services, and other care not covered by SHI are financed by earmarked funds from the Regional Health Agencies. In addition, over 1,000 medical homes, providing multiprofessional services (usually with three to five physicians and roughly a dozen other health professionals) and after-hours care, will be in operation by the end of 2016.

Outpatient specialist care: About 36 percent of outpatient specialist care providers are exclusively self-employed and paid on a fee-for-service basis; the rest are either fully salaried by hospitals or have a mix of income. In October 2014, participation in pay-for-performance programs was extended to all self-employed physicians, including specialists; specialists must meet disease-specific quality targets in addition to those targets that apply to GPs. The average annual income derived from pay-for-performance is EUR5,480 (USD6,602) per physician; such income constitutes less than 2 percent of total funding for outpatient services.

Patients can choose among specialists upon referral by a GP, with the exception of gynecologists, ophthalmologists, psychiatrists, and stomatologists. Bypassing referral results in reduced SHI coverage.

The specialist fee set by SHI is EUR28 (USD34), but specialists can balance-bill. The average yearly income of self-employed specialists is EUR133,460 (USD160,795).10 Half of specialists are in group practices, which are increasing among specialties that require major investments, such as nuclear medicine, radiotherapy, pathology, and digestive surgery.

Specialists working in public hospitals may see private-pay patients on either an outpatient or an inpatient basis, but they must pay a percentage of their fees to the hospital. A 2013 report to the health ministry estimated that 10 percent of the 46,000 hospital specialists in surgery, radiology, cardiology, and obstetrics had treated private patients. The mounting discontent over excessive balance billing revealed in the press, together with claims by private clinics of unfair competition, has prompted several public inquiries—the latest of which resulted in recommendations to increase public control over this activity.

Administrative mechanisms for direct patient payments to providers: Patients pay the full fee (reimbursable portion and balance billing, if any) and claim reimbursement covering the full sum or less, depending on coverage, minus EUR1.00 (USD1.20), capped at a maximum of EUR50.00 (USD60.00) per patient per year. A very controversial article in the 2015 Touraine law was the third-party payment management system (Système du tiers-payant) as a safety net for the poorest populations. Third-party payment makes physicians’ consultations totally free at the point of care: practitioners will be paid directly by social security and supplementary health insurance.11

After-hours care: After-hours care is delivered by the emergency departments of public hospitals, private hospitals that have signed an agreement with their Regional Health Agency, self-employed physicians who work for emergency services, and medical homes financed by SHI and staffed by health professionals on a voluntary basis. Primary care physicians are not mandated to provide after-hours care.

Emergency services can be accessed via the national emergency phone number, which is staffed by trained professionals who determine the type of response needed. The feasibility of telephone or telemedicine advice is undergoing experimentation; it would include sharing information from the patient’s electronic medical record with the patient’s primary care doctor. Publicly funded multidisciplinary health centers with self-employed health professionals (physicians and nonphysicians) allow better after-hours access to care in addition to more comprehensive care; fee-for-service payment is the rule for these centers.

Hospitals: Public institutions account for about 65 percent of hospital capacity and activity, private for-profit facilities account for another 25 percent, and private nonprofit facilities, the main providers of cancer treatment, make up the remainder. As of 2008, all hospitals and clinics are reimbursed via the diagnosis-related group (DRG) system, which applies to all inpatient and outpatient admissions and covers physicians’ salaries in public and not-for-profit hospitals. Bundled payment by episode of care does not exist.

Public hospitals are funded mainly by statutory health insurance (80%), with voluntary insurance and direct patient payment accounting for their remaining income. Public and private nonprofit hospitals also benefit from grants that compensate research and teaching (up to an additional 13% of the budget) and from the provision of emergency services, organ harvesting, and organ transplantation (on average, an additional 10%–11% of a hospital’s budget). Private, for-profit clinics owned either by individuals or, increasingly, by large corporations have the same funding mechanism as public hospitals, but the share of respective payers differs. Doctors’ fees are billed in addition to the DRG in private clinics, and DRG payment rates are lower there than they are in public or nonprofit hospitals. This disparity is justified by differences in the size of facilities, the DRG mix, and the patients’ characteristics (age, comorbid conditions, and socioeconomic status). Rehabilitative hospitals also have a prospective payment system based on length of stay and care intensity.

Mental health care: Services for mentally ill people are provided by both the public and the private health care sector, with an emphasis on community-based provision. Public care is provided within geographically determined areas and includes a wide range of preventive, diagnostic, and therapeutic inpatient and outpatient services. Ambulatory centers provide primary ambulatory mental health care, including home visits.

Mental health care is not formally integrated with primary care, but a large number of disorders are also treated on an outpatient basis by GPs or private psychiatrists or psychologists, some of them practicing psychotherapy and, occasionally, psychoanalysis.

Statutory health insurance covers care provided by GPs and psychiatrists in private practice, public mental health care dispensaries, and private psychiatric hospitals. Copayments do not apply to persons with a diagnosed long-term mental illness. Care provided by psychotherapists or psychoanalysts is fully financed by patients or covered by VHI. Copayments and the flat-rate fee for accommodation can also be fully covered by VHI.

Long-term care and social supports: Total expenditure for long-term care in 2013 was estimated to be EUR39 billion (USD47 billion), or 17 percent of total health expenditures. Statutory health insurance covers the medical costs of long-term care, while families are responsible for the housing costs in hospices and other long-term facilities—on average, EUR1,500 (USD1,809) per month. End-of-life care in hospitals is fully covered. Some funding of care for the elderly and disabled comes from the National Solidarity Fund for Autonomy, which is in turn financed by SHI and the revenues from an unpaid working “solidarity” day. Local authorities, the general councils, and households also participate in financing these categories of care.

Home care for the elderly is provided mainly by self-employed physicians and nurses and, to a lesser extent, by community nursing services. Long-term care in institutions is provided in retirement homes and long-term care units, totaling roughly 10,000 institutions with a total of 720,000 beds. Of these institutions, 54 percent are public, 28 percent private nonprofit, and 18 percent for-profit, although the percentage of for-profit institutions is increasing.

In addition, temporary care for dependent patients and respite services for their caregivers are available without restrictions from the states or regions.

Means-tested monetary allowances are provided for the frail elderly. The allowances are adjusted in relation to the individual’s dependence level, living conditions, and needs, as assessed by a joint health and social care team, and may be used for any chosen service and provider. About 1.1 percent of the total population is estimated to be eligible. Informal caregivers also benefit from tax deductions.

To address loss of autonomy among the elderly, a law enacted at the end of 2015 established local conferences to define priorities, identify existing services, and create new programs as necessary.12

diagram of health care system

What are the key entities for health system governance?

The health ministry sets and implements government policy in the areas of public health and the organization and financing of the health care system, within the framework of the Public Health Act. It regulates roughly 75 percent of health care expenditure on the basis of the overall framework established by Parliament, which includes a shared responsibility with statutory health insurers for defining the benefit package, setting prices and provider fees (including DRG fees and copayments), and pricing drugs.

The French Health Products Safety Agency oversees the safety of health products, from manufacturing to marketing. The agency also coordinates vigilance activities relating to all relevant products.

The Agency for Information on Hospital Care manages the information systematically collected from all hospital admissions and used for hospital planning and financing.

The remit of the National Agency for the Quality Assessment of Health and Social Care Organizations encompasses the promotion of patient rights and the development of preventive measures to avoid mistreatment, particularly in vulnerable populations such as the elderly and disabled, children, adolescents, and socially marginalized people. It produces practice guidelines for the health and social care sector and evaluates organizations and services.

The National Health Authority (HAS) is the main health technology assessment body, with in-house expertise as well as the authority to commission assessments from external groups. The HAS remit is diverse, ranging from the assessment of drugs, medical devices, and procedures to publication of guidelines, accreditation of health care organizations, and certification of doctors.

Competition is limited to VHI, whose providers are supervised by the Mutual Insurance Funds Control Authority.

The Public Health Agency (Santé publique France) was created in 2016 to protect population health.

What are the major strategies to ensure quality of care?

National plans have been developed for treatment of rare diseases and a number of chronic conditions, including cancer and Alzheimer’s, and rare diseases, as well as for prevention and healthy aging. These plans establish governance (for example, the cancer plan to coordinate research and treatment in cancer and establish guidelines for medical practice and activity thresholds), develop tools, and coordinate existing organizations. All plans emphasize the importance of supporting caregivers and ensuring patients’ quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice.

The HAS publishes an evidence-based basic benefit package for 32 chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson’s, and end-stage renal disease.

SHI and the health ministry fund “provider networks” in which participating professionals share guidelines and protocols, agree on best practices, and have access to a common patient record. Regional authorities fund telemedicine pilot programs to improve care coordination and access to care for specific conditions or populations, like newborns or the elderly. The Paerpa (Personnes agées en risque de perte d’autonomie) program, established in 2014 in nine pilot regions, is a nationwide endeavor to improve the quality of life and coordination of interventions for the frail elderly.

For self-employed physicians, certification and revalidation are organized by an independent body approved by the HAS. For hospital physicians, both can be performed as part of the hospital accreditation process.

Doctors, midwives, nurses, and other professionals must undergo continuous learning activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties, such as obstetrics, surgery, and cardiology. Accredited physicians can claim a deduction on their professional insurance premiums.

Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the HAS website (www.has-sante.fr). CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the health ministry, which publishes online technical information, data on hospital activity, and data on control of hospital-acquired infections. Currently, financial rewards or penalties are not linked to public reporting, although they remain a contested issue. Information on individual physicians is not available.

What is being done to reduce disparities?

There is a 6.3-year gap in life expectancy between males in the highest and males in the lowest social categories13 and poorer self-reported health among those with state-sponsored insurance and no complementary insurance. The 2004 Public Health Act set targets for reducing inequities in access to care related to geographic availability of services (so far, only nurses have agreed to limit new practices in overserved areas), financial barriers (out-of-pocket payments will be limited by state-sponsored complementary insurance), and inequities in prevention related to obesity, screening, and immunization. In 2009, launching its Second Cancer Plan, France placed inequalities at the heart of its public health policy. In 2012, the French president reaffirmed this priority with the Third Cancer Plan and later the 2015 Touraine law.14 A contractual agreement allows for the use of incentives for physicians practicing in underserved areas, the extension of third-party payment, and enforced limitations on denial of care.

National surveys showing regional variations in health and access to health care are reported by the health ministry.

What is being done to promote delivery system integration and care coordination?

Inadequate coordination in the health care system remains a problem. Various quality-related initiatives piloted by the health ministry or by regional agencies aim to improve the coordination of hospital, out-of-hospital, and social care (see above). They target the elderly and fragile populations and attempt to streamline the health care pathway, integrating providers of health and social care via a shared portal and case managers.

What is the status of electronic health records?

The initiative to fully integrate electronic health records (EHRs) has faced multiple delays, and the integration of information systems between health care professionals and hospitals remains limited.15 The EHR project (Projet dossier medical personnel) covers 587,443 patients as of 2016, or 0.8 percent of the population, and an estimated 731 hospitals.16 Hospital-based and office-based professionals and patients have a unique electronic identifier, and any health professional can access the record and enter information subject to patient authorization. Interoperability is ensured via a chip on patients’ health cards. By law, patients have full access to the information in their own records, either directly or through their GP. The sharing of information between health and social care professionals is not currently permitted but will be tested as part of the Paerpa program for hospice residents.

The government has created a national agency (ASIP santé) for expanding the uptake and interoperability of existing health information systems.

How are costs contained?

SHI has faced large deficits over the past 20 years, but they have fallen from EUR10.0 billion–EUR12.0 billion (USD12.1 billion–USD14.5 billion) in 2003 to EUR4.6 billion (USD5.5 billion) in 2015.17 This trend is the result of a range of initiatives, including a reduction in the number of acute-care hospital beds; the removal of 600 drugs from public reimbursement; an increase in generic prescribing and the use of over-the-counter drugs; a reduction in the price of generic drugs18; and a reduction of the official fees for self-employed radiologists and biology labs. Other measures include central purchasing to better negotiate costs, increasing the share of outpatient surgery, instituting earlier post-surgery and post-delivery discharge, and reducing duplicate testing. Competition is not used as a cost-control mechanism. Global budgets are used only in price–volume agreements for drugs or devices. Patient cost-sharing mechanisms include increased copayments for patients who refuse generics or do not use the gatekeeping system. The increasing price of drugs is addressed in two ways: 1) by using earmarked funds and capping the total cost of treatments at EUR700 million (USD843 million) in 2015, thus providing treatment to successive waves of patients by decreasing severity; and 2) by negotiating price-volume agreements and undisclosed rebates with manufacturers.

A number of initiatives to reduce “low-value” care, launched by SHI and HAS, include pay-for-performance to reduce prescription of benzodiazepines for elderly persons; reductions in avoidable hospital admissions for patients with heart failure; early discharge after orthopedic surgery and normal childbirth; information on the absence of benefit of prostate cancer screening; using DRG payments to incentivize shifts to outpatient surgery; establishing guidelines for the number of allowable off-work days according to disease or procedure; strengthening controls for the prescription of expensive statins and new anticoagulants; encouraging the use of Avastin over Lucentis, and of other less costly biosimilar drugs; and testing the use of taxi vouchers, instead of ambulances, for chronically ill patients.

What major innovations and reforms have been introduced?

The two major reforms of 2016 have been the universal access to statutory health insurance (effective January 2016) and the deployment of third-party payment for physicians’ consultations (to go into effect in 2017). Both reforms have a clear Beveridgian inspiration and are part of the policy to reduce social inequities in access to care; the latter has also been denounced by physicians’ unions as the “nail in the coffin” for private providers. Reducing health inequities was part of the 2012 presidential campaign platform and has been a recurrent theme for a number of years. While universal insurance access was implemented at once and without political difficulty, third-party payment is being implemented in stages. Starting in July 2016, patients with chronic conditions and pregnant women can obtain it, and by January 2017 all patients will be able to do so, with use becoming mandatory in November 2017. The impact on health inequities will be assessed by monitoring the uptake and patients’ use of medical resources.

References

1O. Nay, S. Béjean, D. Benamouzig et al., “Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities,” Lancet, May 28, 2016 387(10034):2236–49.

2www.ameli.fr

3DREES, Les dépenses de santé en 2014, Etudes et Résultats, no. 935, Ministère des Affaires sociales et de la Santé, Sept. 15, 2015.

4Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.83 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD (2015) for France.

5O. Nay, S. Béjean, D. Benamouzig et al., “Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities,” Lancet, May 28, 2016 387(10034):2236–49.

6DREES, Les dépenses de santé en 2014, Etudes et Résultats, no. 935, Ministère des Affaires sociales et de la Santé, Sept. 15, 2015.

7www.risquesprofessionnels.ameli.fr

8DREES, Portrait des professionnels de santé, Série Etudes et Recherche, no. 134, Ministère des Affaires sociales et de la Santé, Feb. 2016.

9Ibid.

10Ibid.

11O. Nay, S. Béjean, D. Benamouzig et al., “Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities,” Lancet, May 28, 2016 387(10034):2236–49.

12Cour des Comptes, Le maintien à domicile des personnes âgées en perte d'autonomie, July 2016, www.ccomptes.fr.

13DREES, Les dépenses de santé en 2014, Etudes et Résultats, no. 935, Ministère des Affaires sociales et de la Santé, Sept. 15, 2015; O. Nay, S. Béjean, D. Benamouzig et al., “Achieving Universal Health Coverage in France: Policy Reforms and the Challenge of Inequalities,” Lancet, May 28, 2016 387(10034):2236–49.

14Nay et al., ibid.

15Ibid.

16Dossier Médical Personnel, 2016.

17CNAMTS, Direction Déléguée des Finances et de la Comptabilité, Comptes CNAMTS exercice 2015.

18IRDES, Historique de la politique du médicament en France.