HEALTH SYSTEMS IN TRANSITION HiT ( 2010 ): European Observatory on Health Systems and Policies and URC Eco Unité de Recherche en Economie de la Sante d’Ile-de-France at the Assistance Public Hôpitaux de Paris ( AP-HP ) : Karine Chevreul, Isabelle Durand-Zaleski and Stéphane Bahrami.
The French health care system is a mix of public and private providers and insurers. Public insurance, financed by both employees and employer contributions and earmarked taxes ( contribution sociale généralisée, base don total income and not only on earned income , additional 13% come from specific taxes) , is compulsory and covers almost the whole population, while private insurance is of a complementary type and voluntary. Providers of outpatient care are largely private. Hospital beds are predominantly publico or private non-profi-making.
Bismarckian approach with Beveridge goals reflected in the single public payer model, the current increasing immportance of tax-based revenue for financing health care and strong state intervention.
There is SHI, which, under various schemes, currently covers almost 100% of the resident population. The delivery of care is shared among private, fee-forservice physicians, private profit-making hospitals, private non-profit-making hospitals and public hospitals. In addition to the health care sector and the social sector, there is a health and social care sector, known as the third sector, which provides care and services to elderly and disabled people.
Jurisdiction in terms of health policy and regulation of the health care system is divided among the state ( parliament, government and the Asministration of Health and Social Affairs ), SHI and to a lesser extent, local communities, particularly at the regional level. Several regional institutions were created to represent the main stakeholders, such as SHI schemes, the statem health professionals and public health actors.
Fundamental Rights of doctors :
Population has a high level of choice of providers.
Rising cost of health care. Measures to contain costs and increase efficiency. P4P ( pay-for-performance ) for both hospitals and self-employed providers; Increasing quality of profesional practice; refining patient pathways; raising additional revenue for statutory health insurance ( SHI ); and increasing the role of voluntary health insurance ( VHI ). To avoid social inequities : Complementary universal health coverage, couverture maladie universelle complémentaire, CMU-C for lower socioeconomic groups, 7% of population). For long-term, elderly and disabled : National Solidarity Fund for Autonomie , Caisse nationale de solidarité pour l’autonomie, CNSA ) Since 2004 in hospital acute care DRG payment ( tarification à l’activité, T2A ). Self-employed professionals paid fee-for –service ).
Socioeconomic disparities and geographic inequality in the density of health care professionals.
Organizational changes at the regional level. Ministry of Health retains the substantial control over the health system.
2009 Hospital, Patients, Health and Territories Act. ( Loi hôpital, patients, santé et territoirs ) merging stakeholders into the regional health agencies ( agence régionale de santé ) cutting across the traditional boundaries of health care, public health and health and social care sectors.
France : 26 regions, 100 départements, 36 679 municipalities. Population of 64.275.000 persons. Parliamentary democracy with a president and a bicameral parliament ( National Assembly and Senate ).
Financing : mainly through SHI, around three quarters. The remaining one quarter is funded by complementary sources, such as VHL.
Total expenditure ( 2007 ) 208 billion €, 11% of gross domestic product ( GDP ). Since 1996, SHI anual expenditure has been capped by a national ceiling for SHI expenditure ( objectif national des dépenses assurance maladie ONDAM ).
SHI coverage according resident status. Services and godos defined in positive lists. ( from 15% for drugs up to 80% for inpatient care ) . Free from co-insurance : chronic conditions and pregnancy after the fifth month.
Planing and regulation : by means of negociations among provider representatives ( Hospitals, health professionals ), the state – Ministry of Health and Ministry of Budget Public Accounts, the Civil Service and State Reforms, and SHI. Outcome of negotiations translated into administrative decrees and laws passed by the parliament. These include public health acts, social security funding acts and reform acts. But the role of the state is increasing.
EANA – Spring meeting
National Report France
Report from France on changes in the health system and the position of the CSMF
This year saw the end of Michel Chassang's twelve years in office, and the start of a new presidency that will follow the same course as its predecessor. The new President, Dr Jean Paul Ortiz, is a nephrologist and will continue to practise medicine in his region two to three days a week.
He is assisted by an Executive Committee, which has been joined by three new faces: symbolically, the new Vice President is a female general practitioner, a first for CSMF, and the President of the UMESPE, a gastroenterologist, and of the UNOF, both private practitioners, are younger than their predecessors.
The commitments made, particularly as regards national medical agreements, by the exiting team, remain unchanged, whether these concern the upcoming inter-professional agreement negotiations or the application of the contrat d'acces aux soins (healthcare access contracts which set a cap on doctors' consultation fees).
As such, the CSMF will continue the work started concerning changes to the profession, for example those to medical companies, doctors' working conditions and the quality of inter-professional cooperation – both in private practices and in public healthcare facilities – social cover – which must be topped up – and of course, the ongoing issue of pay.
The CSMF remains committed to the national medical agreement and to the implementation of a unique agreement for all practitioners.
As such, the CSMF will place particular focus on group practices, and especially maisons de santé (polyclinics) and pôles de santé (an administrative organisation coordinating healthcare provision between private practitioners), which are one of the new solutions to maintaining geographical coverage of private healthcare provision and to improving the attractiveness of private medicine for young people.
The CSMF will continue to support doctors working as sole practitioners, a more traditional private practice that is, at present, the most predominant.
By appointing, for the first time, a woman as Vice President, the CSMF is sending a clear signal that it is in tune with societal changes and the growing proportion of women in the medical profession, and that it is committed to increasing the number of women on its executive team.
For the coming years, CSMF has set itself three priorities:
Priority 1: Fee negotiations in 2014, raising the fee for standard consultations (the content of which is not in line with the fee fixed by the government) to a minimum of €25. To bring the content of medical consultations into line with their fee, the only solution in our mind is to implement a Classification Commune des Actes Médicaux Cliniques (medical classification for clinical procedures) and to raise the fees for technical procedures, taking into full account the cost of practice.
However, raising medical fees also involves extending the Rémunération sur Objectifs de Santé Publique (performance-based bonus scheme), to all specialist fields and not just general medicine, cardiology and gastroenterology, starting with the specialist fields for which this has already been finalised (paediatrics and endocrinology).
We hope that the issue of permanence des soins (after-hours care) will be reincorporated in the agreements in order to enable urgent negotiation for a rise in compensation and add-on fees (taking into consideration the iniquities and pay decreases since it was entrusted to the Agences Régionale de Santé (regional health agencies)).
It would also like to see all practitioners involved in the system compensated.
In addition, the CSMF has specified that it will not give any ground on the voluntary principle of after-hours care – a hard won gain in 2002 – and which must remain the absolute rule both in outpatient settings and hospital settings.
Priority 2 – The French national healthcare strategy (Stratégie Nationale de Santé) which has become, for the government, the cornerstone of healthcare reform. We would like guarantees to avert the risk of state control and to ensure that, alongside general practitioners, other specialists working in both first- and second-line health services, are included in future care paths. It does not wish to see private medicine brought under the control of the ARS.
Unfortunately, the only negotiation being considered by the government and health insurance bodies is on the future standard pay of multi-disciplinary healthcare teams under the Accord Cadres Inter-Professionnelle (Inter-professional framework agreement).
The CSMF is opposed to the widespread use of third-party payment, as considered at present. It hopes that third-party payment remains limited to the provisions set out in the agreement and that more flexible methods - such as healthcare debit cards - be implemented with the banking system.
Finally, we ask that the transfer of hospital activities to private outpatient practices must be accompanied by corresponding budget transfers to give non-hospital facilities the means to organise.
Priority 3: Full application of the Contrat d’accès aux soins (CAS) with compulsory payment, in future responsible contracts, of the additional fees of doctors who have signed the CAS, without detriment to or undermining the ‘non-fixed fee’ sector.
Current sector 1 fees do not match the service provided by private practitioners, whatever their specialist field. The fee increase demanded by the CSMF in 2014 will boost recognition of and respect for private practitioners. This demand is all the more justified given that the non-hospital national health insurance expenditure target (ONDAM; (objectif national des dépenses d'assurance maladie) is repeatedly under-used, reaching a high of €1 billion in 2013 (but nearly €3 billion over the last three years), and that reducing the number of medical procedures will make it possible to finance this increase without generating ill-considered inflation in healthcare spending. Health insurance bodies and the government should know that the CSMF is particularly determined to see this legitimate claim through and will not hesitate to battle it out if necessary. Indeed, French doctors are still among the lowest paid compared with their OECD colleagues.
Rational development of the healthcare system and of demographic issues requires, in our opinion, reforms to medical training and initial training:
Initial training: the issue with current study programmes is that doctors are trained according to hospitals' needs and hospital training opportunities, without taking into account regional healthcare needs. Training is totally hospital-centred and ill-suited to the work that practitioners will perform once they enter the profession. We are working on the possibility of a regional numerus clausus based on healthcare needs, and also on the development of a programme that places earlier focus on the type of work young doctors will encounter when entering the profession by developing internships earlier in the programme both for general practitioners and for bodies.
Regarding ongoing training: the French law on hospital reform and on patients, healthcare and the regions (Loi Hôpital Patients Santé Territoires) of 2009 replaced practice assessments and ongoing training with compulsory continuous professional development for all health professionals, which comprises an audit of practice followed by training based on the results of the audit then remote assessment – a system that unfortunately has an ill-suited, discouraging and highly onerous administrative organisation.
Disadvantages: It is no longer the training programmes that are accredited, but the training body (opening the door to professional bodies and not just medical bodies).
Particularly the insufficient budget, despite the introduction of a €150,000 tax on the pharmaceutical industry (following the Mediator affair) to finance continuing professional development, and which in reality does not make it possible, despite the law, to train all doctors:
Before continuing professional development: €75 million: 25,000 doctors.
In 2013: €100 million for 31,000 doctors trained.
Difficulty under these circumstances to motivate untrained doctors
Dr Pierre LEVY
April 30, 2014