France Health Profile 2012

The French health care system was inspired by the Bismarckian model, with health insurance funds under the supervision of the national. It relies on a combination of public and private supply, even in the hospital sector. Patients benefit from easy access to care (freedom of choice, direct access to the specialists) and an abundant supply, particularly of self-employed doctors. Complementary VHI to cover the cost of statutory co-payments is widespread.

Recent reforms have transformed the original characteristics of the system:

• the 1996 Juppé reform increased the role of parliament; since then, an annual Social Security Funding Act defines a national spending ceiling for health insurance (ONDAM) in the following year; parliament as well approves a government statement on the next direction of national health policy;
• since 1997, employees’ contributions based on wages have been restored by a contribution based on total income, which has the character of a tax.

This move towards adopting some features of the Beveridge model has been reinforced by the introduction of the Universal Health Coverage (CMU) Act, which extends statutory health insurance coverage to amount French residents. In next, the French health care system will face a number of challenges. On the supply side, the number of doctors will decline as a result of past decisions to impose quotas in medical schools. A lot of fear a shortage of doctors, and this fear as well raises the question of the geographical distribution of doctors; it is already difficult to persuade doctors to practise in some rural or suburban areas. Financial incentives are to be created to encourage doctors to work in these areas, but beyond these incentives, doctors’ freedom of choice in deciding where to locate their practice and the optimal skill mix required are part the issues currently subject to debate.
These debates take place in a tense climate. Relations with doctors have deteriorated since 1996, when a major reform was implemented that put a ceiling on doctors’ fees. Since then the major doctors’ union has refused to sign an agreement with the health insurance schemes. The winter of 2001/2002 was marked by conflict with general practitioners, who have been on strike over out-of-hours care for several months. The conflict recently came to an end, but only after general practitioners were awarded with large increases in their fees. While the arrival of a new government has somewhat eased relationships, tensions persist.

On the request side, it is likely that patients will play a better part in setting priorities and determining quality and safety standards for the delivery of health care, either directly or through representative bodies. Their role has been reinforced by the recent law on patients’ rights and quality of care. The ageing of the people and its impact on health care needs and costs is further area of concern, while the regulation of the health care system raises institutional and financial issues. Juppé’s 1996 reform has changed the institutional balance of the French health care system, shifting power from the health insurance funds to the national (government and parliament) and from the national to the regional level. The current form of ‘mixed organization’ is the source of much debate, as is the continuing process of decentralization at the regional level.

Finally, the financial sustainability of the health care system is a perpetual source of concern, particularly due to the fact that actual spending consistently exceeds the targets set. Until now, the high cost of the health care system has been accompanied by high levels of access to health care, but the demographic change expected within the health professions may lead to an increase in explicit rationing in next years.
The government in place since June 2002 has introduced or announced several reforms. The Public Health Law announced by the Minister of Health has been discussed in parliament. It sets out about hundred goals to be achieved over the next years and proposes the implementation of national public health plans between 2004 and 2008 (on cancer, unhealthy behaviour and addiction, health and environment, rare diseases, quality of life of people suffering from chronic illnesses). The bill as well proposes clarifying the roles of different actors involved in public health policy. Reform of hospital financing, announced in November in the “Hospital 2007” plan, is under way.

The use of payment per case for medicine, surgeryand obstetric activities is currently being tested by private hospitals. The Social Security Funding Act for 2004 details aspects of the implementation of the reform (types of hospitals and activities covered by this payment method, products and services excluded from the prices that will be set for “groups of homogeneous stays”, etc.). As announced in the same hospital plan, an ordinance passed in September 2003 has simplified the hospital planning process by merging the strategic planning of amount hospital facilities and activities into a single tool (the regional strategic plan). Before, this process had been managed using several tools. The ordinance gives additional power to the regional hospital agencies (ARH). These measures are accompanied by an ambitious programme of investment, initiated by a public endowment of €6 billion between 2003 and 2007. In the pharmaceutical sector, the delisting of products announced in 1999 started in July 2003 and should continue in 2004 and 2005. Reference prices have been set for 23 generic groups representing about 5% of th e total market.

A new procedure enables the producers of highly innovative drugs to set, under certain conditions, the price of any new products they put on the market. Lastly, the modernization of health insurance announced by the government is still on the political schedule: a High Council for the next of health insurance was created in October 2003 with the aim of establishing a diagnosis and proposing a direction for reform.