How does the french health system work?

Question

Is it more like the UK's NHS or more like the American's 'without insurance we will let you die'?

Answer 1

better than here

Answer 2

HEALTH INSURANCE AND ACCESS TO CARE --

To best understand how the French health care system works, I think it is best to begin with a look at the French health insurance system.

First of all, all legal residents of France are covered by public health insurance, which is one of the social security system's entitlement programs. The public health insurance program was set up in 1945 and coverage was gradually expanded over the years to all legal residents: indeed, until January 2000, a small part of the population was still denied access to the public health insurance.

The funding and benefits of the French public health insurance system (PHIS), much like Germany's, were originally based on professional activity. The main fund covers 80% of the population. Two other funds cover the self-employed and agricultural workers.

Once varying depending on the fund, disparate reimbursement rates were replaced by uniform rates. The funds are financed by employer and employee contributions, as well as personal income taxes. The latter's share of the financing has been ever-increasing in order to:

� compensate for the relative decrease of wage income,

� limit price distortions on the labor market,

� and more fairly distribute the system's financing among citizens.

Most health insurance funds are private entities which are jointly managed by employers' federations and union federations, under the State's supervision. The joint labor/management handling has always sown discord within the funds' boards, as well as between the boards and the State.

As a consequence, the responsibilities of the various actors in the system are not always shared in the most coherent manner.

For example, the parliament's budget provisions determine how much public money will go to health expenditure, the cabinet decides reimbursement rates and sets the amount of contributions earmarked for the funds, while the funds themselves negotiate with health care professions to set tariffs designed to ensure the system operates at the breakeven point. Responsibilities are frequently redefined, but never to satisfaction of all involved.

1 Permanent Working Group of European Junior Doctors, October 2001.

2 1 rue Paul C�zanne 75008 Paris France. [e-mail], www..fr, Tel: [phone].

The views expressed here are those of the author, and they do not necessarily reflect the views of the IRDES.

Agn�s Couffinhal - IRDES October 2001 2

The public health insurance system covers about 75% of total health expenditures. Half of the outstanding amount is covered by patients' out-of-pocket payments and the other half is paid by private health insurance companies. These supplementary health insurance policies can be taken out by individuals or groups.

About 85% of the population own such policies.

An important peculiarity of the French PHIS is that the funds cover a very wide range of goods and services, including for example, stays in thermal spas.

In the hope of curbing consumption and expenditures, copayments were implemented and have increased over time. These copayments are relatively high for many out-patient services.

For example, patients must pay 30% of Social security's tariff for a physician's visit, moreover, roughly 40% of specialists and 15% of GPs are allowed to charge more than the tariff. Copayments are also high for dental prostheses and eye-ware. This tended to deter the poorest citizens (few of whom had supplementary insurance) from seeking care. Concerns grew over the system's inequity.

In January 2000, a means-tested, public supplementary insurance program called CMU (Couverture maladie universelle) was implemented to ensure the poor access to health care.

For those whose income is below a certain threshold (about 10% of the population is eligible), this insurance covers all public copayments and offers lumps-sum reimbursements for glasses and dental prostheses. Health professionals are not allowed to charge more than the public tariff or the lump-sum for CMU beneficiaries, which means that in theory, access to care is free of charge.

In passing, I'd like to mention that many experts advocate a change in the way health insurance covers care. They think it would be more efficient and equitable to clearly define a set of indispensable goods and services which should be available to everyone and which should be 100% publicly financed. The remaining goods and services would be available to those who desire and can afford them, with or without relying on private insurance.

To close this aside on access to care, I'd like to add that, as far as I know, France is the only country in which access to care is unlimited: patients can see as many physicians as often as they like. Patients do not need referrals to see specialists, and in general, there is no gatekeeping system of any kind. This may partially account for the World Health Organization's high ranking of France's health care system last year: the rating system emphasized the system's responsiveness (a measure of patients' freedom and flexibility), a quality the French system provides, undeniably at the expense of overall efficiency.

Agn�s Couffinhal - IRDES October 2001 3

-- THE STATE'S ROLE --

1. The State decides on what care is to be reimbursed and to what extent, defines the responsibilities of the various actors, and ensures that the entire population has access to care.

2. The State defends patients' rights, drafting and enforcing relevant policy. The State is thus responsible for safety within the health system. The disaster and subsequent cover-up of the contamination of the nation's hemoglobin supply with HIV-tainted blood resulted in the revamping of public health policy. New agencies were created to oversee safety measures concerning the nation's blood supply, organ donor programs, food, and medical goods and services. The recent handling of the mad cow crisis indicates that these changes have improved public safety.

3. The State is also in charge of planning. Health authorities decide on the size and number of hospitals, as well as the amount and allocation of highly technical equipment (MRI, CTscans...). It organizes the supply of specialized wards (transplants, neurosurgery...) and ensures the provision of care at all times, like emergency rooms.

Since 1991, some of the planning has taken place at the regional level. Indeed, more and more policy-making and negotiation are undertaken at the regional level, and this tendency is likely to continue in the coming years.

-- THE CARE SUPPLY HOSPITALS --

In France, hospitals have always been the core of the health care system. This probably accounts for the extremely specialized, technical, curative nature of our care, arguably to the detriment of prevention and community services.

The number of hospital beds has decreased over time: it currently stands at 8.4 per 1,000 inhabitants, which is close to the European average. Hospitals can be roughly divided into two categories: public, and private for-profit.

� The public sector represents about 65% of the beds. Public hospitals have specific obligations such as ensuring the continuity of care, teaching, and training. They receive a budget which is largely based on a historical basis.

� Private for-profit hospitals concentrate on surgical procedures and rely mostly on fee-forservice remuneration for their funding.

A uniform hospital information system has been implemented to monitor the various establishments activity. Gradually, all public and private establishments are to switch to DRG payment systems.

Agn�s Couffinhal - IRDES October 2001 4

-- HEALTH PROFESSIONALS --

Of the many types of health professionals, I would like to focus on physicians, as they play a key political role in the system. There are currently about 200,800 physicians licensed to practice in France. In the last thirty years the number of physicians has tripled, but the rate of increase is now very slight. Indeed, since 1971, the Ministry of Health has limited the number of medical students, a measure which, along with the retirement of currently active doctors, will result in a decrease in the number of physicians in the near future.

Half of the physicians are specialists.

In France, physicians (and other professionals) generally work in two kinds of environments: public hospitals and private practices. 25% of physicians work in public hospitals (another 11% work in other types of public establishments). They are in essence public servants and paid an amount that is fixed by the government. Today, many physicians feel that the prestige of working in a hospital does not compensate for the trying working conditions. 56% of physicians work in private practices3, and are paid on a fee-for-service basis.

The relative weight of the procedures is set by experts and the prices are negotiated by physicians' unions and public health insurance funds4.

Since the creation of Social Security, the relationship between private practice physicians and the State and public insurance funds has always been strained. A contract (convention) which sets the general regulatory framework and the remuneration of the profession is supposed to be signed every 5 years by physicians unions. The first one was signed in 1971, 26 years after public health insurance was created. Subsequent conventions allowed some physicians to charge more than social security tariffs (1980), limited this right (1990) and implemented official medical practice guidelines (RMO, R�f�rences m�dicales opposables) in 1993.

The current situation is particularly strained: negotiations between doctors' unions and the funds have stalled, leaving the specialists without a convention and isolatin

Answer 3

You really NEED travel ins. AND a credit card.  Even with travel ins. you sometimes have to pay (via your credit card)then claim it back when you get home.

Do not go without.

Answer 4

Probably a mixture of the two, but leaning more towards the UK system.

You are taxed on your salary and your company pays a share too to pay for your health coverage, you get reimbursed a certain percentage of your health expenses. For some you get nothing, for others (usually hugely expensive life saving treatment or surgery) you are reimbursed in full. Dentistry and glasses are very badly reimbursed by the way.

You can choose your doctor who is a private practitioner as said above (and to reduce over visiting you now have to choose one and send his name to the Social Security, and you will be reimbursed less if you go to see another one).

You can also take a private insurance (either by yourself or offered by your company which will pay some of it) to cover the part that isn't reimbursed by the S.S.

The system is creaking and groaning and the government is trying to limit it, but one little known fact is that if all the revenues allocated to it went to the S.S. instead of being plundered by the government and different agencies, the S.S. would not be in the red.

Answer 5

as above but there the doctors still tend to prescribe too much medicine.  

there can be a very long wait for an eye test because you have to see a consultant instead of just popping into Boots but I guess the test will be more thorough

there is a lot more aftercare than in parts of the UK.  a district nurse will come around, daily if necessary.  A relative had brilliant return-to-fitness schedule after his heart problems

Not all British people coming to live in France will be accepted into the French system, it depends on your NI contributions record and age.  Some will have to get extra insurance or remain with the NHS and return to the UK for non-urgent treatment

Answer 6

Reece B's answer from the medicalnewstoday site is very detailed. But I just want to correct 2 things. The first being CMU doesn't cover everything unlimited, for example, a CMU covered patient is only allowed a pair of glasses only once a year, and not more than 60€. As for dental treatment , a relative of mine lost all his teeth except the front, CMU wouldn't pay for a good whole set of artificial teeth, they told his dentist that they pay only 900€ which is just about enough to pay a very basic bad quality set of artificial teeth.( An acceptable good quality teeth will cost at least 2000€).

Secondly, we do need referral to see a specialist. Someone in my village had to visit his own doctor who wrote a letter to a neurology specialist. Then this patient carried this letter and made an appointment to see the specialist. Such appointment took him 2 months  cause this area we live ( Les Alpes ) has only 2 such specialists who have to look after all the patients in the whole Hautes Alpes area.

Answer 7

I was gonna answer,but the previous one tells you everything!!!

Answer 8

wow. I was just gunna say whatever they have its pretty good. When i had to go to the hospital in France I got to for free =D.

Answer 9

You go to the doctor, you pay 22 euros and "l'assurance maladie" gives you back 21 euros.

Every visit to doctor is reimbursed.

It's a good system.

Answer 10

To begin with your characterization of the American system is really rather silly. In fact, in the USA, the Hill-Burton Act of 1946 required hospitals receiving Federal grants (which is just about all of them) to provide free health care to indigents.

Furthermore, the medicare and medicaid sytems provide health care to elderly, the disabled, and a wide range of other classes of the poor or potentially poor.

The overwhelming majority of employed workers receive health insurance thru their employers, a system that arose during WWII when wage and price controls were in effect and providing health insurance for "free" was a means of avoiding these controls.

The unfortunate effect of this was that Americans viewed health care as "free" and did not want to see any changes after the war. It was, after all, only after the War that the UK instituted the NHS.

The present crisis in the American system arises because the combination of private insurance supplememted by free care for the poor is breaking down in the face of several factors.

First and foremost is that the cost of health care in the USA is vastly higher than anywhere else and growing. The USA currently spends 13.5% of its GDP on health care, the highest in the world. In 1960 the figure was 5%.

As a result employers, largely in response to globalization competitiveness issues, are shifting the burden of premium costs to workers. Workers, in turn, are stunned to find that what they have come to regard as a "free" benefit isn't free.

Currently 16% of the population has no coverage and, for the most part, this is because they will not buy private insurance even though it is both available and, at least in theory, affordable.

The bottom line is that Americans don't have health insurance because they prefer spending their money on SUV's, bigscreen TVs, central air conditioning etc etc and are unwilling to either pay the premiums for private insurance or see their taxes double to pay for some government program that might be enacted.

Of course, this is a lousy choice and even more people will become uninsured as costs rise and employers dump their health care benefits programs as a result.

So lets be clear that the system in the USA exists because that is what the voters have wanted and, until recently, that system worked fairly well.

Even as it is there really isn't any basis for suggesting that anyone is dying for lack of health insurance and there are statistics that suggest that the American system actually does a better job of treating at least some conditions than European systems.

That being said, the French system is far more attactive that the British NHS model.

It is a system of government assisted and mandated but essentially private health insurance. For working people it is paid for with a tax which amounts to about 20% of wages. The elderly are covered by contributions into the social Security system and otherwise uninsured persons from general revenues.

Citiznes choose their own physicians who are independant workers and not government employees. While they are free to set their own fees the government presecribes the fee to be paid by insurance and doctors or hospitals that charge more must advise the public of this. Because of the existance of universal coverage, the majority of healt care providers charge only the government defined fee.

Patients pay most ordinary costs up front and then apply for reimbursement from their health insurance. the percentage of reimbursement varies and rises with the seriousness of the condition being treated. A routine doctor's visit is reimbursed about 70% while something like major surgery will be almost entirely paid for by insurance.