Health System Operation

Access to care

Access to care is for the most part guaranteed under the statutory health insurance system. This allows the mutualisation of what may often be significant costs, that few people could afford on an individual basis.
Patients are however required to participate in health expenditures, with the aim of fostering consumer responsibility vis-à-vis the cost of health care. In some instances the statutory health insurance system provides 100% coverage, as in the case of perinatal care and costs related to long-term illnesses and industrial injury. Otherwise, the co-payment (ticket modérateur) is reimbursed fully or in part by the patient’s mutuelle or private insurance company. Hospital inpatients (with the exception of patients hospitalised on a long-term basis) must also pay a daily flat-rate fee for accommodation.

While remaining faithful to the fundamental principles of private medical practice, the reform of the health insurance system, passed in 2004, introduced a "patient pathways" system, through the institution of a referring (i.e. gatekeeping) doctor. Under the system (with a few exceptions), patients must be referred to specialists by a general practitioner, with whom they have registered as their referring doctor. Patients still have the possibility of self-referring, but in this case they are reimbursed at a lower rate by the health insurance system.
At the same time, the carte Vitale – a smartcard incorporating a microchip containing the patient’s health insurance details – exempts the patient from paying the portion of the upfront cost to be reimbursed by the health insurance fund. This system is in use in many pharmacies and doctors’ surgeries, as well as hospitals and other health care establishments. Some mutuelles or insurance companies also participate in the system with respect to the co-payment part of the cost (part not reimbursed by the health insurance fund).
The 2004 reform of the health insurance system also provides for the creation of a “personal medical record", which will contain medical data in protected electronic format. This new system should start to come on stream in 2007.

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Funding of Health Care Institutions

Health expenditure represents about 10% of France’s GDP – about €168 billion or €2,732 per person (2003). For several years now health expenditure has been growing faster than GDP.
The government has introduced several measures to attempt to curb this trend. Various ordinances passed in 1996 provided for a national target ceiling for health insurance expenditure (ONDAM, objectif national des dépenses d'assurance maladie), approved each year by parliament under the Social Security Funding Act (LFSS, loi de financement de la Sécurité sociale).
Rather than imposing a fixed limit on health insurance expenditure, ONDAM creates the obligation for regular controls. Five sub-targets are thus fixed, concerning:

• health care in private practice (mainly ambulatory care and prescriptions issued in private practice)
• health care in hospitals with global budgets,
• health care in private for-profit hospitals subject to a target budget known as the “national quantified target” (OQN),
• social care (institutions and services for the elderly and disabled people),
• health care networks.

While the introduction of the LFSS and ONDAM have engaged parliament in the debate about health insurance policy, it has not been able to curb the growth of expenditure, even though this is increasing at a slower rate. The government and the social partners are consequently exploring other possibilities. Apart from the patient pathways and personal medical records mentioned previously, these include:

• the Hospital 2007 Plan, an instrument that should promote the modernisation of the hospital sector (with the introduction of public-private cross subsidies) and the widespread use of diagnosis-related payments allowing a better comparison of volumes of activity and greater transparency of public and private sector costs,
• the reform of hospital governance, which involves the establishment of a cluster-based organisation in order to foster synergies and economies of scale and ensure a comprehensive continuum of care for patients.

Sources:
• Adecri: "La protection sociale en France"
• E. Arié: "Système de santé, mode d'emploi"
• J-C. Barbier, B. Théret: "Le nouveau système français de protection sociale (La Découverte)
• J-M. de Forges: "Le droit de la santé" (PUF)
• J-J. Dupeyroux, X. Prétot: "Droit de la sécurité sociale" (Dalloz)
• F. Kessler: "Droit de la protection sociale" (Dalloz)
• La Documentation Française: "La protection sociale en France"
• B. Palier: "la réforme des retraites"
• Internet sites of the main social welfare and health-sector organisations