Towards a Unified French Health System
Wednesday 04 November 2015
Major changes are planned in the operational arrangements of the French health service, with streamlining of the insurance system and the method of payment to doctors.
There may well be a national health system in France, but it is still one that is not entirely unified.
Like many health systems across the globe, the French system started off after WW2 as a series of mutual schemes between employers and employees, and the present arrangements still bear the hallmarks of that approach.
Unlike the UK, where the Beveridge based system is mainly funded through general taxation, in France the system is funded through insurance levies administered by separate and non-competitive statutory insurance funds.
The main health insurance fund is the Régime Général that covers about 85% of the population employed in industry and commerce.
Those who run their own business in France are insured through a separate State controlled insurance scheme called the Régime Social des Indépendants (RSI).
There are then health insurance funds for agricultural workers and other smaller schemes for certain specialist (and rather privileged) groups, e.g. civil servants, local government staff, railway workers, police, EDF/GDF, military personnel and politicians.
For those not affiliated to an insurance scheme there is the Couverture Maladie Universelle (CMU), which is funded out of a levy on the main schemes.
In the end, therefore, anyone who is legally resident in France is covered for health through one scheme or another (albeit that some expatriates are insured outside of the system through a private health care policy).
And whatever scheme you may be in, everyone uses the same public or private health care services. The separate funds do not have their own doctors and hospitals.
The problem for the patient is what happens when there is a change of circumstances in their life and they need to move from one insurance fund to another eg, loss of job, death of spouse, divorce, termination of business or even relocation.
That change of circumstances may mean that their health card (carte vitale) is no longer valid, possibly making it difficult to access health services, or causing an interruption in reimbursement of their costs.
This lack of continuity in the system is what the government now propose to change, so that from January 2016 there will be in place une protection universelle maladie (Puma).
In other words, insurance cover and reimbursements will be protected whatever the change in circumstances, and without the necessity for an individual to engage in an administrative steeplechase to change their insurance fund.
All that will be necessary will be to go into your account on the website of l'assurance maladie (AMELI) and signal the change in circumstances.
The transfer between one insurance fund and another will then take place behind the scenes within a matter of days, rather than the several weeks (sometimes months) that it presently takes.
Some regard the implementation date for such a change to be rather optimistic, so a delay in the introduction of the new arrangements can be expected!
In a complementary measure the government are also proposing to overhaul the payments system to doctors.
At the present time, most patients pay their doctor for a consultation, a fee that is at least later partially reimbursed to them from the social security system, and from their 'top-up' health insurer, provided they have an assurance complementaire policy in place.
In future, it is proposed that no up-front fee will be payable, and that doctors will be paid for each consultation directly by the local statutory health agencies (caisses), for that part that is reimbursable by the social security system.
This is called the system of 'tiers-payant', a method is already in use for many patients, such as low-income households who benefit from free health care, those with a serious medical condition, and for those who obtain financial assistance with their 'top-up' health policy. It is also already a reality in most hospitals, clinical laboratories and chemists.
Nevertheless, the generalisation of direct payment by the caisses has enraged many in the GPs, who are concerned about a loss of professional freedom, the additional administrative costs, and the possibility of a high level of dysfunctionality in the system.
Like many professionals in France the GPs recollect the digital chaos that occurred following the merger of the social security insurance funds for the self-employed in 2008, with the Régime Social des Indépendants still plagued by administrative shortcomings.
Not all doctors oppose the measure, but those who do support it argue that a universal system of tiers-payant requires that the administrative set-up is simplified, and that it should include the complementary 'top-up' insurers.
If this does not occur they fear they will not be able to cope with the burden of dealing with so many agencies and insurers to recover their fees.
In short, they argue that before the system is introduced France should have in place a unified system of health administration.