French Health Care System

Brief Overview

Physician charges fee based upon contractual agreement between government and physicians.

Patient pays fee on the spot and then sends bill to appropiate insurance fund. They are then reimbursed in a couple of weeks.

National Health Insurance

Who receives it?

Provides basic coverage to all legal residents regardless of employment status.
Offers free supplementary coverage to people earning less than 3,500 francs a month (about $475 US dollars).

Who pays for it?

Payment Distribution of health care expenditures

74% - National Health Insurance
10% - Supplementary Insurance (because of gaps in NHI the majority of people seek supplemental insurance and 87% receive it from private profit and non-profit companies.
13% - Out of pocket payments

What is covered?

Services: Prentive services, inpatient and outpatient hospital care, physician services, mental health care, long-term care, dental care, prescription drugs, rehabilitation.

Sickness Insurance Funds (SIF)

Cover 99% of the population
Autonomous, non-profit, government regulated bodies with national headquarters and regional networks.
There are 3 main SIF that cover 95% of population
Remaining 5% covered by 11 smaller schemes.

Physician Role

Training

Equivalent to high school education plus 2 years, and then pass a difficult examination.
6 years of medical school (Final 3 years serve as clinical clerks in hospital)
Graduate in 1 of 2 tracks

Distribution

As of 1994 68% of French physicians were in private practice while the remaining 32% were in hospitals.
Specialists rising up around 50%, which is up from 35% in 1980.
France is experimenting with a more general practioner system.

Should subscribe to a single GP for treatment who will then refer to a specialist (to discourage patients from consulting several doctors for same condition)
Many physician labor unions object because it interferes with la medecine liberale (patients free choice of physician and physicians freedom to manage care.)

Fees

Paid by fee-for-service.
In 1996 French physicians average pay was about 130,000 before practice expenses and taxes while American counterparts receive about 195,000 before taxes.
Physicians can't price their own services. Have to negotiate with SIF on a price for services. *Have to receive government approval.
Patients pay 30% co-pay fee for office visits ($18-$25), but because of supplemental insurance this fee is not often paid by patients.
Physicians have the ability to prescribe and patients get from 100% back if drug necessary, 65% if moderately necessary, and 0% if a comfort drug (most of these payments come through the SIF).
In 1980 government decided that practioners could charge higher fees than those negotiated with the government. The physicians that charged normal rates were known as sector 1 and physicians that charged higher rates were known as sector 2. The sickness funds would reimburse both sectors the same amount of money. The drawback was that patients who saw sector 2 physicians would have to make up the difference out of their own pockets. The government believed that this would lead to a higher quality level in sector 2, but it didn't quite turn out that way. Findings indicated that sector 2 physicians located in more affluent places and quality did not increase. Now the government restricts physicians who can enter sector 2 to a small elite group of young physicians.

Government Role

What does the government control?

Volume of hospital beds and technological equipment at a regional level.
Volume of manpower by setting a ceiling each year for number of medical students.

If students can pass the difficult exam the government decides how many can continue education. In 1997 nearly 30,000 students vied for only 3,576 spots.
Limits earnings by setting, in accordance with the physicians union, the rates of reimbursement by insurance funds.

Amount of hospital expenditures by determining annual budgets for public hospitals.

Yearly budget for private health care expenditures. Fees of physicians and prescriptions would be included. If physicians overspent their budget they would be responsible for making up most of the deficit. On the other hand, if there was a surplus of funds physicians divide it amongst themselves. This created a direct incentive for physicians to control costs.

Introduction of new drugs as well as their prices through contractual agreements with drug companies.

Through these negotiations and regulations drugs costs are relatively low. These savings are offset with the fact that the French are reputed to have the highest per capita consumption of pharmaceutical products in the world.

Hospitals

Functions and operations of hospitals

Public hospitals are used for teaching and research and are also obligated to accept all patients and provide emergency care to all.
Poor most likely to receive care in public hospitals
Managed by board of directors and the main director is appointed by the Ministry of health in Paris.
2/3 of hospitals are public, while the other 1/3 is private.
Both private and public hospitals have an overall health care budget administered by a single regional authority.
Have far less staffing than US hospitals because they don't tend to have large numbers of administrative and clerical personnel whose main task focus is on billing multiple payers.

Summary and comparison

Number of physicians and hospital beds are higher in France than in US, but technical level appeard to be higher in US because of more specialists and density of staffing.
In the US we value the technical aspect because we assume that it provides more quality, but in looking at the French system the statistics point the other way because the french health care system was ranked number one among the 191 countires surveyed which was based on:

Problem

Public opinion stands against shifting responsibility to private insurance or reduction in coverage. The French prefer to meet deficits by reducing other public budgets. Also, physicians strongly adhere to le medecine liberale, and commonly strike to prevent measures that take away these rights. Both of these factors are very detrimental to the French government when they try to pass laws to curtail medical expenditures. I think that one way to help solve the cost crisis would be to implement a managed care sysem in which patients only go to one physician and then that physician would use referrals if necessary. This would help cut down on the costs associated with patients going to multiple physicians to get two, three, or four opinions. Unfortunately this system is highly against le medecine liberale.