Imagine yourself touristly trapped in the humbug of a hot Paris afternoon, in Montmartre square, sitting in front of an amateurish artist posing for an even amateurish portrait. Suddenly, you begin to feel squeamish. It’s difficult to hold your smile. Falling sick in a foreign country is the stuff of nightmares. You have to go and see a doctor, but before that you have to see the inside of a restroom.
Some hours later you find yourself in the heart of France,
not admiring the Eiffel tower but a doctor’s clinic. This is what you see. A
clinic as simple as can be. No file cabinets for paperwork. In fact no
paperwork! Detailed price list of inexpensive procedures on the walls. After
minutes of arriving, your name is called by a nurse who shows you to the
doctor’s room. Waiting time is minimal. You find the doctor kind and
empathetic who gives you ample time. At the end of your treatment, you receive
a feuille de soin, an amber colored
receipt noting the treatment, the attending physician, and the charges which
you’ll be expected to pay before you leave. The payment is much less than you’d
pay back home, in United States.
WHO’s world health report angered a
lot of countries, including USA. To see France enjoy a seat at the top and to
feel the heat crunched between Costa Rica and Slovenia, at 37th
spot, it didn’t go down well.
Here are some of the indices to get
jealous about.
- Life expectancy: 81 years (USA- 76.6)
- Infant mortality: 4 per 1,000 live births (USA- 6.89)
- Doctors per 10,000 people: 34. (USA- 24.22 )
- Health spending as a percentage of GDP: 11.2%in 2000, 11.6 in 2010 (USA- 13.4 in 2000, 17.6 in 2010). Source: World Health Organization.www.oecd.org/health/healthdata.
History
A long long time ago, there lived an
uninsured French man like the rest of uninsured around the world. Diseased and
sickened with worry, little did he know that his fate was to change soon and in
1928 change it did. That is the year national health insurance (NHI) came into
existence. Not overnight, but in a series of reforms and implementations. At
first, the NHI program covered salaried industry workers who were unable to pay
for healthcare. (Source-
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447687/#r). Then in 1945, it
covered all industrial workers and their families, irrespective of wage levels.
Subsequently: farmers (1961), professionals (1966), and the rest (2000), were
brought under the umbrella. Yes, it took nearly a century. What means to be
universal in healthcare? That it covers everybody, every time and everywhere.
So, the entire population must pay compulsory health insurance. It does take
away the personal choice but bows to personal responsibility as citizens.
Besides, if you can’t pay for the insurance the govt. will help you. That
doesn’t sound too bad.
Basic framework
French health care system is based
on a social insurance model, i.e. contributions to the program are based on income. A premium is
deducted from all employees' pay automatically. The system is not government
run but government financed. Like Medicare and social security, it is funded by
compulsory payroll taxes with some income tax contributions. So, it can be
thought of as a Medicare for everybody, but with a more generous benefit
package. What the French don’t have is a choice of insurer for basic coverage.
What they do have is the privilege of never being turned down for preexisting
conditions and that they will be covered at all times- even when in between
jobs/ or without one.
If the morale behind French
healthcare has to be explained in one word then that word would be solidarity,
which basically means that more ill a person becomes, the less they pay. This
implies that for people with serious or chronic illnesses (cancer, AIDS, severe
mental illness etc.) the insurance system reimburses 100% of expenses and
waives their co-payment charges. Of course like any other nationalized
insurance system there are fees that the system does not cover, but unlike
other systems the French have private players which sell complementary health
insurances. Such extra insurances (Med gaps) commonly pay for lifestyle
medicine - facelift, Viagra, tummy tucks etc. 85% of French people benefit from
complementary private health insurance and hence the market for these
programs is very competitive. All the more such insurance is often subsidized
by the employer, which means that premiums are usually modest.
Interesting facts-
·
Universal: Insurance covers everybody. It is illegal to be without insurance.
·
Premiums are inexpensive.
·
Employer based insurance.
If unemployed, Government provides insurance, and a supplemental insurance pays for the patient’s side also (it is even cheaper!)
If unemployed, Government provides insurance, and a supplemental insurance pays for the patient’s side also (it is even cheaper!)
·
Insurance pays everything, never denies or discriminates.
·
Government negotiates on the behalf of sickness funds.
·
Nonpayers in the French system are: the pregnant, the poor, and the chronically
ill.
·
Insurance plans never have to worry about making profits, hence denying or
delaying claims.
In fact delay in re-reimbursement is illegal. Patient is reimbursed in a month. Doctor in a week
In fact delay in re-reimbursement is illegal. Patient is reimbursed in a month. Doctor in a week
·
The system is not perfect though as some insurance companies are in deficit and
the government often has to help.
Structure
Mutules /sickness funds- There are 3 main NHI funds:
- those for salaried workers (caisse nationale d’assurance maladie des travailleurs salariés, or cnamts). The cnamts covers 84% of legal residents in France, which includes: salaried workers; those, uninsured, who were recently brought into the system.
- for farmers and agricultural workers (mutualité sociale agricole, or msa) which covers 5% of the population.
- and for the independent professions (caisse nationale d’assurance maladie des professions indépendentes, or canam). Covers 7% of the population.
In addition, there are 11 smaller
funds for workers in specific occupations and their dependents. The
beneficiaries of 7 of the smaller funds that are managed by the cnamts are also
covered by cnamts. The remaining 4% of the population is covered by the
remaining 4 funds.
Source-
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447687/#r33
Operation
All NHI funds are legally private
organizations responsible for the provision of a public service. Strictly
non-profit they can be better called as quasi-public organizations supervised
by the government ministry that oversees French social security. The main NHI
funds have a network of local and regional funds that function somewhat like
fiscal intermediaries. They cut reimbursement checks for health care providers,
look out for fraud and abuse, and provide a range of customer services for
their beneficiaries.
Smaller funds with older,
higher-risk populations (e.g., farmers, agricultural workers, and miners) are
subsidized by the cnamts, as well as by the state, on grounds of what is termed
“demographic compensation.” For example, although coinsurance and direct payment
is symbolically an important part of French NHI, patients are exempted from
both when (1) expenditures exceed approximately $100, (2) hospital stays exceed
30 days, (3) patients suffer from serious, debilitating, or chronic illness, or
(4) patient income is below a minimum ceiling, thereby qualifying them for free
supplementary coverage.
The structure of Health insurance
funds is such that they are not permitted to compete by lowering health
insurance premiums or attempting to micromanage health care. They reimburse
differently for different types of services offered at different healthcare
setups: for seeking ambulatory care they reimburse for services rendered; for
inpatient hospital services there are budgetary allocations as well as per diem
reimbursements. The sickness funds annually participate in negotiations with
the state regarding the overall funding of health care in France. Each fund is
free to manage its own budget and reimburse medical expenses at the rate it saw
fit.
Role of the Government- The government has two responsibilities in this system:
1. Playing
the big brother at the negotiating table- The government fixes the rate at
which medical expenses should be negotiated annually and it does this in two
ways. Firstly, the Ministry of Health directly negotiates prices of
medicines with the manufacturers, based on the average price of sale observed
in neighboring countries. A board of doctors and experts decides if the
medicine provides a valuable enough medical benefit to be reimbursed (note that
most medicine is reimbursed, including homeopathy). Secondly, the government
fixes the reimbursement rate for medical services; this means that a doctor is
free to charge the fee that he wishes for a consultation or an examination, but
the social security system will only reimburse it at the pre-set rate.
2.
Supervision of health-insurance funds and public hospital network – It is the
government’s responsibility is to ensure that they are correctly managing the
sums they receive.
Hospitals- Around 65% of hospital beds in France are provided by
public hospitals, around 15% by private non-profit organizations, and 20% by
for-profit companies. Also, unit service chiefs in public hospitals have the
right to use a small portion of their beds for private patients.
Doctors- Patient have a free choice as to which doctor they want to
see. There is no gatekeeping role of GPs(General Physicians), or such terms as
“in network” and “out network”. But this changing slowly as under recent rules,
general practitioners are expected to refer patients to a specialist or a
hospital when necessary. So, when a patient chooses to go to a GP first he/she
gets 70% reimbursed, but if a specialist is seen first the insurance pays only
60% of the bill.
Doctors belong to labor union which
negotiates on their behalf (which means a lot of strikes!). They are also
modest earners who are in the profession for any number of reasons but money
isn’t one of them. The average monthly salary of a GP is $3,620 as
compared to $8,189 of a doctor in USA. Although there are some benefits
provided by the state but nothing compares to a good paycheck and the fact
remains – The French don’t pay their doctors enough. (Source-
http://www.worldsalaries.org/generalphysician.shtml)
The government tries to help the
doctors in many ways-
- Medical Students pay no tuition for medical School. (Source - http://www.kevinmd.com/blog/2009/11/training-doctor-france-differs-united-states.html)
- The French National Insurance system pays for a part of social security taxes owed by doctors that agree to charge the government-approved fees. (Note the compulsory deductions column in the table on http://www.worldsalaries.org/generalphysician.shtml)
- Malpractice costs are negligible in fact less than 1 percent of total health care expenditures. Doctors don’t practice “defensive medicine,” or order unnecessary tests just to cover any potential charges of negligence later on. Government has helped doctors in this regard since 2002 by introducing a national no-fault compensation scheme. What do you call a hundred lawyers at the bottom of the ocean? A good start. The number of attorneys per capita in France is far smaller than in the United States.
·
Economics of price control.
- Small population. Area wise, a smaller country.
- Introduction of Carde vitale - card of life, no unnecessary paperwork.
- High doctor to population ratio.
- Free medical education (This compelling article in NY Times tells us how it is a money saver for the economy in long term - http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=0)
- Low Malpractice insurance costs (1/48 of that in USA)
- Co-pay at the time of treatment (which is later reimbursed). Rational being that the patient is reminded that healthcare is a costly service.
- Last but not the least - a solid system which they keep improving.
·
Physicians in private practice (and
in proprietary hospitals) are paid directly by patients on the basis of a
national fee schedule. Patients are then reimbursed by their local health
insurance funds. Proprietary hospitals are reimbursed on a negotiated per diem
basis (with supplementary fees for specific services) and public hospitals
(including private nonprofit hospitals working in partnership with them) are
paid on the basis of annual global budgets negotiated every year between
hospitals, regional agencies, and the Ministry of Health.
As for prescription drugs, unit
prices allowable for reimbursement under NHI are set by a commission that
includes representatives from the Ministries of Health, Finance, and Industry.
Charges for services provided by
health professionals are negotiated every year within the framework of national
agreements concluded among representatives of the health professions, the 3
main health insurance funds, and the French state. Once negotiated, fees must
be respected by all physicians except those who have either chosen or earned
the right to engage in extra billing, typically specialists located in major
cities. Indeed, in Paris, up to 80% of physicians in selected specialties
engage in extra billing, in contrast to the national average of 20% among
general practitioners.
Major Reforms-
1945 - Different health-care funds
begun to reimburse at the same rate.
1998- A series of reforms extended
the system so that the wealthier with capital income (and not just those with
income from employment) also had to contribute. In its place a wider levy based
on total income was introduced, gambling taxes were redirected towards health
care and the recipients of social benefits were asked to contribute! In simpler
words, everybody contributes and everybody benefits.
2000- The government provided health
care to those who are not covered by a mandatory regime (those who have never
worked and who are not students, meaning the very rich or the very poor).
2001- The social security funding
act, set the rates for health insurance covering the statutory health care plan
at 5.25% on earned income, capital and winnings from gambling and at 3.95% on
benefits (pensions and allowances).
2004- The system underwent a number
of reforms, including the introduction of Carte Vitale smart card
system.
2004- To counter the rise in
health-care costs, the government requires most people to declare a referring
doctor in order to be fully reimbursed for specialist visits
2006 - Installed a mandatory
co-payment.
Pros-
It is a universal health care
system, but not a single-payer system. It features a mix of public and private
services, relatively low expenditure, high patient success rates and low
mortality rates, and high consumer satisfaction.(Source- http://www.ncbi.nlm.nih.gov/pubmed/9158964)
There is no explicit health care
rationing in France. There are no waiting lists for specialized hospital
treatments. There is very easy access, perhaps too easy, to specialized
services. There is excellent prescription drug coverage, and people have
extraordinary choice and freedom to navigate the system as they see fit.
An important characteristic of the
French system is that the sicker you are, the better you’re reimbursed.
They have great access to primary
care. Physician to population ratio is among the best in the world.
In the end it’s not even completely
nationalized! Universal coverage does not preclude the existence of private
insurers. There’s a whole private insurance sector which is thriving.
Cons-
First, despite the achievement of
universal coverage under NHI, there are still striking disparities in the
geographic distribution of health resources and inequalities of health outcomes
by social class.
Second, there is a newly perceived
problem of uneven quality in the distribution of health services. In 1997, a
reputable consumer publication issued a list of hospitals delivering
low-quality, even dangerous care.
Third, although, compared with the
United States, France appears to have controlled its health care expenditures,
within Europe, France is still among the higher spenders. The share of public
spending on health was higher in France than in other European countries
such as Spain and Switzerland, but lower than in most Nordic countries and the
United Kingdom.
Fourth, Prices per service unit are
exceedingly low by US standards, and this has led to increasing tensions
(physicians’ often go on strikes and demonstrations) between physician
associations and their negotiating partners—the NHI funds and the state.
Reception
In terms of consumer satisfaction, a
Louis Harris poll placed France above the United Kingdom, the United States,
Japan, and Sweden(Source- http://www.ncbi.nlm.nih.gov/pubmed/2365256). A
more recent European study reports that two thirds of the population is “fairly
satisfied” with the system. (Source-
http://www.ncbi.nlm.nih.gov/pubmed/9158964)
The rising cost of the system has
been a source of concern, as has the lack of emergency service in
some areas since there are no enforceable budget ceilings on French national
health care expenditures, annual increases tend to exceed spending targets,
which in turn leads to frequent cries that the system is “unsustainable.”
At the same time, France’s medical
costs have been rising sharply, which has led to higher taxes on employers and
workers. Meanwhile, the national insurance system has been running deficits
since 1985 — it currently stands at $13.5 billion. Nevertheless there is a lot
to be learnt from The French Healthcare system.
Lessons from French Healthcare.
- It is not mandatory to be a “single-payer” system in order to provide universal coverage.
- It is possible to bring in a healthcare reform without a “big bang”, it can be accomplished in incremental stages just like the French
- Universal coverage can be achieved without excluding private insurers, there is enough room for everyone.
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Hope this article helped your understanding of the French Healthcare.