Comments from France on the 2013 Commonwealth Fund Survey

Pr Isabelle Durand-Zaleski

Key findings

High population coverage by statutory health insurance

Average:SpendingAccessWaiting times

High complexity and costs of supplemental health insurance

The four paradoxes

Every person is covered but not for 100% of their expendituresSingle payer system for the statutory health insurance (SHI) but huge complexity for voluntary health insurance (VHI)Free choice of physician, but dissatisfaction with accessExpensive for the payer but 2nd worst in financial access to care

Coverage

Good for hospital careMedium for out of hospital with incentives to use gatekeeper and to use genericsVery poor for eye and dental care

Complexity

SHI: ensure that entitlement is recognizedFor means-tested government sponsored supplemental insurance, about 50% of the eligible population has registeredFor employer-sponsored or self paid VHI: complex, opaque (Le Monde survey) with hidden costs

Choice and dissatisfaction with the system

Patients want to choose their physician, not their insurer (evidence from the government-sponsored program)Dissatisfaction with access:Télémédicine experiments

Expensive for the payer but 2nd worst in financial access

Extra billing: 2013 agreement to limit extra billing to 150% of the official tariff eg 70€ for a specialist visitDirect third-party payment from SHI to physicians (resisted by physicians’ unions)Suggested reforms (not implemented):Out of pocket payments based on incomeFree hospital care

National strategy 2014

Increase generic useReduce medication volumeControl medication costsFight against fraud and abuse