The French HealthCare System

February 13, 2014

Ibrahima Sankaré

The Quintessential French Man

Content

• France– French Historical and Current World Presence– Demographics– Immigration

• The French Healthcare System – Governing Agencies– Health Insurance Plans– Worker’s Compensation – Financing – Paying for Care – Prescription Drugs– Physicians and Hospitals

French Colonial Empire12 898 000 km²

France Today552 000 km²

Metropole Overseas Departments

Locations of Overseas Departments

Demographics

• As of January 2013:

• 65.8 million resided in France,

– 63.7 million in the Metropole

– 1.9 million in the overseas departments

– Population >65: 16.4%

• 3.8 million foreigners live in France as legal residents (6% of the population)

• 11% unemployment rate

Demographics (continued)

• Birth rate: 12.6 per 1,000 inhabitants

• Fecundity index: 2.01 children per woman

• Women born outside of the European Union have a higher fecundity index (3.2)

• Life expectancy:

– 78.2 years for men

– 84.9 years for women

Immigration and France

• According to the United Nations an immigrant is a «person who resides in a country that is different from the one where he or she was born».

Immigration

• In 2010, 7.2 million immigrants lived in France (11.1 % of the population)

• France ranked 6th among countries that count the most immigrants in their population.

– United States ranked 1st with a population of 42.8 million immigrants

Where do immigrants originate from?

• Maghreb (41%)

• Sub-Saharan Africa (11%)

• European Union (34 %)

• Asia (14 %)

• In total immigrants and their children (2nd

generation “immigrant”) account for 12 million people (12% of the overall population)

The New Face of The French

Overview of the Healthcare System Governing Agencies

• Ministry of Health—runs two large organizations that cover the funding and provision of health services:

– General Health Management

– Hospital and Healthcare Management

• 22 Regional level service organizations

• 96 departmental level services organizations

Planning

• The government presents every year a budget for the financing of the healthcare system for the following fiscal year

• The parliament debates, amends and vote on the budget

• Drug prices, medical fees are also decided on at the national state level

• The Ministry of Health supervises and delegates to Regions the duty to manage the budget and health policy on a regional level

Public Health Agencies in France

• National Institute of Health

• French Agency of Health Safety of Health Products: (similar to the FDA) reviews food, drugs, cosmetics

• Agency of Environmental Health Safety

• French Institute of Blood

• French Institute of Transplants

• Ministry for Health, Family and the Disabled

National Health Insurance System

• Created and Implemented on October 19, 1945• The national Health Insurance system (NHI) forms an

integral part of France’s social security system. It provides health insurance and workplace accident coverage.

• It is comprised of 3 main funds which are: • The salaried workers’ fund (1)• The farmers and agricultural workers’ fund (2) • The non-salaried professions’ fund (3)• (1) covers 84% the population: it includes salaried workers

and unemployed people that benefit from the Universal Sickness Coverage CMU

• (2) & (3) cover, respectively, 7% and 5% of the population. The remaining 4% of the population is covered by smaller funds that are part of the salaried workers’ fund

“Mutuelles”

• “Mutelles” represent the last piece of the French National Health Insurance system.

• They are non-profit health insurance companies that cover the part of medical fees (on average 20-30%) that is not reimbursed by the National Health System.

Eligibility for Insurance Coverage

• 2 types of health insurance plans: – Standard Health insurance Plan (covers 57 million

people, 89% of the population) – “couverture maladie universelle” (CMU) (covers 1.7 million

people). Mainly covers the long term unemployed

• Eligibility criteria for the Standard Health Plan:– Work at least 60 hours over a period of 30 consecutive

days or paid dues that are at least 60 times the minimum hourly wage ($12.9)

– Citizenship – Legal residency– Employment

CMU

• Eligibility criteria for the CMU: – Ineligibility for the standard health insurance plan

(most cases, unemployed for more than a year) – Revenue – Continuous Residency on French soil for at least 3

months

• Complementary CMU (covers copayments for insurance holders who cannot afford a “mutuelle”)– 4.17 million people benefit from it– However based on household tax files, it estimated

that 14% of lower income households who would qualify for this complementary insurance did not apply for the Complementary CMU (2003)

Universal Access

• The standard health insurance plan and the CMU combined together guarantee universal health insurance access to French citizens and legal residents (99.6% of the population is covered)

CMU Income Eligibility

Household Resources of the last 12 months

(in Euros)

1 person 7,611

2 people 11,417 (9,514 if the second person is

a minor)

3 people 13,700 ( deduct 1,142 if there is a

minor in the household)

4 people 15,984 ( deduct 1,142/minor)

If revenues exceed the income threshold, insurance holders must pay up to 8% of the fraction their revenues that is above the given threshold

Worker’s Compensation“accident du travail”

• Worker’s compensation is included in the national health insurance system.

• There is no additional contribution that need to paid by the employee

• Temporary incapacity: 60% of the daily wage is paid to the injured employee until the 29th day of incapacity. At the 29th day, 80% of the daily wage must be paid to the injured employee

• No hospital stay fee

Worker’s compensation

• Permanent incapacity: the employee receives a pension that is calculated based on an incapacity coefficient and the salary received before the injury

• If the injured employee makes between 18000E and 36000E, the entire salary is taken into account in the equation. For salaries above 36K, 1/3 of the fraction of the salary exceeding 36K will be taken into account in the equation

Worker’s compensation

• If the coefficient of incapacity is 80% or more– the worker will get a complementary pension that

cannot be lower than 13k

– Additional benefits to pay for an in-home care provider, the amount of those benefits depend on the number of daily life things that the injured worker cannot accomplish

– Additional 20% benefit if the worker is married or in “civil union partnership” to cover in part the loss of income

Worker’s compensation

• If the person died to the sustained injuries:

– The spouse will get a pension equal to 40% of the salary of the diseased

– And an additional 25% for the first 2 children, 20% for each children after the first 2 (children must be 20 years old or younger)

Student Health Insurance

• Student health Insurance plan (2.4 million people covered)

• Mandatory coverage for all registered students in France

• Cost on average 200 Euros per year

• Grants access to all heath services

Aide Maladie d’Etat (AME)State Health Insurance

• This insurance scheme has been created to cover undocumented immigrants. There are an estimated 215,000 beneficiaries

• Eligibility criteria: – Continuously reside in France for at least 3 months– Must earn less than 7 611€ per year for an individual – Must state that France is the unique place of residency

• Yearly cost for the insurance holder: 30 €• Benefits:

– Allows the insurance holder to have access to all healthcare services free of charge including dental care and hospital stays

AME (continued)

• This plan has come under attack and scrutiny after politicians from the far right portrayed it as an incentive for undocumented immigrants to settle in France

• In 2011, some legislators have proposed amendments to discontinue the AME

• Secret shopper study done on 725 doctors in 10 French cities has shown that 37% of doctors refused patients with the AME

Free Choice

• Since 2005 the French have to select a “Gate Keeper” physician, However:

• Users can select any doctor—even a specialist

• Users can select any hospital—public or private

• The belief is that choice has led to successfully managed competition and quality care

Quick Facts About Health Expenditures

• In 2009, Healthcare expenditures amounted to 215 billion Euros. This represents 11.2% of France’s GDP or 3,300 € per capita

• The following entities are the main providers for France’s healthcare expenses:

• The NHI system finances 76.7% of those 215 billion Euros.

• “Mutelles” make up 13.8% of that amount. • Finally, household’s out-of-pocket expenses amount to

9.5% of the overall healthcare expenses• The NHI will run a projected deficit of 14 billion Euros

(2 billion more than planned) this year due to a continuously high unemployment rate (11%)

How is the system financed?

• Roughly half of the NHI expenditures (51.5%) are financed by employer payroll taxes

• The “General social contribution, Contribution socialegeneralisee” that is levied by the French Treasury on all earnings, including investment incomes finances 34.6%

• The Remaining sources of financing for the CNAMTS and its affiliated health insurance funds including payroll taxes on employees (3.4%), special taxes on automobiles, tobacco and alcohol (3.3%), a specific tax on the pharmaceutical industry (0.8%), and subsidies from the state (4.9%).

Financing of the System Micro level

Contribution rate for: Employer Employee

NHI 12.8% 0.75%

Worker’s compensation 2.43%

CSG - 7.5%

Contribution to reimburse the NHI’s debt

0.5%

•Contribution rates are decided on a state level and voted into law•Contributions are deducted from the gross income•Employer transfers directly the employee and employer’s contribution to the NIH•Partial exemptions are given to employees (low paid jobs) and employers in some sectors of the activity

How is the system financed?Aggregate

51.5%

3.3%

34.6%

3.4% 0.8%

4.9%

Financing of the NHI

Employer payroll taxes

Employee payroll tax

CSG

Tobacco, alcohol, andautombile taxes

Pharmaceutical Ind. Tax

State subsidies

NIH Aggregate revenues

Employees and employers

Taxes and special taxes on tobacco

CSG

TransfersOther

State subsidies

Paying for Care

• The NHI covers 70% of the cost of healthcare procedures (not including medications). The patient incurs the remainder of the costs

• Even though the subscription to a “mutuelle” is optional, 93% of French people choose to enroll in a “mutuelle” to make up for the uncovered medical costs (30% in most cases).

• The average premium cost for a mutuelle is 450 Euros per year (The Complementary CMU is a subsidy plan for people who cannot afford a “mutuelle”)

ProcedureFee %Reimbursed Co-payment

Primary care 22 € 70% 6,60 €

Specialist 25 € 70% 7,50 €

Psychiatrist 37 € 70% 11,10 €

Cardiologist (consult) 49 € 70% 14,17 €

Filling a cavity 19,28 € - 48,20 € 70% 5,78 € - 14,46 €

Root canal 93,99 € 70% 28,20 €

Teeth cleaning 28,92 € 70% 8,68 €

Prescription Medicine Variable 45-100% Variable

Advil 200 mg 2.51 € 60% 1 €

Optician 23 € 70% 6.90 €

Optometrist Variable 65% for glasses Variable

Hospital Stay (flat rate) 18 € /day 0 18 €

Payment & Reimbursement

• If you are covered under the standard health plan: – You pay a consultation fee up-front and get

reimbursed within a week time through a centralized electronic reimbursement system called carte vitale

• If you are insured under the CMU, there are no consultation fees to pay up-front, the NHI reimburses directly the physician through carte vitale system

However,

• An important element of the French insurance system is solidarity: the more ill a person becomes, the less they pay. This means that for people with severe conditions or chronic illnesses (diabetes, cancer, HIV/AIDS, disability), the insurance system reimburses 100 % of their expenses, and waives their co-pay charges.

Prescription Drugs Prices

• Based on the NHI’s code, the Committee in Charge of Health care Products negotiates the price of prescription drugs with pharmaceutical companies

• Wholesaler and pharmacies margins are also established by the same committee. Retail drug prices are obtained by adding to the manufacturers price, the wholesalers and pharmacies margins and a value added tax.

Negotiated Fixed Margins

• Wholesaler’s margins

• Retail pharmacies’ margins

Price 0-22.90 € 22.90-150

€

150-400 € Above

that price

Margin 9.93% 6% 2% 0%

Price 0-22,90 € 22,90-150 € Above that

price

Margin 26.10% 10% 6%

Health Services Workforce

• 1.2 million employees who work in the health service sector

• There are 209,143 physicians in total

• 101,667 are primary care physicians: a ratio of 165 per 100,000 inhabitants

• 107,476 are specialists: a ratio of 174 per 100,000 inhabitants

Physicians

• The Government establishes a numerus clausus(closed number) of medical students who will graduate to become doctors. The outcome of the national census (takes place every ten years) may prompt the Government to increase or decrease the numerus closus.

• In 2013 the numerus clausus for medical students is 7,492 (there were 49,000 first year medical students)

• Free medical education (financed by tax payers)

Physicians

• Majority of physicians are in private practice:

– 97% participate in a government fixed fee-for-service scheme

– Medical fees are negotiated on the national level between the National Doctor Association of every medical field and the Health Ministry

• Others charge what they wish, accept the government payment, patient picks up the rest

Average Income

Medical field Average annual

income (in Euros)

Surgeons 155,997

Cardiologists 121,309

Gynecologists 94,639

Dermatologists 72,842

General Practioner 70,850

Hospitalists

• Physicians, biologists, and dentists are all salaried as hospital practitioners

• Advancement is based on seniority

• National-wide ranking system of hospital practitioners

Hospitals

• 2,877 hospitals in total • Public (1,066), Private (804), Not-for-Profit

(1,067)• The mix of public and private avoids long wait

lists as in other socialized medicine systems.• Public: About 1032, with 65% of all hospital

beds– 91% financed by endowment funding from health

insurance funds– Centers of research and medical training– Various hospital sizes (large Parisian to small rural)

Private, Not-for-Profit

• Private, Not-for-Profit:

• 15% of hospital beds

• Specialize in medium to long-term care

Private, For Profit

• Private, For Profit

• 20% of total beds

Merci!

• The French have the #1 healthcare system in the world. The US is #37 (Word Health Organization)

• The French system is universal, US excludes 44 million uninsured individuals

• Like US, the French are leaders in technology and research (transplant center in every region, HIV/AIDS research)