The French Healthcare SystemLecture 7

Tracey Lynn Koehlmoos, PhD, MHA

HSCI 609 Comparative International Health Systems

The Best in the World

• A very controversial study released by the World Health Organization in 2000 declared France had the BEST healthcare system in the world!

• Still the French citizens were dissatisfied!

Where are we now?

French Republic (France)

Capital: Paris

Population: 60,876,000

Government: Republic

Divisions: 22 Regions,

96 Departments

Updated Facts about France

• Life Expectancy: 76.1 m/ 83.5 f (2006)• Infant Mortality: 4.21 per 1000 (2006)• Population >65: 16.4% (2006)• Health care expenditures as percent of

GDP: 9.7 (2002)• Per capita health expenditure: $2762 US

• Leading causes of mortality: cancer, heart disease

Organization

• 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

Public Health Agencies in France• National Institute of Health (1998)

• French Agency of Health Safety of Health Products: (1998) (like our FDA) reviews drugs, cosmetics, foods

• Agency of Environmental Health Safety (2000)

• French Institute of Blood (1992): safe blood

• French Institute of Transplants: (1994)—arms and faces!

• Ministry for Health, Family and the Disabled

Planning The government presents a law to

parliament every year in order to finance social security which includes the national expenditure on health insurance. Delineates specific goals for the healthcare system.

• Ministry of Health—delegates to the Regions who develop:

• General Regional Health Organization Plans

How does French Health Insurance Work?

• National Health Insurance (NHI) guarantees universal access

• Administered in schemes according to occupation– 80%: CNAMTS, salaried workers and their

families– The rest: 17 separate funds—occupationally

specific, doctors, agricultural workers, students

Financing the French Healthcare System

• 60% from workers salaries go into the health insurance branch of social security

• The rest is from indirect taxes on alcohol and tobacco and by direct contribution paid by all revenue in proportion to income including retirement pensions and capital revenues.

• More than 80% of French people carry a supplemental form of private insurance often linked to employment

Paying for care

• Public payment covers 76% of French health expenditure

• 21% of expenditures are on pharmaceuticals• Patients pay the physicians directly and apply for

reimbursement• For 96% of the population, health care is entirely

free of reimbursed up to 100%.– This is a new change as of 2005– Previously 80% with 100% for specific diseases like

AIDS, diabetes– Or certain “conditions”: pregnancy, handicapped

children, invalids, injured workers

Freedom of 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

Health Services Workforce

• >1.2 million employees in the health service sector

• Many public hospital jobs are considered undesirable and filled by foreign doctors

• More than 185,000 physicians

Health Services Workforce

• Majority of physicians in private practice– Many participate in a government fixed fee-for-

service scheme (Sector 1)– Others charge what they wish, accept the

government payment, patient picks up the rest– French GP’s make about $55K per year

• Physicians are unevenly distributed between rural and urban areas

More about Physicians

• About 50% of physicians are women

• Physician visits can take 15 to 30 minutes

• Physicians see about 10 patients per day

• Publicly funded medical education

Hospitalists

• 1:1 ratio of generalist to specialist physicians

• National-wide ranking system of hospital practitioners

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

• Advancement is based on seniority

Hospitals• Global budgeting based on prior

expenditures• Public, Private, Not-for-Profit• 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 levels (large Parisian to small rural)

More on Hospitals

• Public Hospital example:

• Public Assistance Hospital of Paris– Created after the French Revolution– Today it employs over 80,000 people– Complex organization responsible for a high

standard of medical care, technology and research

Private, Not-for Profit

• Private, Not-for-Profit:

• 15% of French hospitals

• Specialize in medium to long-term care

• Many of these hospitals throughout Europe trace their roots back to first era of Christianity (old religious affiliations—health, alms, healing)

Private, For-Profit Hospitals

• Private, For Profit

• 20% of total beds

• Started by surgeons and obstetricians but evolved into hospitals

• The Private sector conducts:– 50% of surgeries – 60% of cancer care

The French Approach to Hospitalization

• CHOICE is a number one priority to the French healthcare consumer

• The excellence of procedural service is the paramount decision item

• However, things like access to bottled water, private rooms and high quality food are taken for granted across hospital settings (unlike in England or US)

Long Term Care• France has a tradition of long term care in the

home—dating to the 1962 Laroque Report• France maintains strict boundaries between

health and social services (like US)• Home health and nursing homes are means-

tested• Aid is in the form of APA (Allocation for Loss of

Autonomy)—6.4 of the over 60 pop.• APA recipients must use the money to purchase

care—even from family members or other unskilled labor (a means to promote employment)

Nursing Homes• Many are denominationally based• > 50% of patients have dementia and are

over age 80• Room and board are separate from

nursing/health care and are paid from pension funds or covered by welfare funds

• Residents are legally entitled to be involved in the governance of their home

• Nursing homes have a strong public reputation (unlike in US)

Compared to US• The French have the #1 healthcare

system in the world. The US is #37.

• 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)

• French costs are on the rise too—we will have to wait and compare!

Parting Shots

• Let’s talk about resources for YOUR country project

• WHO www.who.int

• CIA www.cia.gov

• Other places: – AARP (Long Term Care)– OECD, PAHO, CIVITAS (UK)